The clinical characteristics and risk factors of steroid-induced ocular hypertension following 23-gauge pars plana vitrectomy

The clinical characteristics and risk factors of steroid-induced ocular hypertension following 23-gauge pars plana vitrectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The clinical characteristics and risk factors of steroid-induced ocular hypertension following 23-gauge pars plana vitrectomy Shuanghong Jiang, Hongxia Yang, Jing Yuan, Ting Chen, Zhenyu Ji, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4775239/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study aimed to assess the incidence and risk factors for the development of steroid-induced ocular hypertension (SIOH) following 23-gauge (23G) pars plana vitrectomy. Methods The clinical data of patients treated with 23G vitrectomy from January 2019 to March 2022 was reviewed retrospectively. The incidence and characteristics of SIOH post-operatively and treatment were recorded. The clinical risk factors for developing SIOH were analyzed using logistic regression analysis. Results Among the 540 eligible patients, 111 (20.56%) cases developed SIOH. The majority (83.78%) of the SIOH cases developed between the third and seventh day postoperatively. Among these cases, 65 (58.56%) patients had an intraoperative pressure (IOP) of 30 mmHg or higher, and 31 (27.9%) had an IOP of 40 mmHg or higher. The IOP of all SIOH patients returned to normal within 1 month following the discontinuation of steroid and IOP-lowering medicine treatment. The independent risk factors for SIOH (IOP ≥23 mmHg) were myopia (odds ratio (OR) 5.22) and silicone oil filling (OR 8.20). For severe SIOH (IOP ≥30 mmHg) myopia and silicone oil filling were also identified as risk factors with an OR of 3.23 and 12.86, respectively. After adjusting the steroid administration pattern, the incidence of all SIOH and severe SIOH decreased to 17.11% and 9.14% respectively. Conclusions Myopia and silicone oil filling were identified as independent risk factors for the development of SIOH after vitrectomy. Reducing the duration of topical steroid therapy could potentially decrease the incidence of SIOH particularly in high-risk patients. steroid-induced ocular hypertension myopia silicon oil vitrectomy Introduction Raised intraocular pressure (IOP) is a common postoperative complication of vitrectomy. Topical steroids and antibiotics are often administered after a vitrectomy to reduce inflammation and risk of infection, thereby promoting better healing and visual outcomes. However, the administration of steroids has also been linked with the development of raised IOP ( 1 ). At our local center, we also observed that some patients developed high IOP accompanied by severe eye pain, headache, nausea, and vomiting following the administration of topical steroids. Elevated IOP usually normalizes within a few days after discontinuing the steroid treatment. However, raised IOP can result in optic nerve damage and potentially irreversible vision loss ( 2 ). Factors such as a family history of open-angle glaucoma, myopia, connective tissue disorders, and age have been linked with the development of raised IOP ( 3 ). In recent years at our center, we have replaced the 20-gauge (20G) vitrectomy system with the 23-gauge (23G) system. Compared to the 20G system, the smaller size of the 23G surgical instruments results in less invasive surgery, faster healing, reduced postoperative discomfort, and fewer complications. As a result, the 23G could potentially reduce the need for administering steroid treatment to reduce inflammation post-surgery ( 4 ). Although several studies evaluated the incidence of high IOP after vitrectomy, few studies assessed the risk factors that lead to steroid-induced ocular hypertension (SIOH). Therefore, in this study, we aimed to evaluate the incidence of SIOH following 23G vitrectomy. In addition, we also aimed to identify the risk factors for developing SIOH after 23G vitrectomy and the impact of early steroid discontinuation on IOP in patients at risk of developing SIOH. Methods Study subjects Adult patients who underwent vitrectomy in our hospital from January 2019 to March 2022 were eligible for the study. The exclusion criteria are as follows: preoperative glaucoma or ocular hypertension, ocular trauma, diabetic retinopathy, postoperative conditions including exudative anterior uveitis, elevated IOP caused by pupil block, anterior chamber or vitreous hemorrhage, and incision leakage (defined as IOP < 9 mmHg on the first day postoperative)( 5 ). Data collection The clinical characteristics of the patients including age, gender, medical history, diagnosis, pre-and postoperative IOP, presence of myopia, surgical method, and medication used were collected by reviewing the electronic medical records. In addition, the occurrence of high IOP and treatment after discharge reported at 1 month postoperatively at outpatient clinics were also recorded. Those patients who did not have follow-up reports were called up and asked whether their general practitioner had told them if they had raised IOP. Surgical procedure and postoperative management Most surgical procedures were performed under local retrobulbar anesthesia. Some patients were treated under general anesthesia. A standard scleral incision was made 3.5 mm posterior to the limbus corneoscleralis, and a three-channel closed 23G vitrectomy (Bausch & Lomb, USA) was performed. During the surgery, phacoemulsification, cryotherapy, intraocular laser photocoagulation, silicone oil filling, or filtered air filling were performed according to the patient's condition. For aphakic eyes, a 6-o’clock peripheral iridectomy was performed intraoperatively. Patients usually stayed in the hospital for 3 to 7 days for postoperative observation. After the surgery, patients who received silicone oil or filtered air filling were instructed to rest in the prone position. In addition, patients were also asked to apply tobramycin and dexamethasone eye drops three times daily to the operated eye, and tobramycin and dexamethasone ointment once every night for 2 weeks after surgery. Patients at risk of developing proliferative vitreoretinopathy were administered systematic prednisone (40 mg daily) for 1 to 3 days. Postoperative visual acuity, non-contact IOP measurements, and slit-lamp examinations of the anterior and posterior eye segments were performed. The patients were reviewed 2 weeks after surgery, and the steroid medication was discontinued and replaced with a nonsteroidal anti-inflammatory drop. Management of SIOH The IOP value was recorded as the average of three valid measurements. SIOH was defined as an IOP of 23 mmHg or higher that developed on the second days post-surgery before the discontinuation of tobramycin dexamethasone and controlled within 1 month following the discontinued administration of tobramycin dexamethasone and administering IOP-lowering drugs. Patients with SIOH (23 mmHg to 40 mmHg) were treated by discontinuing the use of tobramycin dexamethasone and the administration of topical IOP-lowering drugs including carteolol hydrochloride, brimonidine tartrate, and brinzolamide, while those with severe SIOH (IOP > 40 mmHg) were treated with topical IOP-lowering drugs and an additional dose of 20% mannitol intravenously. The risk factors for developing SIOH were identified by reviewing the data of SIOH patients treated with traditional