Cataract and Ocular Hypertension in Children
on Inhaled Corticosteroid Therapy
Abdulmutalib H. Behbehani, MD, FRCSC; Abdulla F. Owayed, MD;
Zeinat M. Hijazi, MD; Esmail A. Eslah, MD; and Adel M. Al-Jazzaf, MD
ABSTRACT
Purpose: To ascertain the incidence of posterior
subcapsular cataract and ocular hypertension in a
cohort of children
12 years on inhaled steroid
therapy.
Patients and Methods: In this prospective study, a
detailed history regarding corticosteroid therapy
was obtained for children attending an asthma
clinic. The presence and type of lens changes
(cataract) was recorded and intraocular pressure
(IOP) was measured. The children underwent
another eye examination 2 years later.
Results: Ninety-five patients were enrolled in the
study. Mean patient age was 73 years, and mean
duration of inhaled steroid therapy was 21
years. Thirty-six percent of patients received
inhaled steroids exclusively, 61% received
inhaled steroids with a short course of oral
steroids, and 3% received inhaled steroids with a
Dr. Behbehani is from the Department of Surgery, Ophthalmology
Division, Faculty of Medicine, Kuwait University, and the Albahar Eye
Center; Drs. Owayed and Hijazi are from the Department of Pediatrics,
Faculty of Medicine, Kuwait University, and Mobarak Alkabeer Hospital;
and Drs. Eslah and Al-Jazzaf are from the Albahar Eye Center, Alsafat,
Kuwait.
Originally submitted October 15, 2003.
Accepted for publication January 7, 2004.
Address reprint requests to Abdulmutalib H. Behbehani, MD, FRCSC,
Department of Surgery, Ophthalmology Division, Faculty of Medicine,
Kuwait University, P.O. Box 24923, Alsafat 13110, Kuwait.
JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS
long course of oral steroids. Only 3 (3%) patients
had cortical changes that were not visually signif-
icant, and none had posterior subcapsular or
nuclear cataract. There was no significant differ-
ences between children with cataract and those
without cataract with respect to age; duration of
asthma; and duration, average daily dose, and
cumulative dose of inhaled steroids. IOP ranged
from 11 to 20 mm Hg (mean, 163 mm Hg).
None of the children had ocular hypertension or
glaucoma. Ninety patients underwent eye exami-
nation 2 years later; none was found to develop
posterior subcapsular cataract or increased IOP.
Conclusion: This study indicates the use of
inhaled steroids in children with asthma is prob-
ably safe as far as not inducing posterior subcap-
sular cataract or ocular hypertension.
J Pediatr Ophthalmol Strabismus 2005;42:23-27.
INTRODUCTION
The association between systemic steroid thera-
py and the development of posterior subcapsular
cataract in adults was first described in 1960.1 The
appearance of cataract in patients treated with topi-
cal ocular steroids was noted in 1963.2 Some reports
found an association between inhaled corticosteroid
and posterior subcapsular cataract, while others
failed to find this association.3-9 The use of cortico-
23
steroids, including oral glucocorticoids, periocular
steroid injections, topical steroids, and cortico-
steroid creams, lotions, or ointments placed on the
eyelids, face, or even remote sites, also has been
associated with ocular hypertension and open-angle
glaucoma.10,11 Some reports have suggested sys-
temic absorption of inhaled and nasal glucocorti-
coids may lead to ocular hypertension and open-
angle glaucoma.12-14
For children with asthma, inhaled steroids fre-
quently are used as one of the main modalities of
therapy. This modality of therapy is presumed to be
safer compared to systemic therapy. However, chil-
dren are probably at higher risk of developing
cataract or ocular hypertension and other side
effects of inhaled steroids compared to adults. The
reasons for this assumption are the early onset of
therapy, the potential longer duration of treatment,
and the sensitivity of the growing and young eye to
medication. In addition, the development of
cataract or glaucoma in young children can be
amblyogenic, resulting in a permanent decrease in
vision if not detected and treated properly. The
potential for developing cataract or glaucoma in
children with asthma on inhaled steroids has not
been completely excluded.
The purpose of the present study was to ascer-
tain the incidence of cataract and ocular hyperten-
sion in a cohort of children
12 years with asthma
who were being treated with inhaled steroids.
