Journal of Ophthalmology · 2 authors, 2 centres
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This systematic review and meta-analysis of 19 observational studies found that inhaled corticosteroid (ICS) use in asthma and COPD patients is associated with approximately a doubled risk of cataract development. A daily ICS dose of ≥1000 μg significantly increases cataract risk, and oral corticosteroids confer an even higher risk than ICS. These findings highlight the need to target ICS dosing to improve the risk-benefit ratio in maintenance treatment.
**Background:** Cataract is a leading cause of acquired blindness worldwide, and long-term systemic corticosteroid use has been linked to posterior subcapsular cataract. Inhaled corticosteroids (ICS) are a mainstay of asthma and COPD management, but their association with cataract risk remains debated. This systematic review and meta-analysis aimed to quantify the association between corticosteroid exposure (ICS and/or oral corticosteroids [OCS]) and cataract development in asthma and COPD patients.
**Methods:** A systematic literature search was conducted in PubMed and EMBASE (last updated March 2023) following PRISMA guidelines. Studies were included if they were original research published within the last three decades, reporting on cataract risk in asthma and/or COPD patients prescribed systemic and/or inhaled corticosteroids. Non-English publications and systematic reviews were excluded. Two authors independently screened studies and extracted data using the PICO approach. Quality assessment was performed using the Newcastle-Ottawa Scale (NOS) for cohort and case-control studies and an adapted NOS for cross-sectional studies. Meta-analyses were performed separately by study design (cohort, cross-sectional, case-control) using a random effects model to pool odds ratios (OR). Meta-regression assessed dose-response relationships. Sensitivity analyses and publication bias assessment (Harbord test, trim and fill) were conducted.
**Key Results:** Nineteen studies met inclusion criteria (total 1,274,878 individuals); 12 provided effect estimates for meta-analysis. All but one study reported a significant association between corticosteroid use and cataract. Pooled ORs were: cohort studies OR 1.60 (95% CI 1.11–2.31), cross-sectional studies OR 2.78 (95% CI 2.09–3.71), and case-control studies OR 2.0 (95% CI 0.93–4.30). Meta-regression confirmed a significant dose-response relationship (OR 1.99, 95% CI 1.39–2.88, p<0.001). Studies consistently showed that daily ICS dose ≥1000 μg substantially increased cataract risk (e.g., Cumming et al.: PSC OR 5.1, 95% CI 1.3–19.8; Jick et al.: RR 2.2, 95% CI 1.3–3.8). OCS exposure conferred higher risk than ICS alone (e.g., Derby et al.: RR 4.6, 95% CI 3.7–5.7 with ≥10 OCS prescriptions). Sensitivity analyses showed no single study unduly influenced results. Publication bias was suggested by funnel plot asymmetry (Harbord test p<0.01), but trim and fill analysis did not alter conclusions (adjusted OR 1.60, 95% CI 1.12–2.29).
**Clinical Implications:** ICS treatment in asthma and COPD is a significant risk factor for cataract, with a clear dose-response relationship. High daily doses (≥1000 μg) and frequent OCS use markedly increase risk. Clinicians should weigh the benefits of ICS against cataract risk, particularly in patients requiring high doses. Cataract screening may be warranted in patients on high-dose ICS or frequent OCS. Future research should focus on optimizing corticosteroid strategies to minimize long-term ocular adverse effects.