steroids between January 2019 to July 2019 at our center. Based on these findings, all patients treated after December 2019 with a high risk of developing SIOH and a mild intraocular inflammatory response to steroids received a shorter duration of topical tobramycin and dexamethasone administration according to the patient’s needs. The latter patients were identified as the adjusted steroid group. Statistical analyses Univariate and multivariate logistic regression analyses were used to identify the risk factors for developing SIOH under the traditional medication model. The difference in the occurrence of SIOH between the traditional treatment group and the adjusted model was compared using the t-test or chi-square test. All statistical tests were performed using the Stata software version 15.0 and a P -value below 0.05 was considered statistically significant. Ethical considerations This research study was approved by the Institutional Review Board (WDRY2022-K123). Written informed consent was waived due to the retrospective nature of this study. Results Baseline characteristics of the participants A total of 540 patients were included in this study of whom 201 patients were treated using the traditional steroid method and 339 were treated with adjusted steroids. The average age of the patients was 57.50 ± 12.01 years. Males accounted for 50.56% of the participants. The pre-operative assessment showed that 34.81% were myopic. The average preoperative IOP was 15.86 ± 3.32 mmHg. The main indications for vitrectomy for the patients in this study were rhegmatogenous retinal detachment (54.44%), macular membrane and macular hole (18.52%), retinal vein occlusion with vitreous hemorrhage (9.44%), and isolated vitreous hemorrhage (4.44%). Incidence of SIOH post-surgery A total of 111 (20.56%) patients were diagnosed with SIOH post-surgery. Among them, 65 (58.56%) had an IOP of 30 mmHg and higher, and 31 (27.9%) had an IOP of 40 mmHg and higher. The average IOP elevation onset was 4.82 ± 1.89 days and ranged between 2 to 10 days. Notably, 83.78% of the cases occurred between the third and seventh day after surgery. After discontinuing the use of steroid eye drops and administering IOP-lowering medications, the IOP of all patients normalized within 1 month. Risk factors for SIOH The univariate analysis identified myopia, preoperative vitreous hemorrhage, cryotherapy, silicone oil, and gas filling as risk factors for developing SIOH (IOP ≥ 23 mmHg) and myopia, cryotherapy, and silicone oil filling as risk factors for developing severe SIOH (IOP ≥ 30 mmHg) (Table 1 ). Table 1 Univariate logistic regression of risk factors for SIOH in vitrectomy patients Factors IOP ≥ 23mmHg IOP ≥ 30mmHg OR (95%CI) P value OR (95%CI) P value Age (every 20 years) 0.67 (0.40–1.14) 0.145 0.74 (0.40–1.36) 0.343 Male vs female 1.05 (0.55–1.98) 0.873 1.20 (0.57–2.51) 0.626 Myopia vs non-myopia 5.92 (2.99–11.74) < 0.001 3.89 (1.80–8.38) 0.001 Vitreous hemorrhage preoperative 0.42 (0.18–0.96) 0.040 0.54 (0.21–1.40) 0.211 Phacoemulsification 0.85 (0.22–3.21) 0.812 1.51 (0.39–5.84) 0.543 Cryotherapy 2.13 (1.10–4.10) 0.024 2.61 (1.17–5.79) 0.018 Photocoagulation 1.93 (.86-4.31) 0.105 2.27 (.82-6.21) 0.110 Silicone oil filling 11.96 (3.56–40.13) < 0.001 21.02 (2.80-157.51) 0.003 Air filling 0.15 (0.04–0.68) 0.014 No case - Systemic use of steroid 0.75 (0.31–1.77) 0.514 0.37 (0.10–1.31) 0.126 SIOH = steroid-induced ocular hypertension. IOP = intraocular pressure. OR = odds ratio. CI = confidence interval. The multivariate analysis identified myopia (odds ratio (OR) 5.22) and silicone oil filling (OR 8.20) as independent risk factors for SIOH. For severe SIOH (IOP ≥ 30 mmHg) myopia and silicone oil filling were also identified as risk factors with an OR of 3.23 and 12.86, respectively (Table 2 ). Table 2 Multiple logistic regression of risk factors for SIOH in vitrectomy patients IOP ≥ 23mmHg IOP ≥ 30mmHg Factors OR(95%CI) P value OR(95%CI) P value Age (every 20 years) 1.14(0.61–2.10) 0.670 1.17(0.60–2.30) 0.631 Male vs female 0.87(0.41–1.90) 0.743 1.22(0.52–2.85) 0.642 Myopia vs non-myopia 5.22(2.39–11.40) < 0.001 3.23(1.36–7.68) 0.008 Cryotherapy 1.26(0.53–22.97) 0.585 1.70(0.64–4.52) 0.282 Silicone oil filling 8.20(2.22–30.20) 0.002 12.86(1.61–102.9) 0.016 SIOH = steroid-induced ocular hypertension. IOP = intraocular pressure. OR = odds ratio. CI = confidence interval. Comparison between the traditional and adjusted steroid treatment There was no significant difference in age, preoperative IOP, the proportion of myopia, and the number of cases with silicone oil filling between the two treatment groups at baseline. The patients in the traditional steroid group received an average of 9.80 ± 3.31 days of topical steroids and 0.37 ± 0.89 days of systemic steroids. The patients treated with adjusted steroid therapy received on average a shorter treatment (7.09 ± 3.14 days) of topical steroids and a longer treatment of systemic steroids (1.36 ± 1.77 days) (Table 3 ). After excluding patients who discontinued topical steroids due to SIOH, the myopic patients in the traditional steroid group received significantly more days of topical steroid treatment (10.86 ± 2.59 days versus 6.42 ± 2.96 days ( P = 0.004)). Similarly, the patients with silicone oil tamponade in the traditional treatment group received more days of topical steroid treatment when compared to the adjusted steroid group (10.88 ± 2.55 days and 7.03 ± 3.06 days P < 0.001). Table 3 Characteristics of the study population before and after control medication duration. Factors Traditional steroid administration Adjusted steroid administration P value Age, mean ± SD, years 57.66 ± 10.93 57.41 ± 12.63 0.814 Preoperative IOP, mean ± SD, mmHg 16.07 ± 3.28 15.74 ± 3.34 0.255 Gender, n(%) Male 114(56.72) 159(46.90) 0.027 Female 87(43.28) 180(53.10) Myopic eye 70(34.83) 118(34.81) 0.997 Days of topical steroids using, mean ± SD 9.80 ± 3.31 7.09 ± 3.14 < 0.001 Days of systemic steroids using, mean ± SD 0.37 ± 0.89 1.36 ± 1.77 < 0.001 Tamponade, n(%) Air 32(15.92) 91(26.84) 0.003 Silicone oil 135(67.16) 212(62.54) 0.278 SD = standard deviation. IOP = intraocular pressure. As shown in Table 4 , when compared with the traditional steroid group, the incidence of SIOH was significantly lower in the adjusted steroid group for both IOP of 23 mmHg or higher (26.37% versus 17.11%, P = 0.010 and IOP of 30 mmHg or higher (16.92% versus 9.14%, P = 0.007). The adjusted steroid group also had a longer mean average onset for SIOH than the traditional steroid group (5.26 ± 1.90 versus 4.43 ± 1.80 days P = 0.02) Table 4 SIOH related factor before and after change the topical steroid administration. Factors All Traditional steroid administration Adjusted steroid administration P value SIOH case IOP ≥ 23mmHg, n (%) 111(20.56) 53 (26.37) 58 (17.11) 0.010 SIOH case IOP ≥ 30mmHg, n (%) 65(12.03) 34(16.92) 31(9.14) 0.007 The day postoperative that SIOH occured, Mean ± SD 4.83 ± 1.89 5.26 ± 1.90 4.43 ± 1.80 0.020 SIOH = steroid-induced ocular hypertension. IOP = intraocular pressure. SD = standard deviation. Discussion SIOH is a common side effect following vitrectomy. Although the IOP of most patients with SIOH can be restored to normal levels by stopping steroid therapy, studies have shown that even a short-term state of high IOP may cause irreversible damage to the optic nerve and other tissues ( 6 , 7 ). The introduction of new more accurate surgical