PATIENTS AND METHODS
This prospective cohort study was approved by
the hospitals Internal Review Board. A consultant
pediatric ophthalmologist prospectively and consec-
utively examined children attending the Asthma
Specialist Clinic at Mobarak Al Kabeer Hospital,
Alsafat, Kuwait. The examination included slit-
lamp biomicroscopy and direct and indirect oph-
thalmoscopy following pupillary dilatation with
tropicamide 0.5%. Intraocular pressure (IOP) was
measured before pupil dilatation when possible
using the Tonopen (Mentor, Norwell, MA) with or
without a small dose of 50 mg/kg of chloral hydrate
oral sedation. The presence or absence and the type
of lens changes (cataract) were recorded.
A detailed history of current and previous oral,
ocular, and inhaled corticosteroid therapy was
obtained by the attending pulmonologist but masked
24
from the ophthalmologist. The daily dose of inhaled
steroids was calculated and expressed in micrograms,
and the cumulative dose was calculated by adding up
the daily doses and expressed in milligrams. Two
types of inhaled steroids were used, beclomethasone
(Becotide, GSK, United Kingdom) 50 g/dose and
budesonide (Pulmicort, Astrazeneca, Sweden) 100
g/dose. Prednisolone was the oral steroid used when
needed. Patients were called to have another eye
examination 2 years after the initial one at the Al
Bahar Eye Center eye clinic by a different ophthal-
mologist who was masked from the findings of the
initial eye examination.
For statistical analysis, Fishers exact and two-
tailed t tests were performed using SPSS software ver-
sion 10.01 (SPSS Inc, Chicago, IL) and GraphPad
Instat 3.01 (GraphPad Software, San Diego, CA). A
P value
.05 was considered significant. All means
are reported with standard deviation.
RESULTS
Ninety-five patients with asthma who were on
inhaled corticosteroid therapy were examined for
the first time between January 2001 and June 2001.
Of the 95 patients, 62 were boys and 33 were girls
for a male:female ratio of 2:1. Age at time of first
examination ranged from 1.25 to 12 years (mean,
73 years). The duration of asthma ranged from
0.75 to 11 years (mean, 4.52 years), and the dura-
tion of inhaled steroid treatment ranged from 0.75
to 5.5 years (mean, 21 years). Forty-five patients
used budesonide, 42 used beclomethasone, and 8
patients used a combination of these during the
course of treatment. The daily dose of inhaled
steroids ranged from 100 to 1,050 g (mean,
574208 g), and the total cumulative dose of
inhaled steroids ranged from 90 to 2,068 mg
(mean, 473356 mg) (Table 1). Thirty-four (36%)
patients received inhaled steroids exclusively, 58
(61%) received inhaled steroids and a short course
(
2 weeks) of oral steroids, and 3 (3%) received a
long course of oral steroids (> 2 weeks) in addition
to the inhaled steroids; 2 of the 3 patients who
received a long course of oral steroids and inhaled
steroids also received short oral steroid courses.
Of the 95 children, changes in the lens
(cataract) of variable degrees were found in only 3
(3%) patients. All of the lens changes were cortical
and were not visually significant; no patient had
JANUARY/FEBRUARY 2005/VOL 42 NO 1
 TABLE 1 TABLE 2
TYPE AND DOSE OF INHALED STEROID THERAPY IN COMPARISON OF CHILDREN WITH ASTHMA ON
CHILDREN WITH ASTHMA (N = 95) INHALED CORTICOSTEROID THERAPY (N = 95)
WITH AND WITHOUT CATARACT
MeanSD MeanSD
Inhaled No. Daily Cumulative Cataract* No Cataract*
Steroid Patients Dose (g) Dose (mg) (n = 3) (n = 92) P Value
Budesonide 45 637225 398215 Age (years) 9.22.5 7.03.0 .213
Beclomethasone 42 486163 466340 Asthma duration 6.03.6 4.42.3 .246
Both 8 681146 933678 (years)
Total 95 574208 473356 Inhaled steroids
Duration (years) 3.01.7 2.21.1 .225
Daily dose (g) 50087 576210 .535
Total dose (mg) 530212 471361 .780
posterior subcapsular or nuclear changes. None of Oral steroids
the patients on inhaled steroids only or on long Short courses 2.71.5 1.61.7 .272
courses of oral steroids in addition to the inhaled Long courses 0 0.040.025 1.0
steroids had lens changes. All of the patients who *Given as meanSD.
