JUN 2019

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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I DRY EYE DEVELOPMENTS N FOCUS 50 | EYEWORLD | JUNE 2019 Contact information de Luise: vdeluisemd@gmail.com Holland: eholland@holprovision.com Hovanesian: jhovanesian@harvardeye.com Pflugfelder: stevenp@bcm.edu by Chiles Samaniego EyeWorld Contributing Writer those exacerbations, nothing substitutes for a steroid," he reiterated. "The use of topical steroids depends on diagnosis," Dr. de Luise said, adding there is no "one-size-fits-all" regimen. "For routine postoperative care, for ex- ample after uncomplicated cataract and IOL surgery, a TID or QID regimen for a week with a rapid taper is one effective strategy," Dr. de Luise said. "Often, if a topical NSAID is used concomitantly with the topical steroid in the postoperative period, it is begun and tapered in similar or identical frequency." For "episodic dry eye"—a term Dr. de Lu- ise considers ambiguous and "nowhere near as common" as chronic dry eye—an ester steroid such as loteprednol can be employed as a pulse topical steroid. "As a general rule, pulsing topical steroids is better than using them long term in low-dose daily use, but even here there are exceptions," Dr. de Luise said. One exception is when using very low-dose topical steroids at one drop a day for chronic recalcitrant herpes zoster kera- touveitis. "If this one drop a day is summarily stopped, the inflammation recurs. Thus, this is a scenario where a taper down to a low daily dosage for a chronic period has scientific sense and can be a community standard for chronic recalcitrant HZ keratouveitis." Dr. Holland typically starts with lotepred- nol for induction therapy, followed by lifitegrast, shifting to cyclosporine if unresponsive to lifitegrast. "I like loteprednol because it has a lower risk of elevating intraocular pressure, and I have not seen cataract formation with loteprednol in using it with patients over the years, even with long-term therapy," he said. "It is an ester ste- roid, the only ester steroid that we have, which makes it safer than all the other steroids, which are ketone steroids." Dr. Holland also uses steroid pulses when dry eye flares, which he said occurs in the majority of patients. "Whether the patient has episodic flares and in the interval is relatively quiet or the patient is on maintenance therapy with an immunomodulator, they are going to "O cular surface disease has many different etiologies, but inflammation is a common component in the majority of patients," said Edward Holland, MD. "Over the years we've developed treatment strategies to include anti-inflammatories." Anti-inflammatory agents currently in use for ocular surface management broadly fall into two categories: steroids, mainly loteprednol etabonate, which "are immediate and work con- sistently," said John Hovanesian, MD; and im- munomodulators, encompassing cyclosporines and lifitegrast (Xiidra, Shire), which, according to Vincent de Luise, MD, do not have the side effect profile of the topical steroids. Nonsteroidal anti-inflammatory drugs (NSAIDs) are no longer used in the manage- ment of dry eye by Dr. Holland, Dr. Hovane- sian, and Stephen Pflugfelder, MD, having fallen out of favor since "the complication of scleral and corneal melts that are associated with NSAIDs, especially the generics, make this class of drug less ideal for chronic use for dry eye," Dr. Holland said. "The melt complication is a greater risk in dry eye patients." Drs. de Luise, Holland, Hovanesian, and Pflugfelder shared their expertise on the current use of anti-inflammatory therapeutics for ocular surface management. Steroid use "If you've got a very inflamed, red eye that needs quieting down, there's nothing that sub- stitutes a steroid for doing that," Dr. Hovane- sian said. Prior to cataract surgery, for instance, many doctors prefer steroids "because they are so rapid, they work fairly universally, they're well-tolerated by patients. They do have the side effect of causing intraocular pressure increases and the long-term risk of cataract, but in the short term, in a patient being monitored, those are pretty small risks." Dr. Hovanesian situates steroid pulses in the context of dry eye. "Dry eye is a chronic disease that has acute exacerbations, and during Anti-inflammatory therapeutics for ocular surface management At a glance • Anti-inflammatory agents currently in use are steroids and immunomodulators, while NSAIDs have fallen out of favor due to the risk of scleral and corneal melts. • While there is no "one-size- fits-all" regimen, steroids are best for immediate relief and so are often used to initiate treatment. • Newer formulations of existing agents offer better drug penetration and improved tolerance, but experience is currently limited.

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