techniques may reduce the need for post-operative steroid treatment. Therefore in the study, we aimed to identify the risk factors for developing SIOH following vitrectomy to optimize the post-operative steroid dose for these patients. In our study, 20.56% of patients experienced SIOH and nearly 27.9% of the patients with SIOH experienced an IOP of 40 mmHg. Some of the SIOH patients suffered from significant eye pain accompanied by headache, vomiting, and other symptoms. Moreover, some patients developed asymptomatic elevated IOP, which was detected during routine follow-up visits. Although their IOP returned to normal later, glaucomatous optic disc atrophy was found months later in the clinic work. Cheng et al. ( 8 ) reported an SIOH incidence rate of 14.6% following a 20G vitrectomy, while Brennan et al. reported a 22% elevated IOP incidence rate within two weeks after a 23G vitrectomy ( 9 ). The slight difference in the SIOH incidence rate compared to that of our study might be due to different surgical techniques and definitions used to define high IOP. However, consistent with previous work, our findings highlight the importance of monitoring the IOP of patients treated with steroids to minimize the risk of damaging the eye ( 6 , 7 ). The onset and duration of raised IOP varied between studies. Roberti et al. noted that the onset of IOP can occur within a few hours to several years after chronic steroid use( 2 ). The IOP usually returned to normal within 1 to 4 weeks after stopping the medication ( 2 ). Cheng et al. ( 8 ) reported that SIOH occurred on average within 12 days post-surgery (range 4 to 20 days). In this study, cases of SIOH occurred 2 to 10 days after surgery, with about 83.78% of the cases occurring between the third and seventh day after surgery. In our study, we did not observe an onset of SIOH after 10 days post-surgery since the steroid treatment was discontinued 2 weeks after surgery. However, compared to previous studies, we observed a more rapid increase in the IOP within 24 hours. The differential response to steroids in our study may be attributable to genetic variations that influence the patients’ sensitivity to steroids ( 10 ). Consistent with previous work, in our study, myopia was identified as an independent risk factor for SIOH ( 2 , 3 , 11 ). Steroids may inhibit the trabecular meshwork cells' ability to phagocytose cellular debris, leading to debris blockage and subsequent obstruction of aqueous humor outflow and ultimately raised IOP ( 2 , 11 ). Cho et al. found that individuals with lower trabecular meshwork height (especially < 646.75 µm) are more prone to SIOH ( 12 ). Myopic patients tend to have a lower trabecular meshwork height and a larger Schlemm's canal( 13 ). Therefore these patients are more at risk of developing IOP. Silicon oil tamponade is one of the major causes of elevated IOP after vitrectomy ( 14 ). Although the mechanism behind the development of raised IOP in patients treated with silicon oil remains unclear, several confounding factors can increase the risk of developing SIOH. The silicon oil tamponade can cause inflammation and pupil block. In addition, the silicon oil may leak into the anterior chamber and increase the IOP. In the late postoperative stages, silicon oil emulsification( 15 ), anterior chamber angle closure( 16 ), and intraocular inflammation may further increase the risk of developing SIOH ( 17 ). Previous studies have confirmed that both standard and heavy silicon oil can lead to intraocular inflammation ( 18 ). Histopathological analysis of retinal samples indicates that silicon oil may cause a delayed type 4 hypersensitivity reaction( 18 ). Patients treated with silicone oil tamponade are more likely to have severe retinal detachment that requires a longer surgical duration and recovery time. Moreover, following the surgical procedure, the patient has to lie in a prone position to ensure the proper positioning of the silicone oil, enhance healing, and reduce the risk of complications. However, the prone position may increase the risk of developing IOP ( 19 ). This study has some limitations that have to be acknowledged. The diagnosis of myopia was not determined by the axial length of the eye, which may have resulted in the omission of a small number of patients with mild to moderate myopia. The 23G vitrectomy, as a suture-free incision technique, may have a higher risk of early scleral incision leakage compared to the 20G suture-tightened incision technique( 20 ), which may affect the accuracy of early postoperative IOP measurements. However, some studies have found no statistical difference in IOP between sutured and non-sutured 23G surgeries( 9 ). Finally, this study defined postoperative raised IOP as exceeding 23 mmHg, which may have missed some patients with low baseline IOP. Conclusion Myopia and silicone oil filling were identified as independent risk factors for SIOH after vitrectomy. Reducing the duration of topical steroid therapy can decrease the incidence of SIOH particularly in high-risk patients. Abbreviations IOP: intraocular pressure; SIOH: steroid-induced ocular hypertension; 23G: 23-gauge; OR: odds ratio; CI: confidence interval; SD: standard deviation; Declarations Ethics approval and consent to participate The ethics approval was obtained from the Renmin Hospital of Wuhan University and all research was conducted according to the tenets of the Declaration of Helsinki. Written informed consent was waived due to the retrospective nature of this study. Acknowledgments We would like to thank the ophthalmology medical staff involved in patient management, including surgeons, nurses, and others. We acknowledge TopEdit LLC for the linguistic editing and proofreading of this manuscript. Authors’ contributions Study conception and design were performed by S. J, X. Y, and data collection and analysis were performed by S. J, X. Y, H. Y, J. Y, T. C, and Z. J, all authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the Key Research and Development Program of Hubei Province (No. 2021BCA125). Author details Eye Center, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan, China. References Notivol R, Amin D, Whitling A, et al. Prophylactic effectiveness of tobramycin-dexamethasone eye drops compared with tobramycin/vehicle eye drops in controlling post-surgical inflammation in cataract patients : prospective, randomised, double-masked, two-arm, parallel-group, placebo-controlled, multicentre study. Clinical drug investigation. 2004;24(9):523-33. Roberti G, Oddone F, Agnifili L, et al. Steroid-induced glaucoma: Epidemiology, pathophysiology, and clinical management. Survey of ophthalmology. 2020;65(4):458-72. Phulke S, Kaushik S, Kaur S, et al. Steroid-induced Glaucoma: An Avoidable Irreversible Blindness. Journal of current glaucoma practice. 2017;11(2):67-72. Singh CN, Iezzi R, Mahmoud TH. Intraocular pressure instability after 23-gauge vitrectomy. Retina. 2010;30(4):629-34. Schweitzer C, Delyfer MN, Colin J, et al. 23-Gauge transconjunctival sutureless pars plana vitrectomy: results of a prospective study. Eye (London, England). 2009;23(12):2206-14. Tsai JC, Lin PW, Teng MC, et al. Longitudinal changes in retinal nerve fiber layer thickness after acute primary angle closure measured with optical coherence tomography. Invest Ophthalmol Vis Sci. 2007;48(4):1659-64. Kong JH, Park SP, Na KI. Differences in optic nerve head structure between acute angle-closure glaucoma and open-angle glaucoma. Sci Rep. 2023;13(1):7935. Ming C, Xiangge H. Research on corticoster induced ocular hypertension after vitreoretinal surgery. Journal of third military medical university. 