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SUMMARYSteroid creams applied topically to the skin are routinely used in the treatment of many dermatoses. Their use on the face in severe atopic eczema is relatively common. We report a series of three patients who whilst using topical facial steroids developed advanced glaucoma. A further two cases of ocular hypertension secondary to topical facial steroids are also described. This is the first series of cases to be reported demonstrating the potentially blind ing complications of topical facial steroids. Recommend ations are made with regard to screening such patients for glaucoma.The risk of glaucoma with the use of topical steroid to the eye is well known.I-3 The risk associated with systemic steroids, although uncommon, has been described.4,5 Glaucoma developing secondary to the use of topical ster oids to the face, first described in 1975 by Cubey,6 has attracted little attention; to our knowledge the literature contains only a few isolated case reports. 7,8 The real risk of visual loss in young people who use steroid preparations to their face remains unrecognised. We describe the first series of patients who developed an elevation in intra ocular presssure (lOP) secondary to the use of topical facial steroids. They presented between June 1991 and September 1992; three were found to have advanced glau coma and a further two had ocular hypertension. CASE REPORTS Case 1A 24-year-old Asian man presented with a history of blurred vision in the left eye. He had eczema involving the skin of the face including the eyelids and had been using 0.25% desoxymethasone cream on these areas for over 2 years. On examination unaided visual acuities were 6/5 right and 6/60 left, with no improvement on refraction. He had a left relative afferent pupillary defect and the lOPs were 44 mmHg right and 74 mmHg left. On gonioscopy there was no angle abnormality, and both anterior chamber angles were wide open (Shaffer grade III to IV). Both optic discs exhibited extensive pathological cupping (cup/ disc ratio 0.8 right, 0.95 left). Goldman perimetry revealed marked glaucomatous visual field defects in both eyes, particularly on the left. On discontinuing the steroids and with the use of guttae timolol 0.5%, the right lOP was con trolled. The left eye, however, failed to respond to topical treatment, necessitating a trabeculectomy. Although this controlled the lOP, 12 months following presentation the patient was totally blind in his left eye. Case 2A 23-year-old Chinese man presented with a 6-month history of gradual visual loss affecting his left eye. He had severe atopic eczema of the periorbital skin, for which he had been using 1 % hydrocortisone cream intermittently for about 12 years. On examination, with a myopic correc tion of -6.75 D sphere, visual acuities were 6/5 right and 6/36 left. His lOPs were 28 mmHg right and 54 mmHg left. He had a left posterior subcapsular cataract. There was no gonioscopic abnormality found and both anterior chamber angles were open (Shaffer grade III). On fun doscopy both optic discs were ...

Aim-The authors investigated the safety and intraocular pressure (IOP) lowering eVectiveness of trabeculectomy augmented with mitomycin C application beneath the scleral flap, and assessed the influence of preoperative risk factors on the surgical outcome. Methods-A retrospective study of 72 consecutive high risk eyes undergoing trabeculectomy with adjunctive mitomycin C (0.2 mg/ml) applied under the scleral flap for 5 minutes was performed. Each eye was ascribed a score based on the number of preoperative risk factors, and categorised into one of three risk factor groups. Success was described as unqualified where IOP was < 21 mm Hg without medication and qualified where antiglaucomatous therapy was required to maintain it at such a level. A life table analysis of IOP control was calculated. Results-The mean IOP (SD) fell from a preoperative level of 28.4 (6.9) to a level of 16.63 (8.06) mm Hg at the last follow up (paired Student's t test: p< 0.0001). Fifty two eyes (72%) were classed as unqualified successes. The survival rates did not differ significantly between diVerent risk factor groups (log rank test: 2 = 0.967, p>0.1). The incidence of postoperative complications compared favourably with reports of mitomycin C application between Tenon's capsule and the undissected scleral bed. Conclusion-The results illustrate that mitomycin C applied beneath the scleral flap during trabeculectomy in high risk eyes is associated with a success rate comparable to other modes of application. The incidence of potentially serious complications such as conjunctival wound leak and prolonged hypotony was lower than previously published data reporting subTenon's administration of mitomycin C. The number and nature of preoperative risk factors do not appear to influence the surgical outcome. A possible mechanism of action is proposed. (Br J Ophthalmol 1998;82:397-403)

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