had lens changes received short courses of oral
steroids in addition to the inhaled steroids. There
was no significant difference between patients with Delcourt et al.15 reported the use of oral cortico-
lens changes and those with no lens changes with steroids for at least 5 years and a history of asthma
respect to age; duration of asthma; and duration, or bronchitis in an adult population increased the
average daily dose, and cumulative dose of inhaled risk for cataract or cataract surgery. Oral steroids are
steroids (Table 2). There also was no significant dif- classically associated with posterior subcapsular
ference between the two groups with respect to their cataract.16 Posterior subcapsular cataract has been
oral steroid intake. reported to develop following as little as 5 mg pred-
IOP was measured with the Tonopen in all chil- nisolone daily and in as little as 2 months, although
dren. In children who were very young and unco- the usual time to onset is at least 1 year with a
operative, IOP was measured under chloral hydrate dosage equivalent to 10 mg/day of prednisolone.16
sedation (50 mg/kg). IOP was measured without The incidence of posterior subcapsular cataract
sedation in 83 patients and with sedation in 12 associated with steroids increases with increased
patients. IOP ranged from 11 to 20 mm Hg (mean, dosage and duration of treatment, but there is con-
163 mm Hg). Optic nerve examination was nor- siderable variation in susceptibility among individ-
mal in all of the patients, with no glaucomatous uals.17
optic disk observed in any of the children. Biological explanations for the effect of corti-
All 95 patients were called to schedule a follow- costeroids on the lens include inhibition of sodium-
up eye examination 2 years after the initial eye potassium pumps in the lens epithelium, leading to
examination. Ninety patients returned for this 2- accumulation of water within the lens fibers, and
year follow-up examination, including those with agglutination of lens proteins.18,19 It has been sug-
previously recorded cortical lens changes. None of gested the lens in children might be more sensitive
these 90 patients had posterior subcapsular cataract to the effects of corticosteroids than in adults.18,20,21
or increased IOP during this second eye examina- This might be explained by the large doses of oral
tion. The cortical changes observed previously in corticosteroids relative to the body size received by
three eyes of three children did not progress and children. Genetic factors have been proposed for
remained visually insignificant. predisposition to cataractogenesis.22
The association of inhaled corticosteroids and
DISCUSSION cataract is much less certain. In 1980, Kewley4 was
the first to report a case suggesting that inhaled
The association between systemic steroid thera- steroids might cause cataract. Cumming et al.3
py and the development of posterior subcapsular found a strong association between use of inhaled
cataract in adults was first described in 1960.1 corticosteroids and posterior subcapsular cataract or

JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS 25

 TABLE 3
COMPARISON OF PREVIOUS STUDIES ON THE RELATIONSHIP OF INHALED STEROID
THERAPY AND POSTERIOR SUBCAPSULAR CATARACT (PSC)
Mean Inhaled Mean PSC
Age Steroids Dosage PSC* Oral Inhaled
Authors Setting Population (years) (N) (g/day) (N) Steroid Steroids*
3
Cumming et al. Community Adult 65 158 486 22 Yes Yes
Toogood et al.5 Asthma clinic Adult 61 48 1,500 14 Yes No
Nassif et al.6 Asthma clinic Children 13 32 532 1 Yes No
Abuekteish et al.7 Asthma clinic Mixed 12 140 592 1 Yes No
Tinkelman et al.8 Asthma clinic Children 12 108 336 0 No No
Simons et al.9 Asthma clinic Children 14 95 750 0 No No
Current study Asthma clinic Children 7 95 574 0 Yes No
*Association between PSC and inhaled steroids.

nuclear cataract, but not cortical cataract in their
adult population. The effect was dose related as
heavy users (> 2 g of beclomethasone during their
lifetime) were at particularly high risk of having
posterior subcapsular cataract or nuclear cataract.
The strong association persisted when the analysis
was restricted to those participants who never used
oral corticosteroids. The association was believed to
be even stronger than that observed with oral
steroids, probably because the inhaled steroid acci-
dentally got onto the eye surface. Toogood et al.5
found no association between inhaled steroids and
the presence of cataract in their adult patients as all
of their patients with posterior subcapsular cataract
had also used oral corticosteroids.