2006(12):1339-41. Brennan N, Reekie I, Ezra E, et al. The role of day one postoperative review of intraocular pressure in modern vitrectomy surgery. The British journal of ophthalmology. 2017;101(9):1281-4. Kersey JP, Broadway DC. Corticosteroid-induced glaucoma: a review of the literature. Eye. 2006;20(4):407-16. Kersey JP, Broadway DC. Corticosteroid-induced glaucoma: a review of the literature. Eye (London, England). 2006;20(4):407-16. Won Jeong C, Yitak K, Jung Dong K, et al. Association of trabecular meshwork height with steroid-induced ocular hypertension. Sci Rep. 2023;13. Chen Z, Song Y, Li M, et al. Schlemm's canal and trabecular meshwork morphology in high myopia. Ophthalmic & physiological optics : the journal of the British College of Ophthalmic Opticians (Optometrists). 2018;38(3):266-72. Lexin G, Na S, Wen F, et al. Risk Factors and Management of Intraocular Pressure Elevation After Vitrectomy Combined with Silicone Oil Tamponade. Int J Gen Med. 2024;17. Teresio A, Vincenza B, Adelaide C, et al. Correlation between quantity of silicone oil emulsified in the anterior chamber and high pressure in vitrectomized eyes. Retina. 2002;22. Branisteanu D, Moraru A, Maranduca M, et al. Intraocular pressure changes during and after silicone oil endotamponade (Review). Experimental and therapeutic medicine. 2020;20(6):204. Francesco S, Andrea R, Francesco M, et al. Comparative assessment of intraocular inflammation following standard or heavy silicone oil tamponade: a prospective study. Acta Ophthalmol. 2018;97. Russo A, Morescalchi F, Donati S, et al. Heavy and standard silicone oil: intraocular inflammation. International ophthalmology. 2018;38(2):855-67. Sedgewick JH, Sedgewick JA, Sedgewick BA, et al. Effects of different sleeping positions on intraocular pressure in secondary open-angle glaucoma and glaucoma suspect patients. Clinical ophthalmology (Auckland, NZ). 2018;12:1347-57. Ahn SJ, Woo SJ, Ahn J, et al. Comparison of postoperative intraocular pressure changes between 23-gauge transconjunctival sutureless vitrectomy and conventional 20-gauge vitrectomy. Eye (London, England). 2012;26(6):796-802. 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Topical steroids and antibiotics are often administered after a vitrectomy to reduce inflammation and risk of infection, thereby promoting better healing and visual outcomes. However, the administration of steroids has also been linked with the development of raised IOP (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). At our local center, we also observed that some patients developed high IOP accompanied by severe eye pain, headache, nausea, and vomiting following the administration of topical steroids. Elevated IOP usually normalizes within a few days after discontinuing the steroid treatment. However, raised IOP can result in optic nerve damage and potentially irreversible vision loss (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Factors such as a family history of open-angle glaucoma, myopia, connective tissue disorders, and age have been linked with the development of raised IOP (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn recent years at our center, we have replaced the 20-gauge (20G) vitrectomy system with the 23-gauge (23G) system. Compared to the 20G system, the smaller size of the 23G surgical instruments results in less invasive surgery, faster healing, reduced postoperative discomfort, and fewer complications. As a result, the 23G could potentially reduce the need for administering steroid treatment to reduce inflammation post-surgery (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although several studies evaluated the incidence of high IOP after vitrectomy, few studies assessed the risk factors that lead to steroid-induced ocular hypertension (SIOH). Therefore, in this study, we aimed to evaluate the incidence of SIOH following 23G vitrectomy. In addition, we also aimed to identify the risk factors for developing SIOH after 23G vitrectomy and the impact of early steroid discontinuation on IOP in patients at risk of developing SIOH.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy subjects\u003c/h2\u003e \u003cp\u003eAdult patients who underwent vitrectomy in our hospital from January 2019 to March 2022 were eligible for the study. The exclusion criteria are as follows: preoperative glaucoma or ocular hypertension, ocular trauma, diabetic retinopathy, postoperative conditions including exudative anterior uveitis, elevated IOP caused by pupil block, anterior chamber or vitreous hemorrhage, and incision leakage (defined as IOP\u0026thinsp;\u0026lt;\u0026thinsp;9 mmHg on the first day postoperative)(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe clinical characteristics of the patients including age, gender, medical history, diagnosis, pre-and postoperative IOP, presence of myopia, surgical method, and medication used were collected by reviewing the electronic medical records. In addition, the occurrence of high IOP and treatment after discharge reported at 1 month postoperatively at outpatient clinics were also recorded. Those patients who did not have follow-up reports were called up and asked whether their general practitioner had told them if they had raised IOP.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure and postoperative management\u003c/h2\u003e \u003cp\u003eMost surgical procedures were performed under local retrobulbar anesthesia. Some patients were treated under general anesthesia. A standard scleral incision was made 3.5 mm posterior to the limbus corneoscleralis, and a three-channel closed 23G vitrectomy (Bausch \u0026amp; Lomb, USA) was performed. During the surgery, phacoemulsification, cryotherapy, intraocular laser photocoagulation, silicone oil filling, or filtered air filling were performed according to the patient's condition. For aphakic eyes, a 6-o\u0026rsquo;clock peripheral iridectomy was performed intraoperatively.\u003c/p\u003e \u003cp\u003ePatients usually stayed in the hospital for 3 to 7 days for postoperative observation. After the surgery, patients who received silicone oil or filtered air filling were instructed to rest in the prone position. In addition, patients were also asked to apply tobramycin and dexamethasone eye drops three times daily to the operated eye, and tobramycin and dexamethasone ointment once every night for 2 weeks after surgery. Patients at risk of developing proliferative vitreoretinopathy were administered systematic prednisone (40 mg daily) for 1 to 3 days. Postoperative visual acuity, non-contact IOP measurements, and slit-lamp examinations of the anterior and posterior eye segments were performed. The patients were reviewed 2 weeks after surgery, and the steroid medication was discontinued and replaced with a nonsteroidal anti-inflammatory drop.