1. CORTICOSTEROIDS
IN
OPHTHALMOLOGY
Dr PAAVAN KALRA
Department of Ophthalmology,
S P Medical College, Bikaner

2. INTRODUCTION

3. • Steroids are molecules
having GONANE nucleus
• Produced in body from cholesterol
• Adrenal Cortex – Glucocorticoids ( Cortisol ),
Mineralocorticoids ( Aldosterone ), weak Androgens
• Testes – testosterone
• Ovary & Placenta – Oestrogens and progesterone
• Glucocorticoids ( Cortisol ) have a wide range of Physiologic
roles involving metabolism and hemostasis.
• A major component of response to STRESS Stimulus
• Apart from replacement therapy in Adrenocortical
deficiency, Supra Physiologic doses have been used
extensively in medicine for treatment of spectrum of
disorders (natural & synthetic)

4. • 1930 – Swingle, Pfiffner, Hartman – prepared
adrenocortical extracts
• 1935 – Kendall isolated cortisone in lab
• 1942 – Reichstein and Shoppee – chemical structure of
steroids
• 1949 – Hench – first clinical use of steroids –
Rheumatoid arthritis
• 1950 – Cordon and Mclean – introduced steroids into
ocular therapy

5. BASIC PATHOPHYSIOLOGY

6. INFLAMMATION

7. INFLAMMATION

8. CHRONIC INFLAMMATION AND FIBROSIS

9. GRANULOMATOUS INFLAMMATION

10. MEDIATORS

11. MEDIATORS

12. AUTO IMMUNITY

13. TYPE - I HYPERSENSITIVITY

14. TYPE IV HYPERSENSITIVITY

15. ALLOGRAFT REJECTION

16. EICOSANOIDS

17. VEGF
increase in trancytosis – increased permeability in
inflammed or chronic hypoxic tissues
proliferation of endothelial cells – granulation tissue and
fibrosis

18. MECHANISM OF ACTION

19. MECHANISM OF ACTION
• ..DownloadsVideoAnimation explaining mechanism of action
of glucocorticoids.flv

20. • GLUCOCORTICOID RECEPTOR - Member of nuclear
receptor superfamily
carboxyl end  binds ligand ( steroid)
middle region  Zn fingers (9 cysteine residues) bind
to pallindromic sequence in GRE
(promotor DNA)
amino terminal  activation of Transcription by RNA
polymerase II

21. • COREGULATORS
 bridge with other nuclear factors like
NF- kB and AP1 – affect transcription
of other genes – TRANSREPRESSION
 enzymes for acetylation / deacetylation of Histones –
altering structure of nucleosomes
• ONSET OF ACTION – 90 to 120 mins
• DURATION - long

22. • Constriction of blood vessels & reduction in permeability
• Inhibition of macrophage recruitment and migration
• Reduction in circulating monocytes, basophils,
eosinophils and lymphocytes. However neutrophilic
leukocytosis occur
• Decrease in expression of adhesion molecules (ICAM)
over endothelium
• Decrease in Diapedesis
• Stability of basophil, mast cell, neutrophil intracellular
granules

23. • Decrease in Antigen Presentation
• T lymphocyte function and proliferation affected more
than B lymphocytes
(cell mediated immunity)
• Suppression of Fibroplasia

25. ROUTES OF DELIVERY
• Topical – skin ointments
eye drops
eye ointments
• Peri Ocular Injections –
sub conjunctival
sub tenon – anterior and posterior
retrobulbar
• Intra Vitreal – injections
implants
• Systemic – Oral
Parenteral – iv, im

26. SYSTEMIC ADMINISTRATION

27. SYSTEMIC PHARMACOKINETICS
• Well absorbed orally
• i v route – water soluble compounds like Hydocortisone
hemisuccinate, dexamethasone sod phosphate
• i m route – both water soluble or insoluble compounds like
hydrocortisone acetate, triamcinolone acetonide etc given
depending upon duration of effect desired
• Hydrocortisone is 90 % bound to plasma proteins – CBG
and albumin
• Metabolized by hepatic microsomal enzymes –
reduction/hydroxylation/oxidation followed by conjugation.
• Metabolites excreted in urine – major form is 17 keto
compound
• Biologic t ½ is much longer than Plasma t ½

