Pediatric Steroid High-Responder Phenotype: Bilateral Blindness and Refractory Glaucoma Following Chronic Cutaneous-Ocular Dexamethasone Misuse

Background: Chronic misuse of potent topical corticosteroids can lead to irreversible visual loss, particularly in the pediatric population which exhibits a more aggressive trabecular meshwork remodeling response than adults. This case aims to delineate the silent progression of steroid-induced ocular hypertension in the absence of red-eye symptoms and emphasizes the critical pharmacokinetic risks of percutaneous absorption in children. Case presentation: We report a catastrophic case of a 7-year-old male presenting with bilateral vision loss following six years of unsupervised, intermittent use of a combined Neomycin-Polymyxin B-Dexamethasone ointment for periocular dermatitis. The cumulative exposure exceeded 500 mg of Dexamethasone. Examination revealed dense posterior subcapsular cataracts (PSC) and advanced glaucomatous optic neuropathy. Central corneal thickness was thin (505 µm), masking the severity of the measured Intraocular Pressure (IOP). Following sequential phacoaspiration, the left eye exhibited an acute hypertensive crisis (IOP spike to 59 mmHg) attributed to decompensated outflow facility. Management required urgent Trabeculectomy with intraoperative 5-Fluorouracil (50 mg/mL). The high-responder phenotype in children involves rapid formation of Cross-Linked Actin Networks (CLANs) and MYOC gene upregulation. We discuss the double-hit mechanism where cataract extraction washes out hyposecretory factors, unmasking total trabecular blockage. The choice of 5-Fluorouracil over Mitomycin C is defended based on the safety profile regarding hypotony maculopathy in pediatric myopic eyes. Conclusion: Dexamethasone carries a high risk of transdermal absorption in pediatric eyelids. Regulatory reform reclassifying antibiotic-steroid combinations as non-repeatable prescriptions is imperative to prevent such preventable blindness.