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eManagement of SIOH\u003c/h2\u003e \u003cp\u003eThe IOP value was recorded as the average of three valid measurements. SIOH was defined as an IOP of 23 mmHg or higher that developed on the second days post-surgery before the discontinuation of tobramycin dexamethasone and controlled within 1 month following the discontinued administration of tobramycin dexamethasone and administering IOP-lowering drugs. Patients with SIOH (23 mmHg to 40 mmHg) were treated by discontinuing the use of tobramycin dexamethasone and the administration of topical IOP-lowering drugs including carteolol hydrochloride, brimonidine tartrate, and brinzolamide, while those with severe SIOH (IOP\u0026thinsp;\u0026gt;\u0026thinsp;40 mmHg) were treated with topical IOP-lowering drugs and an additional dose of 20% mannitol intravenously.\u003c/p\u003e \u003cp\u003e The risk factors for developing SIOH were identified by reviewing the data of SIOH patients treated with traditional steroids between January 2019 to July 2019 at our center. Based on these findings, all patients treated after December 2019 with a high risk of developing SIOH and a mild intraocular inflammatory response to steroids received a shorter duration of topical tobramycin and dexamethasone administration according to the patient\u0026rsquo;s needs. The latter patients were identified as the adjusted steroid group.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analyses\u003c/h2\u003e \u003cp\u003eUnivariate and multivariate logistic regression analyses were used to identify the risk factors for developing SIOH under the traditional medication model. The difference in the occurrence of SIOH between the traditional treatment group and the adjusted model was compared using the t-test or chi-square test. All statistical tests were performed using the Stata software version 15.0 and a \u003cem\u003eP\u003c/em\u003e-value below 0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e This research study was approved by the Institutional Review Board (WDRY2022-K123). Written informed consent was waived due to the retrospective nature of this study.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics of the participants\u003c/h2\u003e \u003cp\u003eA total of 540 patients were included in this study of whom 201 patients were treated using the traditional steroid method and 339 were treated with adjusted steroids. The average age of the patients was 57.50\u0026thinsp;\u0026plusmn;\u0026thinsp;12.01 years. Males accounted for 50.56% of the participants. The pre-operative assessment showed that 34.81% were myopic. The average preoperative IOP was 15.86\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32 mmHg. The main indications for vitrectomy for the patients in this study were rhegmatogenous retinal detachment (54.44%), macular membrane and macular hole (18.52%), retinal vein occlusion with vitreous hemorrhage (9.44%), and isolated vitreous hemorrhage (4.44%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIncidence of SIOH post-surgery\u003c/h2\u003e \u003cp\u003eA total of 111 (20.56%) patients were diagnosed with SIOH post-surgery. Among them, 65 (58.56%) had an IOP of 30 mmHg and higher, and 31 (27.9%) had an IOP of 40 mmHg and higher. The average IOP elevation onset was 4.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89 days and ranged between 2 to 10 days. Notably, 83.78% of the cases occurred between the third and seventh day after surgery. After discontinuing the use of steroid eye drops and administering IOP-lowering medications, the IOP of all patients normalized within 1 month.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRisk factors for SIOH\u003c/h2\u003e \u003cp\u003eThe univariate analysis identified myopia, preoperative vitreous hemorrhage, cryotherapy, silicone oil, and gas filling as risk factors for developing SIOH (IOP\u0026thinsp;\u0026ge;\u0026thinsp;23 mmHg) and myopia, cryotherapy, and silicone oil filling as risk factors for developing severe SIOH (IOP\u0026thinsp;\u0026ge;\u0026thinsp;30 mmHg) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate logistic regression of risk factors for SIOH in vitrectomy patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIOP\u0026thinsp;\u0026ge;\u0026thinsp;23mmHg\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eIOP\u0026thinsp;\u0026ge;\u0026thinsp;30mmHg\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (every 20 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.67 (0.40\u0026ndash;1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.74 (0.40\u0026ndash;1.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.343\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale vs female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.05 (0.55\u0026ndash;1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.20 (0.57\u0026ndash;2.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.626\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyopia vs non-myopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.92 (2.99\u0026ndash;11.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e3.89 (1.80\u0026ndash;8.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVitreous hemorrhage preoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.42 (0.18\u0026ndash;0.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.54 (0.21\u0026ndash;1.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhacoemulsification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.85 (0.22\u0026ndash;3.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.812\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e1.51 (0.39\u0026ndash;5.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.543\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCryotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.13 (1.10\u0026ndash;4.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.61 (1.17\u0026ndash;5.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhotocoagulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.93 (.86-4.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e2.27 (.82-6.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSilicone oil filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.96 (3.56\u0026ndash;40.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e21.02 (2.80-157.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAir filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15 (0.04\u0026ndash;0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eNo case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystemic use of steroid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.75 (0.31\u0026ndash;1.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e0.37 (0.10\u0026ndash;1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eSIOH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;steroid-induced ocular hypertension. \u003cem\u003eIOP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;intraocular pressure. \u003cem\u003eOR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;odds ratio. \u003cem\u003eCI\u003c/em\u003e\u0026thinsp;=\u0026thinsp;confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe multivariate analysis identified myopia (odds ratio (OR) 5.22) and silicone oil filling (OR 8.20) as independent risk factors for SIOH. For severe SIOH (IOP\u0026thinsp;\u0026ge;\u0026thinsp;30 mmHg) myopia and silicone oil filling were also identified as risk factors with an OR of 3.23 and 12.86, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple logistic regression of risk factors for SIOH in vitrectomy patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eIOP\u0026thinsp;\u0026ge;\u0026thinsp;23mmHg\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eIOP\u0026thinsp;\u0026ge;\u0026thinsp;30mmHg\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR(95%CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eOR(95%CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (every 20 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.14(0.61\u0026ndash;2.