28. • Systemic corticosteroids are the initial drug of choice for
most patients with bilateral endogenous sight threatening
uveitis.
• Prednisone/prednisolone is the most commonly used oral
corticosteroid
• Initial dose 1-2 mg/kg/day
• Maximum adult oral dose 60 – 80 mg/day
• Maintenance dose (adult) = 10mg/day
• Single morning dose after breakfast, if possible on alternate
days
• Combined with proton pump inhibitors or anti H 2 anti
histaminics

29. SYSTEMIC SIDE EFFECTS
• Sodium and water retention, hypokalaemic hypochloremic
alkalosis
• Rise in BP
• Edema occurs in cases of hypoproteinemia, renal disease,
liver disease
• Heart failure in compromised myocardial function
• Cushing’s Habitus – rounded face (moon face), narrow
mouth, supraclavicular hump, obesity of trunk with relatively
thin limbs –iatrogenic cushing’s syndrome occurs >100 mg
hydrocort / day
• Fragile skin, striae, telangiectasias, hirsutism , acne
• Growth retardation in children
• Diabetes MellitusHyperlipidemia
• Secondary amenorrhoea

30. • Muscle weakness
• Osteoporosis
• Avascular necrosis
• Nausea
• Peptic ulceration
• Pancreatitis
• Intestinal perforation
• Hypomania, insomnia, acute psychosis, later depression
• Raised intracranial tension – pseudotumor cerebri
• Delayed healing
• Flaring up of latent infections especially TB/ acquisition
of secondary infections – fungal (opportunistic)
• Thrombosis

31. • Steroids in pregnancy – category C
Fetal abnormalities
• Nursing mothers – secretion into breast milk
Adrenocortical suppression and growth
retardation in child

32. OCCULAR SIDE EFFECTS
• cataract
• occular hypertension and glaucoma
• secondary infections
• retardation of wound healing – post operative
• inhibition of corneal epithelial & stromal
healing – corneal melting
• central serous retinopathy
• exophthalmos
• pseudotumor cerebri

33. HPA AXIS SUPPRESSION
• If systemic steroid given for more than 2-3 weeks
• HPA suppression due to feedback mechanisms
• sudden stoppage precipitates acute adrenocortical
deficiency. Tapering of dose has to be done to avoid this
During tapering, glucocorticoid dependence may
manifest nausea, vomiting, weight loss, lethargy,
headache, fever, muscle pain , postural hypotension

34. • During acute stress, dose has to be increased
even if stressful event occurs months after tapering has
been done
• Many patients achieve normal serum cortisol levels in
less than one year of stopping steroids but in majority of
cases, the ability to respond to stress by increase in
steroid levels remains hampered for upto 2 years
Minor – 2 fold maintenance dose for 24-48 hrs
Major – 10 fold maintenancedose for 48-72 hrs
• If patients on steroids develop systemic infection,
steroids should not be discontinued. Dose needs to be
increased along with addition of specific antimicrobial.

35. GENERAL GUIDELINES
• Use local therapy wherever possible.
• A single dose ( even excessive ) is not harmful – can tide
over mortal crisis even when benefit is not certain
• Short courses ( even high doses ) are not likely to be
harmful in the absence of contradictions
• Long term use is potentially hazardous – duration and dose
to be kept at minimum, which is found by trial and error.
• High doses to begin with, in severe diseases, titrating
downwards acc to response whereas low doses to begin
with, in mild diseases, titrating upwards.
• If chronic use beyond 1 month, addition of immuno -
suppresants to be considered
• No abrupt stoppage after use for 2-3 weeks

36. • TAPERING SCHEDULE for oral prednisolone
> 40mg/day, decrease by 10mg/day every 1-2 weeks
40–20mg/day, decrease by 5mg/day every 1-2 weeks
20–10mg/day, decrease by 2.5mg/day every 1-2 weeks
10-1 mg/day, decrease by 1-2.5mg/day every 1-4 weeks

37. • EVALUATION
Chest X Ray
Tuberculin test
Assessment of DM, osteoporosis, peptic ulcer,
psychological disturbances, cardiovascular status, renal
and hepatic status
• MONITOR-Blood Pressure, Weight, Blood Glucose level
every 3 months and annually.
Measure bone density within first 3 months and annually
thereafter. Supplementary treatment - Calcium 1500 mg
daily andVitamin D 400 IU daily. Bisphosphonates and
Estrogens as needed.
Increased potassium and protein intake