Several relevant studies have been conducted in
children. Nassif et al.6 and Abuekteish et al.7 found
no association between the use of inhaled steroids
and cataract. All of their patients who developed
posterior subcapsular cataract had used oral steroids
in addition to the inhaled steroids. Studies in chil-
dren who used only inhaled steroids failed to show
such an association. Tinkelman et al.8 did not find
any cataract in 108 children treated only with
inhaled beclomethasone for 1 year, and Simons et
al.9 did not find cataract in 95 children treated only
with inhaled steroids for 5 years.
The failure of studies5-9 other than that by
Cumming et al.3 to find an association between
inhaled steroids and posterior subcapsular cataract
probably can be explained by their small sizes and
the fact that most participants had also used oral
corticosteroid. Nevertheless, the results of the
Cumming et al. study need to be replicated before
concluding with absolute certainty that inhaled cor-
ticosteroids can cause posterior subcapsular
cataract.23 The small studies of children with asth-
ma conducted to date have not found an associa-
tion, but this may be a false reassurance. The inci-
dence of cataract in children is unknown but is
certainly very low. Even if the incidence were as
high as 1 in 1,000 per year, a study would need to
include at least 2,200 children to detect even a 10-
fold increase in cataract incidence due to inhaled
corticosteroids (assuming that 50% of the children
used inhaled corticosteroids and 50% did not).23
In our study, none of our patients who were on
inhaled steroids only had any lens changes. The
safety of inhaled steroids in the children in our
study coincides with other previous reports6-9 (Table
3). Only three of our patients were found to have
lens changes, and all three used at least one course
of oral steroids. The lens changes in those children
were cortical and visually insignificant. The posteri-
or subcapsular changes that are typically seen in
patients on steroids were not found in any of our
children. The possibility that such minor cortical
lens changes observed in these children may be
unrelated to the steroids remains as other factors
including congenital lens opacity cannot be exclud-
ed. None of our children who were on long courses
of oral steroids were found to have cataract. We are
reassured that inhaled steroids have a low risk of
inducing visually significant lens opacities.
It is generally believed that glucocorticoids raise
IOP by increasing the resistance to aqueous humor
outflow.24-26 It is well established that steroids taken
as topical ophthalmic drops or ointments can pro-

26 JANUARY/FEBRUARY 2005/VOL 42 NO 1

duce ocular hypertension and secondary open-angle
glaucoma in susceptible individuals.10,11 Other
routes of corticosteroid administration also have
been implicated but to a lesser degree.10 The associ-
ation of ocular hypertension and open-angle glau-
coma with inhaled steroids is even less certain.
Some studies have suggested systemic absorption of
inhaled and nasal glucocorticoids may lead to ocu-
lar hypertension and open-angle glaucoma.12-14
Garbe et al.14 found this risk may be associated with
prolonged continuous use of high doses of inhaled
steroids. Both factors, high-dose administration and
prolonged duration of use, had to be present to ele-
vate the risk. High dose of inhaled steroid was
defined as an average daily dose of at least 1,500
g14 as doses
1,500 g in adults appear to have
little, if any, effect on pituitary adrenal function.27
IOP measurement was within normal range in all
children examined either during the initial or sub-
sequent examinations and so was their optic disk.
None of these children had changes in the optic
nerve head suggestive of glaucoma. Visual field
analysis was not performed. The absence of ocular
hypertension in any of the children we examined
coincide with the findings of Garbe et al.14 as the
average daily dose in our children was only 574 g
and the children took their medication only inter-
mittently.
CONCLUSION
The findings of this study indicate the use of
inhaled steroids in children with asthma is probably
safe as far as inducing posterior subcapsular cataract
or increased IOP.
REFERENCES
1. Black RL, Oglesby RB, Von Sallmann L, Bunim JL. Posterior
subcapsular cataracts induced by corticosteroids in patients with
rheumatoid arthritis. JAMA 1960;174:166-171.
2. Valerio M. Les dangers de la cortisonnotherapie locale prolongee.
Bull Mem Soc Fr Ophthalmol 1963;76:572-580.
3. Cumming RG, Mitchell P, Leeder SR. Use of inhaled cortico-
steroids and the risk of cataracts. N Engl J Med 1997;337:8-14.
