Eyeworld

EW FEATURE 46 Steroids roundup • August 2017 AT A GLANCE • Depending on level of inflammation, many surgeons like to start with the most potent steroid available, with the idea that it will treat inflammation faster. • IOP increase and cataract development are risks associated with steroid use, but surgeons carefully consider potency when determining the right steroid to use. Additionally, cataracts can be easily treated. • Cost and compliance are factors when selecting a steroid, but surgeons once again think that a more effective treatment for a shorter time period can help address cost and compliance issues. • In the future, steroid treatments that eliminate the need for eye drops will become more common. by Vanessa Caceres EyeWorld Contributing Writer discontinuing. However, if the patient has diabetes, an epiretinal membrane, or uveitis, he prescribes difluprednate twice a day and nepafenac (Ilevro, Alcon) once a day for 3 weeks, difluprednate once a day and nepafenac once a day for 2 more weeks, and then stop. If there is a history or presence of cystoid macular edema (CME), Dr. Verdier prescribes difluprednate b.i.d. and nepafenac q.d. for a full 2 months, and longer if CME is ongoing. In addition to a postoperative regimen, Dr. Perry will also prescribe steroid use preoperatively for 1 to 3 days. "One thing we've found is if you treat preoperatively, we have significantly less inflammatory problems, better pupillary dilation, and the pupil tends to stay larger throughout the case," he said. He'll taper steroids over 2 to 3 weeks except in heavily pigmented individ- uals and patients with diabetes; in the latter two patient groups, he'll prescribe steroids for 6 weeks. There's one area where Dr. Verdier has found less use for steroids. "I think topical steroids are overutilized for the treatment of dry eye, for which they should be used sparingly and for several weeks at most. There are other better treatments available for chronic treatment of dry eyes," he said. He also finds that vernal disease can be tough to treat even with high doses of steroids. "If there is a bacterial component to the ocular surface pathology, I'll use a combination steroid like Zylet [loteprednol/tobramycin, Bausch + Lomb] or TobraDex ST [tobramycin/ dexamethasone, Alcon]," he said. For contact lens-related stem cell deficiency, David Verdier, MD, Verdier Eye Center, Grand Rapids, Michigan, has found occasional success with prednisolone acetate four times a day over many weeks. He'll use that same agent for severe epidemic keratoconjunctivitis and short bursts for allergic eye disease. He finds that Thygeson's superficial punctate keratitis responds to lower strength steroids like fluorometho- lone. For low- to moderate-risk corneal transplants, he prefers pred- nisolone acetate four times a day for postop month 1 and 2, three times a day for the third month and two times a day for the fourth month, and then once a day (he'll use fluorometholone if the patient is a steroid responder). After a year, he'll switch to fluorometholone and con- tinue long term unless the patient is phakic or a steroid responder. After pterygium and conjunctival allograft surgery, Dr. Verdier prescribes pred- nisolone acetate four times a day for 1 month. For cataract surgery, Dr. Verdier prescribes prednisolone acetate four times a day for 2 weeks, followed by three times a day for a week, two times a day for a week, and once a day for one more week before said John Sheppard, MD, president, Virginia Eye Consultants, Norfolk, Virginia. Difluprednate is Dr. Holland's go-to choice for corneal and ocular surface transplants, routine cataract surgery patients, and for conjuncti- val surgery. Because difluprednate is dosed less frequently than other steroids, patient compliance is usually less of an issue. In a Phase 3 study with uveitis patients, difluprednate used four times a day was as effective as prednisolone acetate (Pred Forte, Allergan, Dublin, Ireland) used eight times a day. 1,2 This research is often cited when surgeons state their pref- erence for difluprednate. One example of a dosing reg- imen for difluprednate was shared by Christopher Starr, MD, associate professor of ophthalmology, director of the cornea fellowship, director of refractive surgery, and director of ophthalmic education, Weill Cornell Medicine, New York-Presbyterian Hospital, New York. "I typically start at four times a day for the first week for most patients," he said. "If there is significant inflammation, edema, or a complex uveitis patient, I some- times increase to six to eight times a day. In routine cataract cases, I'll de- crease to two times or even one time a day at the 1-week visit, assuming the inflammation is negligible and corneal edema is resolved, which it almost always is." He then has patients do either twice a day for 1 week and then once a day for 1 week or once a day for 1 week and then stop. For higher risk patients with complex cases, Dr. Starr will begin a 4-3-2-1 taper at the 1-week postoperative visit. Other steroid choices Other steroids have a role as well, depending on what you are treat- ing and the inflammation present or expected. "We're fortunate in ophthalmology that we have several different options in terms of corti- costeroid medications varying from mild to potent," said Henry Perry, MD, Ophthalmic Consultants of Long Island, Rockville Centre, New York. For most ocular surface disorders and laser vision correction surgery on low myopes, Dr. Starr defaults to loteprednol (Lotemax, Bausch + Lomb, Bridgewater, New Jersey). Aggressive treatment with potent steroids preferred when appropriate W hen it comes to steroids, more potent is usually better— depending on the extent of the patient's inflammation, of course. Surgeons interviewed about top- ical steroids used in ophthalmology concurred that their go-to steroid treatment for more severe cases is difluprednate (Durezol, Alcon, Fort Worth, Texas) because it's the strongest choice available and can treat inflammation more quickly. That means there's less medication to use over time and better patient compliance. "I think it's better to treat with the strongest steroid first and taper rather than start with a weaker steroid and then increase the dosage. I want to aggressively treat inflammation as efficiently as I can," said Edward Holland, MD, director of cornea services, Cincin- nati Eye Institute, and professor of clinical ophthalmology, University of Cincinnati. "For surgical inflammation, uveitis, and keratitis, the sooner you can quell the inflammation with the strongest tolerable anti-inflammato- ry, the better the outcome will be," Steroid options abound in ophthalmology Acute allergic conjunctivitis is one condition that can be treated with topical steroids. Source: Henry Perry, MD

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