38. I V METHYL PREDNISOLONE PULSE
selected cases where immediate effect is needed
1 g/day or 250 mg q 6 hrly, slow I v infusion X 3 days
Followed by oral prednisolone
Temporarily “switches off ” the IMMUNE SYSTEM
Optic neuritis
Severe corneal graft rejection
Severe sight threatening posterior uveitis
Sympathetic ophthalmitis
VKH

39. PRECAUTIONS
• Should be given under ICU settings
• Monitoring of BP and pulse every 15 – 20 mins
• Electrolyte imbalances and ECG changes likely to occur

40. TOPICAL ADMINISTRATION

41. TOPICAL PHARMACOKINETICS
• Topical – eye drops – solutions and suspensions –
hydrochloride, phosphates, alcohol, acetates
- eye ointments
- drug depots on ocular surface – cotton pledgets
and collagen shields – steady sustained and
slow release

42. EXTENT OF ABSORPTION INTO CORNEA AND
ANTERIOR CHAMBER
time for which drug remains in cul de sac and tear film
flow to lacrimal passage
binding to taer proteins
Metabolism by tear and external tissues
status of corneal epithelium and stroma
type of steroid and its solubility
concentration
osmolarity, pH, viscosity, vehicle, size of particles
dosing frequency

43. • CORNEA  TRILAMINAR STRUCTURE
• Corneal and aqueous humor concentrations - Studies in
animal models –
• Keratitis with intact epithelium – Pred acetate > pred
sod phosphate > dexamethasone alcohol. No
dexamethasone sod phosphate was absorbed
• Keratitis with denuded epithelium – Pred sod
phosphate > dexamethasone sod pshpate > pred
acetate
• Intraocular inflammation with intact corneal epithelium
– Pred acetate = pred sod phosphate =
dexamethasone sod phosphate

45. • CONCENTRATION : Prednisolone e/d 1% vs 0.125 %
• DOSING FREQUENCY

46. • PREDNISOLONE SOLUTION VS PREDNISOLONE
SUSPENSION
 equivalent for intra ocular inflammation models (anterior
uveitis)
 rabbit keratitis model shows superiority of prednisolone
acetate over prednisolone sod phosphate
But sophisticated mathematical models show equivalence
 in practice efficacy of suspension(pred acetate) is
assumed to be lower due to lack of patient compliance in
shaking well before instillation

47. • OINTMENT VERSUS DROPS
Dexamethasone phosphate ointment had lower
penetration into cornea and aqueous humor than
solution because of slow release of drug molecule
Whereas FML ointment produced similar concentrations
as suspension
• VEHICLE – cyclodextrin (Gate-Dx, Apdrops-Dx)
improves corneal penetration of dexamethasone

48. • TYPE OF STEROID
-FML 0.1 % and 0.25 % has much less corneal
penetration but is comparable to Prednisolone 1% in
alleviating corneal inflammation
 gets concentrated in corneal epithelium
-Loteprednol ( modification of prednisolone ) –
undergoes rapid hydrolysis by esterase in anterior
chamber. Effective for corneal and conjunctival
inflammations
-Medrysone 1% – very low penetration of cornea –
discontinued by FDA – used earlier for mild conjunctival
inflammations

49. • SYSTEMIC ABSORPTION after topical treatment is
considerable – through conjunctiva, nasal mucosa and
aqueous humor
By passes hepatic metabolism
 suppression of adrenal cortex after 6 weeks of topical
0.1 % dexamethasone phosphate
 elevation of blood glucose levels in controlled diabetics

50. OCCULAR SIDE EFFECTS
• occular hypertension and glaucoma
• secondary infections – viral keratitis, fungal keratitis,
toxoplasmosis
• retardation of post operative wound healing
• inhibition of corneal epithelial & stromal
healing – corneal melting
• cataract
• uveitis
• mydriasis
• ptosis
• Toxic to cornea, conjunctiva, skin e g punctate keratopathy
• hypersensitivity

51. PRECAUTIONS AND CONSIDERATIONS
-for initial prescription and renewal beyond 14 days - to rule
out infective pathology especially viral, fungal,
mycobacterial- Slit Lamp biomicroscopy and fluorescein
staining if necessary
-Re evaluate if no improvement in 2 days of start of therapy
-Any drug used beyond 10 days – monitoring of IOP
-Suspicion of fungal infection in long term therapy –
cultures may have to be taken
-To remove contact lens before instillation and re insertion
after 15 mins – absorption of BAK by CL
-Separate bottle for other eye in case of post op treatment
-to be SHAKEN WELL
- Storage b/w 8 – 25 deg celsius
- No abrupt withdrawl – to prevent rebound flaring up

