Intraocular pressure: Focus on corticosteroids.

Dear Editor,

Sudhalkar and colleagues comprehensively reviewed intraocular pressure (IOP) profile of intravitreal drugs.[1] The undisputed elephant in the room is intravitreal corticosteroid; and in the Indian context, triamcinolone acetonide (IVTA), which merits further discussion:

The first issue is the dose: the authors have stated that 2 mg and 4 mg are the most common doses. Is this statement based on any study or survey? SCORE study indeed showed that 1 mg triamcinolone was as effective as 4 mg drug with no significant IOP rise.[2]

Route of delivery: Posterior subtenon route has been suggested to be safer than IVTA, but without references. The head-to-head trials of the two routes have invariably shown subtenon route to have similar,[3] and sometimes more prolonged IOP rise than IVTA.[4] Suprachoroidal route, more popular currently for lower propensity for glaucoma, may be a better alternative.[5]

Safety: Finally, is it possible to get a take-home for the practicing clinician from the clutter of conflicting studies about IVTA in standard or reduced dose, and the safe number of repetitions for corticosteroid responders or those with ocular hypertension or glaucoma, controlled by one, two or more topical medications? For example, would IVTA be safer in an eye with lower IOP (10–15 mmHg) than that with higher IOP (20-24 mmHg)? Or should one focus more on optic nerve and nerve fiber layer status rather than IOP before starting treatment with corticosteroids?

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