Abstract
To The Editor:
C
We report the case of an adolescent who developed hypomania during treatment with topical steroid eye drops, which resolved after cessation of the steroid and adding quetiapine treatment.
Case Report
A, a 15-year-old male, had ocular surgery (secondary intraocular lens implantation) and started using a topical steroid (fluorometholone 0.1%) eye drops for three times a day postoperatively. He referred to our outpatient clinic 10 days after the operation and reported a 7 day history of insomnia, extreme irritability, and restlessness. He had a decreased need for sleep (3–4 hours of sleep per night) compared with his usual sleep habits (7–8 hours of sleep per night). His parents reported that he had developed aggressiveness and hostility toward them. His motor and verbal activity increased markedly. During the clinical interview, he displayed psychomotor agitation and was restless, verbally aggressive, and irritable. In his psychiatric assessment he was cooperative; oriented; and aware of the time, place, and the people around him. He did not show grandiosity or report delusions or hallucinations. He did not report drug or alcohol use and had no known drug allergy. He had a past history of attention-deficit/hyperactivity disorder and had received methylphenidate treatment when he was 10 years old for 2 years. His mother had a history of depression.
He and his parents reported that his psychiatric complaints began immediately 2 days after the ocular surgery and commencement of topical fluorometholone eye drops. After consultation with his physician, the fluorometholone was discontinued and quetiapine (100 mg/day) was administered for his insomnia and agitation. All his psychiatric symptoms resolved rapidly 1 week after, and quetiapine was ceased in the 3rd month.
According to the clinical picture and history of the presented case, we gave a diagnosis of steroid-induced hypomania. There was a clear temporal association between the use of the topical steroid and onset of hypomanic symptoms. Kumagai and Ichimiya (2014) described a 76-year-old man who developed a manic episode induced by steroid (fluorometholone) eye drops and treated with sodium valproate. It appears that topical steroids may cause mood disturbances in some individuals.
Discussion
Topical steroids (e.g., fluorometholone) are commonly used after ocular surgery because of their anti-inflammatory effects (Kwok et al. 1997). Medications administered topically are variably absorbed from the eye into the systemic circulation, avoiding first-pass hepatic metabolism, and should be considered as potentially potent systemically (Goldberg et al. 2008). The reported case emphasizes that even a drug that is administered topically can cause psychiatric adverse effects. Schweitzer et al. (2001) also reported two patients who developed depression during topical betaxolol (β blocker) treatment.
The association of psychiatric adverse effects with the use of steroids has been well documented. The most common psychiatric symptoms include depression, psychosis, and, especially, euphoria and mania or hypomania. Naber et al. (1996) found that 26% of patients developed “manic-type” symptoms, and that only 10% developed depressive symptoms during steroid treatment. Most symptoms began in the first 3 days of treatment. In our case, hypomanic symptoms developed on the 3rd day of steroid treatment.
Management should begin with dose reduction or cessation, but in some cases, psychopharmacologic treatment may be required because of the inability to discontinue steroid treatment or the severity of psychiatric symptoms (Hergüner et al. 2006; Drozdowicz and Bostwick 2014). In this case, we discontinued the steroid therapy and added quetiapine for the patient's insomnia and psychomotor agitation.
Our case suggests an association between topical steroids and mood symptoms. Clinicians should take into account the psychiatric adverse effects associated with topical corticosteroids and inform the patients about these potential side effects when prescribing.
Disclosures
No competing financial interests exist.