52. PERIOCULAR INJECTIONS

53. High concentrations at site of inflammation without systemic
toxicity
To be given close to site of inflammation
Eliminates daily compliance
Blood – ocular barrier limits diffusion
INDICATIONS – resistent anterior uveitis, intermediate
uveitis, posterior uveitis, CME (mainly unilateral)
especially in patients contraindicated to systemic steroids
CONTRAINDICATIONS – conditions associated with scleral
thinning like scleritis – scleral perforation may occur
PRECAUTIONS – to rule out steroid responders
- and infections

54. SUBCONJUNCTIVAL Inj– absorption directly across the
sclera as compared to sub conjunctival antibiotics
soluble drugs for sub conjunctival inj – insoluble drug will give
unsightly appearance and will lead to irritation
SUB TENON(ANTERIOR and POSTERIOR) – suspensions
are used for better absorption
depot steroids :
Inj Depo Medrone(methyl pred acetate) (0.5ml of 80mg/ml)
Inj Kenalog (triamcinolone acetonide)
effect lasts for 1-2 weeks

55. COMPLICATIONS RELATED TO TECHNIQUE
perforation of globe and intraocular injection
sub conjunctival hemorrhage
retrobulbar hemorrhage
Extraocular muscle fibrosis
scarring between conjunctiva and globe

56. INTRAVITREAL INJECTIONS

57. • More targeted delivery
• Controlled and consistent
• Immediate achievement of therapeutic concentration
• By passes BLOOD OCULAR barrier
• Reduced systemic toxicity
• Compliance eliminated

58. Dexamethasone – very short half life – 3-4 hours
Triamcinolone acetonide– longer half life.
4 mg inj : detectable after 3 months
effect upto 6 months
earlier TRICORT and KENACORT Inj – Benzyl alcohal
newer preservative free FDA approved preparations
TRIVARIS (80mg/ml) – 0.05 ml : Uveitis
TRIESCENCE (40mg/ml) – 0.025 to 0.1 ml :
visualization of tissues ILM, ERM in VR
surgery

59. • Off label uses of IVTA
ARMD
Diabetic Retinopathy
Venous Occlusions
Pseudophakic Macular Edema
Proliferative vitreoretinopathy

60. • IVTA Injection
Tranconjunctivally, 3.5 – 4 mm from limbus,
inferotemporally
26 / 27 / 30 guage needle over tuberculin syringe
Under direct visualization : dilated pupils required
Immediately afterwards – CRA pulsations are
checked by IDO
IOP measured after 30 mins
Biomicroscopy after 3 and 7 days

61. • Inj ANECORTAVE Acetate for ARMD

62. • IMPLANTS
RETISERT – 0.59 mg Fluocinolone acetonide
Sustained Release implant for chronic non infectious
posterior uveitis
implanted through pars plana incision, after vitrectomy
lasts for 30 months : has to be removed
ILUVIEN – half of retisert : FAME study for DR : not
approved yet
OZURDEX – 0.7 mg dexamethasone in injectable,
biodegradable implant for macular edema after CRVO
& BRVO and non infectious chronic posterior uveitis.
lasts upto 6 weeks

64. COMPLICATIONS DUE TO TECHNIQUE
Sub conjunctival hemorrhage
vitreous hemorrhage
traumatic cataract
Vitreous detachment
retinal detachment
pseudo endophthalmitis / pseudo hypopyon
(more likely in aphakia and pseudophakia)
sterile endophthalmitis ( benzyl alcohol related )
infective endophthalmitis
dislocation of implant

65. INDICATIONS

66. • As Post-operative treatment- In most intraocular & ocular
surface surgeries, topical CSd are usually given
according to the severity of inflammation for few days to
weeks.
Refractive surgery, corneal surgery, intraocular surgery,
glaucoma surgery ( prevents scarring)
Delayed wound healing in cataract surgery may lead to
bleb formation

67. • Periorbital Dermatitis (Atopic, Contact, Irritant,
Seborrheic).
Most patients benefit from short course of CSd ointment
application for 1-2 weeks.

