Systemic tolerance of corticosteroid therapy in ophthalmology depending on the route of administration

Corticosteroids have been a major therapeutic improvement, particularly in ophthalmology. Depending on the different therapeutic modalities used, the ophthalmologist will mainly encounter a risk of short-term adverse effects (intravenous administration, high doses, etc.) or a risk of long-term side effects (related to the cumulative dose received). In any case, the underlying status of each patient must be carefully assessed in order to choose the best individual treatment modalities that will minimize the risk of undesirable effects. Intravitreal and topical steroid administrations do not seem to be associated with a significant risk of systemic adverse effects, because blood diffusion of the product is minimal. Conversely, periocular injections lead to a rapid and nearly total systemic diffusion of the steroid, with hyperglycemic effects similar to those observed after intravenous pulse methylprednisolone. Thus, periocular and intravenous routes of administration carry similar risks of systemic effects and both cases require similar monitoring, with strict blood glucose monitoring useful in diabetic patients only. The various systemic complications of long-term oral steroid therapy can be reduced by always prescribing the minimal efficient dosage for controlling the disease, together with preventive measures against adverse effects when possible, e.g., the prevention of corticosteroid-induced osteoporosis. In the future, new glucocorticoids or agonists, e.g., the dissociated glucocorticoids or SEGRAs (SElective Glucocorticoid-Receptor Agonists), now in clinical development, should further reduce the risk of adverse effects of steroids while maintaining their remarkable anti-inflammatory action.