4. Kewley GD. Possible association between beclomethasone dipro-
pionate aerosol and cataracts. Aust Paediatr J 1980;16:117-118.
JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS
5. Toogood JH, Markov AE, Baskerville J, Dyson C. Association of
ocular cataracts with inhaled and oral steroid therapy during
long-term treatment of asthma. J Allergy Clin Immunol 1993;
91:571-579.
6. Nassif E, Weinberger M, Sherman B, Brown K. Extrapulmonary
effects of maintenance corticosteroid therapy with alternate-day
prednisolone and inhaled beclomethasone in children with
chronic asthma. J Allergy Clin Immunol 1987;80:518-529.
7. Abuekteish F, Kirkpatrick JN, Russell G. Posterior subcapsular
cataract and inhaled corticosteroid therapy. Thorax 1995;50:674-
676.
8. Tinkelman DG, Reed CE, Nelson HS, Offord KP. Aerosol
beclomethasone dipropionate compared with theophylline as pri-
mary treatment of chronic, mild to moderately severe asthma in
children. Pediatrics 1993;92:64-77.
9. Simons FE, Persaud MP, Gillespie CA, Cheang M, Shuckett EP.
Absence of posterior subcapsular cataracts in young patients treat-
ed with inhaled glucocorticoids. Lancet 1993;342:776-778.
10. Skuta GL, Morgan RK. Corticosteroid-induced glaucoma. In:
Ritch R, Shields MB, Krupin T, eds. The Glaucomas. St Louis,
Mo: Mosby-Year Book; 1996:1177-1188.
11. Armaly MF. Corticosteroid glaucoma. In: Carins JE, ed.
Glaucoma. London, England: Grune and Stratton; 1986:697-710.
12. Opatowsky I, Feldman RM, Gross R, Feldman ST. Intraocular
pressure elevation associated with inhalation and nasal cortico-
steroids. Ophthalmology 1995;102:177-179.
13. Dreyer EB. Inhaled steroid use and glaucoma. N Engl J Med
1993;329:1822.
14. Garbe E, LeLorier J, Boivin JF, Suissa S. Inhaled and nasal gluco-
corticoids and the risk of ocular hypertension or open-angle glau-
coma. JAMA 1997;277:722-727.
15. Delcourt C, Cristol JP, Tessier C, Michel F, Papoz L. Risk factors
for cortical, nuclear, and posterior subcapsular cataracts: the
POLA study. Am J Epidemiol 2000;51:497-504.
16. Dulphy RG. Effect of inhaled beclomethasone dipropionate and
budesonide on adrenal function, skin changes and cataract for-
mation. Respir Med 1998;92:15-23.
17. Hanania NA, Chapman KR, Kesten S. Adverse effects of inhaled
corticosteroids. Am J Med 1995;98:196-208.
18. Urban RC, Coltier E. Corticosteroid-induced cataract. Surv
Ophthalmol 1986;31:102-110.
19. Karim AK, Jacob TJ, Thompson GM. The human lens epitheli-
um; morphological and ultrastructural changes associated with
steroid therapy. Exp Eye Res 1989;48:215-224.
20. Loredo A, Rodriguez RS, Murillo L. Cataract after short-term
corticosteroid treatment. N Engl J Med 1972;286:160.
21. Havre DC. Cataracts in children on long-term corticosteroids
therapy. Arch Ophthalmol 1965;48:215-224.
22. Fournier C, Milot JA, Clermont MJ, ORegan S. The concept of
cataractogenic factor revisited. Can J Ophthalmol 1990;25:345-
347.
23. Cumming RG, Mitchell P. Inhaled corticosteroids and cataract.
Drug Saf 1999;20:77-84.
24. Armaly MF. Effect of corticosteroid on intraocular pressure and
fluid dynamics, I: the effect of dexamethasone on the normal eye.
Arch Ophthalmol 1963;70:482-491.
25. Becker B, Mills DW. Corticosteroid and intraocular pressure.
Arch Ophthalmol 1963;70:500-507.
26. Kass MA, Johnson T. Corticosteroid-induced glaucoma. In: Rich
R, Shields MB, Krupin T, eds. The Glaucomas. St Louis, Mo: CV
Mosby; 1989:1161-1168.
27. Barners PJ. Inhaled glucocorticoids for asthma. N Engl J Med
1995;332:868-875.
27
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