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1.17(0.60\u0026ndash;2.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.631\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale vs female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87(0.41\u0026ndash;1.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.743\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1.22(0.52\u0026ndash;2.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyopia vs non-myopia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.22(2.39\u0026ndash;11.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e3.23(1.36\u0026ndash;7.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCryotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.26(0.53\u0026ndash;22.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.585\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1.70(0.64\u0026ndash;4.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.282\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSilicone oil filling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.20(2.22\u0026ndash;30.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e12.86(1.61\u0026ndash;102.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eSIOH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;steroid-induced ocular hypertension. \u003cem\u003eIOP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;intraocular pressure. \u003cem\u003eOR\u003c/em\u003e\u0026thinsp;=\u0026thinsp;odds ratio. \u003cem\u003eCI\u003c/em\u003e\u0026thinsp;=\u0026thinsp;confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComparison between the traditional and adjusted steroid treatment\u003c/h2\u003e \u003cp\u003eThere was no significant difference in age, preoperative IOP, the proportion of myopia, and the number of cases with silicone oil filling between the two treatment groups at baseline. The patients in the traditional steroid group received an average of 9.80\u0026thinsp;\u0026plusmn;\u0026thinsp;3.31 days of topical steroids and 0.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89 days of systemic steroids. The patients treated with adjusted steroid therapy received on average a shorter treatment (7.09\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14 days) of topical steroids and a longer treatment of systemic steroids (1.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77 days) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After excluding patients who discontinued topical steroids due to SIOH, the myopic patients in the traditional steroid group received significantly more days of topical steroid treatment (10.86\u0026thinsp;\u0026plusmn;\u0026thinsp;2.59 days versus 6.42\u0026thinsp;\u0026plusmn;\u0026thinsp;2.96 days (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004)). Similarly, the patients with silicone oil tamponade in the traditional treatment group received more days of topical steroid treatment when compared to the adjusted steroid group (10.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.55 days and 7.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.06 days \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the study population before and after control medication duration.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional steroid administration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdjusted steroid administration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.66\u0026thinsp;\u0026plusmn;\u0026thinsp;10.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.41\u0026thinsp;\u0026plusmn;\u0026thinsp;12.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.814\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative IOP, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.07\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.74\u0026thinsp;\u0026plusmn;\u0026thinsp;3.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e114(56.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e159(46.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87(43.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e180(53.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyopic eye\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70(34.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118(34.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDays of topical steroids using, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.80\u0026thinsp;\u0026plusmn;\u0026thinsp;3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.09\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDays of systemic steroids using, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTamponade, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAir\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32(15.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91(26.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSilicone oil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135(67.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e212(62.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;standard deviation. \u003cem\u003eIOP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;intraocular pressure.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, when compared with the traditional steroid group, the incidence of SIOH was significantly lower in the adjusted steroid group for both IOP of 23 mmHg or higher (26.37% versus 17.11%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010 and IOP of 30 mmHg or higher (16.92% versus 9.14%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.007). The adjusted steroid group also had a longer mean average onset for SIOH than the traditional steroid group (5.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90 versus 4.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80 days \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSIOH related factor before and after change the topical steroid administration.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTraditional steroid administration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdjusted steroid administration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSIOH case IOP\u0026thinsp;\u0026ge;\u0026thinsp;23mmHg, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111(20.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (26.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58 (17.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSIOH case IOP\u0026thinsp;\u0026ge;\u0026thinsp;30mmHg, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65(12.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34(16.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31(9.