Steroid-Induced Ocular Hypertension in a Pediatric Patient with Acute Lymphoblastic Leukemia: A Case Report

Abstract

Glucocorticoids play a pivotal role in therapeutic protocols in acute lymphoblastic leukemia (ALL) treatment. Systemic steroids are known to be less likely to elevate the intraocular pressure when compared to topical administration, and reports addressing hypertensive ocular response in the Asian pediatric ALL population are currently limited. We report a case of a nine-year-old girl with acute lymphoblastic leukemia (ALL) who was found to have highly elevated intraocular pressure (IOP) during maintenance treatment when taking oral dexamethasone (6 mg/m2/day). Her IOP increased on day 5 after taking dexamethasone, reached a peak on day 7 or 8, and returned back to baseline on day 13 before anti-glaucoma medications were used. Thus, we prescribed IOP-lowering agents for 10 consecutive days starting on the day oral dexamethasone was administered, and observed that not only did the peak levels lower remarkably, but the IOP levels returned to baseline more rapidly as well.

Corticosteroid-Induced Ocular Hypertension in Children and Adolescents With Acute Lymphocytic Leukemia and Non-Hodgkin Lymphoma: A Systematic Review

“…The third study, also a case report, by Lai et al 18 , nine-year-old girl with acute lymphoblastic leukemia who was referred by a pediatric hematologist with a 3-day history of bilateral blurred vision and mild intermittent headache during maintenance-phase chemotherapy. She was treated according to the Taiwan Pediatric Oncology Group protocol: prednisolone 40 mg/m 2 /day for 4 weeks during induction therapy and dexamethasone 12 mg/m 2 /day for 5 days every four weeks in the maintenance phase.…”

“…Of these, 6 were excluded 6,[11][12][13][14][15] . The 8 articles [16][17][18][19][20][21][22][23] remaining met the criteria and were included in the systematic review (Figure 1).…”

“…The 8 articles reviewed were a case report in abstract form 16 , published at the 25th Annual Meeting of the American Society of Pediatric Hematology/Oncology, 2012, New Orleans, Louisiana; and 7 complete studies, two case reports 17,18 , a series of 5 cases 19 , two prospective observational cohort studies -one with 55 patients20 and one with 90 patients 21 -and two retrospective observational studies -one with 54 22 and one with 12 patients 23 . All included studies were published in English and the presence of ocular hypertension was the assessed outcome.…”

“…In studies by Barzilai-Birenboim et al 21 , Chang et al 22 , Sugiyama et al 23 and Lai et al 18 , dexamethasone therapy was the most significant of the potential risk factors for ocular hypertension evaluated. Dexamethasone increases the protein load secreting extracellular matrix proteins in the endoplasmic reticulum (ER) of trabecular meshwork cells, thereby inducing chronic ER stress 24 and promoting IOP increase through transforming growth factor signaling β2 25 .…”

“…The treatment protocols for hematological neoplasms evaluated in this study [16][17][18][19][20][21][22][23] are based on high doses of corticosteroid therapy: prednisolone and/or dexamethasone.…”