Inflammatory bowel disease in Pakistan: Are we looking at it in the eye?

Abstract

As of 2019, there were an estimated number of 4.9 million cases of inflammatory bowel disease (IBD) globally.¹ For clinical remission and management of acute flares, IBD is treated with corticosteroids due to their anti-inflammatory potential. Even with promising therapeutic potential for this disease, steroid use for maintenance therapy in IBD patients has always been questioned due the adverse effects associated with their long-term use. Some recognised effects include decreased bone mineral density, opportunistic infections and increased mortality rate.²

No epidemiological data available in Pakistan and underreporting remains a huge problem. However, the prevalence in Asia has been identified to be about 0.24 to 7.5 per 100,000 persons.³ These figures point to a significant disease burden in the region, and brings into consideration whether unavailability of costly diagnostic tests could be behind decreased diagnosis as compared to a lack of prevalence.

Currently, international gastroenterology guidelines emphasise the impact of chronic steroid use in IBD patients on metabolic bone health. A similar practice is followed in Pakistan, where IBD patients who have chronic corticosteroid exposure are recommended to be screened for vitamin D deficiency and metabolic bone disease.

Recently, Amrik et al. evaluated the effect that systemic steroid therapy in IBD patients had on increasing intraocular pressure.⁴ Their analysis concluded that IBD patients undergoing corticosteroid therapy for >4 weeks may have an increased prevalence of ocular hypertension which puts them at risk of developing optic nerve damage and irreversible blindness. Even though in this limited sample size it cannot be ruled out that increased IOP could be a disease manifestation itself, this data still identifies extraocular manifestations and possible association with steroid therapy.

At this time, there are no guidelines for ocular screenings for IBD patients on corticosteroid therapy in Pakistan or worldwide. There is also limited information regarding extra intestinal/extra ocular manifestations of the disease prevalent in our population. Therefore, further research into the disease prevalence in Pakistan and the identification of pervasive extra intestinal manifestations needs to be prioritized. Establishing treatment guidelines for ophthalmic follow up in IBD patients could aid both in identifying eye complications of the disease itself, and help prioritizing at-risk patients which will benefit from further visits. Identifying new associations in our population will help in creating mass awareness and improving patient prognosis.

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