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe day postoperative that SIOH occured, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.26\u0026thinsp;\u0026plusmn;\u0026thinsp;1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eSIOH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;steroid-induced ocular hypertension. \u003cem\u003eIOP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;intraocular pressure. \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSIOH is a common side effect following vitrectomy. Although the IOP of most patients with SIOH can be restored to normal levels by stopping steroid therapy, studies have shown that even a short-term state of high IOP may cause irreversible damage to the optic nerve and other tissues (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The introduction of new more accurate surgical techniques may reduce the need for post-operative steroid treatment. Therefore in the study, we aimed to identify the risk factors for developing SIOH following vitrectomy to optimize the post-operative steroid dose for these patients.\u003c/p\u003e \u003cp\u003eIn our study, 20.56% of patients experienced SIOH and nearly 27.9% of the patients with SIOH experienced an IOP of 40 mmHg. Some of the SIOH patients suffered from significant eye pain accompanied by headache, vomiting, and other symptoms. Moreover, some patients developed asymptomatic elevated IOP, which was detected during routine follow-up visits. Although their IOP returned to normal later, glaucomatous optic disc atrophy was found months later in the clinic work. Cheng et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) reported an SIOH incidence rate of 14.6% following a 20G vitrectomy, while Brennan et al. reported a 22% elevated IOP incidence rate within two weeks after a 23G vitrectomy (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The slight difference in the SIOH incidence rate compared to that of our study might be due to different surgical techniques and definitions used to define high IOP. However, consistent with previous work, our findings highlight the importance of monitoring the IOP of patients treated with steroids to minimize the risk of damaging the eye (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe onset and duration of raised IOP varied between studies. Roberti et al. noted that the onset of IOP can occur within a few hours to several years after chronic steroid use(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The IOP usually returned to normal within 1 to 4 weeks after stopping the medication (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Cheng et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) reported that SIOH occurred on average within 12 days post-surgery (range 4 to 20 days). In this study, cases of SIOH occurred 2 to 10 days after surgery, with about 83.78% of the cases occurring between the third and seventh day after surgery. In our study, we did not observe an onset of SIOH after 10 days post-surgery since the steroid treatment was discontinued 2 weeks after surgery. However, compared to previous studies, we observed a more rapid increase in the IOP within 24 hours. The differential response to steroids in our study may be attributable to genetic variations that influence the patients\u0026rsquo; sensitivity to steroids (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsistent with previous work, in our study, myopia was identified as an independent risk factor for SIOH (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Steroids may inhibit the trabecular meshwork cells' ability to phagocytose cellular debris, leading to debris blockage and subsequent obstruction of aqueous humor outflow and ultimately raised IOP (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Cho et al. found that individuals with lower trabecular meshwork height (especially\u0026thinsp;\u0026lt;\u0026thinsp;646.75 \u0026micro;m) are more prone to SIOH (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Myopic patients tend to have a lower trabecular meshwork height and a larger Schlemm's canal(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Therefore these patients are more at risk of developing IOP.\u003c/p\u003e \u003cp\u003eSilicon oil tamponade is one of the major causes of elevated IOP after vitrectomy (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Although the mechanism behind the development of raised IOP in patients treated with silicon oil remains unclear, several confounding factors can increase the risk of developing SIOH. The silicon oil tamponade can cause inflammation and pupil block. In addition, the silicon oil may leak into the anterior chamber and increase the IOP. In the late postoperative stages, silicon oil emulsification(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), anterior chamber angle closure(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and intraocular inflammation may further increase the risk of developing SIOH (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Previous studies have confirmed that both standard and heavy silicon oil can lead to intraocular inflammation (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Histopathological analysis of retinal samples indicates that silicon oil may cause a delayed type 4 hypersensitivity reaction(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Patients treated with silicone oil tamponade are more likely to have severe retinal detachment that requires a longer surgical duration and recovery time. Moreover, following the surgical procedure, the patient has to lie in a prone position to ensure the proper positioning of the silicone oil, enhance healing, and reduce the risk of complications. However, the prone position may increase the risk of developing IOP (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study has some limitations that have to be acknowledged. The diagnosis of myopia was not determined by the axial length of the eye, which may have resulted in the omission of a small number of patients with mild to moderate myopia. The 23G vitrectomy, as a suture-free incision technique, may have a higher risk of early scleral incision leakage compared to the 20G suture-tightened incision technique(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), which may affect the accuracy of early postoperative IOP measurements. However, some studies have found no statistical difference in IOP between sutured and non-sutured 23G surgeries(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Finally, this study defined postoperative raised IOP as exceeding 23 mmHg, which may have missed some patients with low baseline IOP.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMyopia and silicone oil filling were identified as independent risk factors for SIOH after vitrectomy. Reducing the duration of topical steroid therapy can decrease the incidence of SIOH particularly in high-risk patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eIOP: intraocular pressure;\u003c/p\u003e\n\u003cp\u003eSIOH: \u0026nbsp;steroid-induced ocular hypertension;\u003c/p\u003e\n\u003cp\u003e23G: 23-gauge;\u003c/p\u003e\n\u003cp\u003eOR: odds ratio;\u003c/p\u003e\n\u003cp\u003eCI: confidence interval;\u003c/p\u003e\n\u003cp\u003eSD: standard deviation;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethics approval was obtained from the Renmin Hospital of Wuhan University and all research was conducted according to the tenets of the Declaration of Helsinki.\u0026nbsp;Written informed consent was waived due to the retrospective nature of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We would like to thank the ophthalmology medical staff involved in patient management, including surgeons, nurses, and others. We acknowledge TopEdit LLC for the linguistic editing and proofreading of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eStudy conception and design were performed by S. J, X. Y, and data collection and analysis were performed by S. J, X. Y, H. Y, J. Y, T. C, and Z. J, all authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u0026nbsp;\u003c/strong\u003eThis research was funded by the Key Research and Development Program of Hubei Province (No. 2021BCA125).