68. • Allergic conjunctivitis (Hay fever, AKC, VKC, GPC,
Phlyctenular)-
Topical CSd are used only as 2nd or 3rd line drugs CSd
bring dramatic improvement with potential side effects..
Use diluted CSd (e.g. 0.01% Dexamethasone or
0.12%Prednisolone) or ‘milder’ CSd (e.g.
Flurometholone, Loteprednol) as pulse therapy (4-8x/day
for 1 week followed by fast tapering).
Tear substitutes, Antihistamine vasoconstrictor
combination, Mast cell stabilizers are the first line drugs
generally.

69. • Chronic Adenoviral Keratoconjunctivitis-
Topical CSd only temporarily resolve the subepithelial
infiltrates without affecting the clinical course.
• Herpetic (H. simplex) stromal keratitis-
CSd contraindicated in any form of active epithelial
keratitis while topical diluted CSd (1:10 dexamethasone)
bd/tds is useful for stromal disease (immunological
basically)
given along with prophylactic antiviral treatment.

70. • Scleritis-
Topical steroids are not effective unlike in episcleritis.
Periocular steroids are contraindicated (chances of
scleral thinning & perforation).
oral Prednisolone is given for 2-3 weeks followed by
slow tapering.

71. • Corneal chemical injury-
topical steroids, qid to 2 hourly depending upon the
severity) for the first week only followed by shifting to
topical NSAIDs.
Risk of corneal melting/ulceration is very minimal in the
first week of chemical injury. After which corneal stromal
repair is inhibted

72. • Herpes Zoster Keratitis-
Topical CSd are used for stromal keratitis & uveitis.
Sometimes also used for epithelial keratitis, cautiously
topical CSd don’t increase viral replication in Zoster
epithelial keratitis.
Pseudodendrites are present (elevated mucous plaques)
that are fluorescein stain negative.

73. • Corneal graft rejection-
Topical CSd every hourly for endothelial rejection.
Topical CSd 4x/day for epithelial rejection (relatively
benign).
Systemic CSd, if topical CSd fail or recurrence occurs.
For severe rejection (generalised corneal edema), IV
methyl Pred (pulse steroid therapy) is given along with
intensive topical CSd (1 hourly).
• Also as prophylaxis

74. • Anterior uveitis-
In acute non-granulomatous uveitis, topical pred acetate
drops every 1-6 hourly depending on the severity.
Periocular steroids are used for noncompliant patients.

75. • Intermediate uveitis
i) Topical CSd are not much effective. Might be given
along with periocular CSd.
ii) Periocular CSd (posterior subtenon’s injection of
combination of steroid depot
iii) Systemic CSd is required in bilateral cases or those
with severe inflammation.
Generally no treatment is required if visual acuity is >/=
6/12..

76. • Posterior uveitis-
Non-specific posterior uveitis needs oral prednisolone
Very severe cases may need IV Methylpred pulse.
posterior subtenon depot inj,
IVTA(TRIVARIS),
Depot CSd implants (RETISERT & OZURDEX)
• VKH, sarcoidosis, sympathetic ophthalmitis – systemic
(oral) therapy. I v methyl prednisolone pulse may haveto
be given

77. • Postoperative endophthalmitis)
i)In early endophthalmitis, along with antibiotics, give
topical prednisolone 1-2 hrly or I-Vit Dexamethasone
(0.4 mg) with antibiotic.(role controversial)
ii) Late endoph (starting after a week) - Avoid all CSd
until fungus infection is ruled out & patient is definitely
responding to antibiotics.

78. • Thyroid eye disease-
oral Prednisolone 1-2mg/kg/ D for significant proptosis
causing exposure keratopathy, significant diplopia or
vision loss because of optic neuropathy..

79. • Orbital pseudotumour-
Early & aggressive systemic therapy is the mainstay of
treatment.
For recurrent & non-responding cases, retrobulbar or
intralesional CSd injection may be tried.
Low dose orbital irradiation & immunosuppressives are
the alternatives

80. • Optic neuritis-
If patient seen early, IV methyl prednisolone pulse
therapy followed by oral prednisolone 1 mg/kg/D
X11days with tapering over a week.
Oral CSd not recommended, recurrences become
commoner (ONTT study).
IV CSd offers- Reduced recurrence rate, Shortened
visual recovery time, But no long term visual benefit
Only observe, in cases of recurrent ON or known case of
multiple sclerosis.

81. • Arteritic Ischemic optic neuropathy-
suspicion of Giant Cell Arteritis in a case of AION,
immediately start pulse steroid therapy, followed by oral
prednisolone for 2- 4 weeks if temporal artery biopsy is
positive, thereafter maintaining for 6 months to a year
(monitor ESR).
Blindness from GCA is usually permanent & CSd
basically help to prevent it in the other eye as the
contralateral eye can get involved within 24 hours

82. • Optic nerve injury-
Immediately institute ‘Mega’ intravenous methyl-pred
doses like that for spinal cord injuries. Loading dose of
30mg/kg by slow IV infusion followed by maintenance
dose of 5.4mg/kg every hour for 48 hours. Followed by
oral prednisolone
Monitor the visual acuity & relative afferent pupillary
defect (RAPD) closely.

83. OCULAR HYPERTENSION
• Increase in IOP when applied locally or given systemically.
• IOP elevation may lead to optic nerve damage & changes in
visual field similar to POAG.
• Incidence of ocular hypertension – 5 % in patients with no
family history of POAG ; upto 90% in patients with positive
history
• Mostly reversible on stopping, but long term usage may lead
to permanent elevations.
• Mucopolysaccharide deposition in trabecular meshwork.
• Gene involved – GLC1A / TIGR / MYOC on ch 1q21 – 1q31

84. • Development of softer topical steroids –
FML (0.1 % and 0.25 %)
Loteprednol (0.2 % and 0.5 %)
Rimexolone
Less percentage of patients developing ocular HTN and
that too after longer duration compared to
dexamethasone 0.1% or prednisolone 1%
structure activity studies indicate close relationship
between anti inflammatory potency and occular
hypertensive effect

85. • PRECAUTIONS
Regular IOP and Optic Disc monitoring, if steroids are
used for than 10 days, INCLUDING ‘SOFTER’ TOPICAL
DRUGS
Analysis of Risk Benefit ratio in cases already diagnosed
with POAG
Identification of steroid responders before PERIOCULAR
and INTRAVITREAL injections – effect of 6 weeks of
therapy with topical Dexamethasone 0.1 %
• MANAGEMENT
Require concurrent anti glaucoma medication
Removal of implants/periocular depot, vitrectomy in case
of IVTA, and trabeculectomy may have to be
undertaken.

86. CATARACT
• Development of posterior subcapsular cataract reported
more commonly in literature with long term systemic
therapy
• Recent Advances - intravitreal implants(RETISERT and
OZURDEX) and multiple intravitreal injections (IVTA) -
upto 100 % incidence
• Incidence correlates with the dose and duration of
systemic therapy
• 75 % patients >16mg/day prednisolone develop PSC
• Dose of 10 mg/day for 1 year have minimal risk
• Long term topical therapy also at risk e.g. vernal & atopic
Keratoconjunctivitis, keratoplasty for keratoconus
• Irreversible changes in lens due to binding of steroid
molecules with lens fibres and biochemical alterations
• Enhanced by concomitant Diabetes Mellitus

87. • Children are particularly at risk
• Cataract progresses despite stopping treatment
• Periodic slit lamp examination is recommended

88. CONCLUSION
• 2 edged swords
• Effect of Steroids are non specific, palliative and never
curative
• Concomitant specific treatment has to given
• Appropriate Use relies on good clinical judgement and
close watch on complications
• Newer molecules having higher selectivity for anti
inflammatory activity
• Newer methods of drug delivery

89. REFERENCES
• Goodman and Gilman : Pharmacological Basis of
therapeutics – 12th ed (2011)
• Katzung : Basic & Clinical Pharmacology – 11th ed (2011)
• K D Tripathi : Pharmacology - 6th Ed (2010)
• Albert Jakobiec : Principles & Practice of Ophthalmology in
ch 23 Corticosteroids in practice – 3rd ed (2008)
• Robbins : Pathologic Basis of Diseases – 8th ed (2012)
• Corticosteroids in ophthalmology- overview : DOS Times-
vol 12, no 8 ( 2007)
• Steroids & immunosuppressives in Ophth : Kerela Journal of
Ophthalmology – vol 18, no 3 (2006)

90. • Steroids for posterior segment : delivery systems &
indications : DOS Times – Vol 10, No 4 (2004)
• Intravitreal steroids in retinal disorders : DOS Times, vol
11, no 4 ( 2005)
• Corticosteroid implant for vascular occlusions : DJO - vol
22, no 2 (2011)
• www.fda.gov

91. THANK YOU