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEye Center, Renmin Hospital of Wuhan University, 238\u003c/p\u003e\n\u003cp\u003eJiefang Road, Wuhan, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNotivol R, Amin D, Whitling A, et al. Prophylactic effectiveness of tobramycin-dexamethasone eye drops compared with tobramycin/vehicle eye drops in controlling post-surgical inflammation in cataract patients : prospective, randomised, double-masked, two-arm, parallel-group, placebo-controlled, multicentre study. Clinical drug investigation. 2004;24(9):523-33.\u003c/li\u003e\n \u003cli\u003eRoberti G, Oddone F, Agnifili L, et al. Steroid-induced glaucoma: Epidemiology, pathophysiology, and clinical management. Survey of ophthalmology. 2020;65(4):458-72.\u003c/li\u003e\n \u003cli\u003ePhulke S, Kaushik S, Kaur S, et al. Steroid-induced Glaucoma: An Avoidable Irreversible Blindness. Journal of current glaucoma practice. 2017;11(2):67-72.\u003c/li\u003e\n \u003cli\u003eSingh CN, Iezzi R, Mahmoud TH. Intraocular pressure instability after 23-gauge vitrectomy. Retina. 2010;30(4):629-34.\u003c/li\u003e\n \u003cli\u003eSchweitzer C, Delyfer MN, Colin J, et al. 23-Gauge transconjunctival sutureless pars plana vitrectomy: results of a prospective study. Eye (London, England). 2009;23(12):2206-14.\u003c/li\u003e\n \u003cli\u003eTsai JC, Lin PW, Teng MC, et al. Longitudinal changes in retinal nerve fiber layer thickness after acute primary angle closure measured with optical coherence tomography. Invest Ophthalmol Vis Sci. 2007;48(4):1659-64.\u003c/li\u003e\n \u003cli\u003eKong JH, Park SP, Na KI. Differences in optic nerve head structure between acute angle-closure glaucoma and open-angle glaucoma. Sci Rep. 2023;13(1):7935.\u003c/li\u003e\n \u003cli\u003eMing C, Xiangge H. Research on corticoster induced ocular hypertension after vitreoretinal surgery. Journal of third military medical university. 2006(12):1339-41.\u003c/li\u003e\n \u003cli\u003eBrennan N, Reekie I, Ezra E, et al. The role of day one postoperative review of intraocular pressure in modern vitrectomy surgery. The British journal of ophthalmology. 2017;101(9):1281-4.\u003c/li\u003e\n \u003cli\u003eKersey JP, Broadway DC. Corticosteroid-induced glaucoma: a review of the literature. Eye. 2006;20(4):407-16.\u003c/li\u003e\n \u003cli\u003eKersey JP, Broadway DC. Corticosteroid-induced glaucoma: a review of the literature. Eye (London, England). 2006;20(4):407-16.\u003c/li\u003e\n \u003cli\u003eWon Jeong C, Yitak K, Jung Dong K, et al. Association of trabecular meshwork height with steroid-induced ocular hypertension. Sci Rep. 2023;13.\u003c/li\u003e\n \u003cli\u003eChen Z, Song Y, Li M, et al. Schlemm\u0026apos;s canal and trabecular meshwork morphology in high myopia. Ophthalmic \u0026amp; physiological optics : the journal of the British College of Ophthalmic Opticians (Optometrists). 2018;38(3):266-72.\u003c/li\u003e\n \u003cli\u003eLexin G, Na S, Wen F, et al. Risk Factors and Management of Intraocular Pressure Elevation After Vitrectomy Combined with Silicone Oil Tamponade. Int J Gen Med. 2024;17.\u003c/li\u003e\n \u003cli\u003eTeresio A, Vincenza B, Adelaide C, et al. Correlation between quantity of silicone oil emulsified in the anterior chamber and high pressure in vitrectomized eyes. Retina. 2002;22.\u003c/li\u003e\n \u003cli\u003eBranisteanu D, Moraru A, Maranduca M, et al. Intraocular pressure changes during and after silicone oil endotamponade (Review). Experimental and therapeutic medicine. 2020;20(6):204.\u003c/li\u003e\n \u003cli\u003eFrancesco S, Andrea R, Francesco M, et al. Comparative assessment of intraocular inflammation following standard or heavy silicone oil tamponade: a prospective study. Acta Ophthalmol. 2018;97.\u003c/li\u003e\n \u003cli\u003eRusso A, Morescalchi F, Donati S, et al. Heavy and standard silicone oil: intraocular inflammation. International ophthalmology. 2018;38(2):855-67.\u003c/li\u003e\n \u003cli\u003eSedgewick JH, Sedgewick JA, Sedgewick BA, et al. Effects of different sleeping positions on intraocular pressure in secondary open-angle glaucoma and glaucoma suspect patients. Clinical ophthalmology (Auckland, NZ). 2018;12:1347-57.\u003c/li\u003e\n \u003cli\u003eAhn SJ, Woo SJ, Ahn J, et al. Comparison of postoperative intraocular pressure changes between 23-gauge transconjunctival sutureless vitrectomy and conventional 20-gauge vitrectomy. Eye (London, England). 2012;26(6):796-802.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"steroid-induced ocular hypertension, myopia, silicon oil, vitrectomy","lastPublishedDoi":"10.21203/rs.3.rs-4775239/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4775239/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e This study aimed to assess the incidence and risk factors for the development of steroid-induced ocular hypertension (SIOH) following 23-gauge (23G) pars plana vitrectomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e The clinical data of patients treated with 23G vitrectomy from January 2019 to March 2022 was reviewed retrospectively. The incidence and characteristics of SIOH post-operatively and treatment were recorded. The clinical risk factors for developing SIOH were analyzed using logistic regression analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Among the 540 eligible patients, 111 (20.56%) cases developed SIOH. The majority (83.78%) of the SIOH cases developed between the third and seventh day postoperatively. Among these cases, 65 (58.56%) patients had an intraoperative pressure (IOP) of 30 mmHg or higher, and 31 (27.9%) had an IOP of 40 mmHg or higher. The IOP of all SIOH patients returned to normal within 1 month following the discontinuation of steroid and IOP-lowering medicine treatment. The independent risk factors for SIOH (IOP ≥23 mmHg) were myopia (odds ratio (OR) 5.22) and silicone oil filling (OR 8.20). For severe SIOH (IOP ≥30 mmHg) myopia and silicone oil filling were also identified as risk factors with an OR of 3.23 and 12.86, respectively. After adjusting the steroid administration pattern, the incidence of all SIOH and severe SIOH decreased to 17.11% and 9.14% respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e Myopia and silicone oil filling were identified as independent risk factors for the development of SIOH after vitrectomy. Reducing the duration of topical steroid therapy could potentially decrease the incidence of SIOH particularly in high-risk patients.\u003c/p\u003e","manuscriptTitle":"The clinical characteristics and risk factors of steroid-induced ocular hypertension following 23-gauge pars plana vitrectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-20 07:21:38","doi":"10.21203/rs.3.rs-4775239/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ba017a3-cc15-4b9d-96f2-95ed227e56ff","owner":[],"postedDate":"August 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-23T18:23:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-20 07:21:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4775239","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4775239","identity":"rs-4775239","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}