Eyeworld

EW FEATURE 50 Steroids roundup • August 2017 administer subconjunctival dexa- methasone in patients who are high risk for inflammation, which tends to be very safe and effective. He injects preservative-free dexametha- sone intracamerally, into the anteri- or chamber, for best effects. Dr. Lee prefers topical drops after cataract surgery, and if he is concerned about postoperative inflammation/uveitis, he will give sub-Tenon's capsule ste- roid injections in addition to topical steroids, topical NSAIDs, and topical antibiotics. Dr. Perry thinks inject- ed steroids introduce an additional intraoperative step, which can lead to complications and endophthalmi- tis. "There are many other mistakes than can occur, such as mistakes in concentrations, and I think that topical use is sufficient," he said. Dr. Perry finds the subconjunctival delivery method safe and just as effective as intraocular. EW References 1. Ask the Ethicist: Off-Label Medications. EyeNet. May 2011. 2. Perry HD, et al. Topical cyclosporin A in the management of postkeratoplasty glaucoma. Cornea. 1997;16:284–8. 3. Wilson SE, et al. Long-term resolution of chronic dry eye symptoms and signs after top- ical cyclosporine treatment. Ophthalmology. 2007;114:76–9. 4. Dastjerdi MH, et al. Topical bevacizumab in the treatment of corneal neovasculariza- tion: results of a prospective, open-label, noncomparative study. Arch Ophthalmol. 2009;127:381–9. Editors' note: Drs. Holland, Lee, and Perry have no financial interests related to their comments. Contact information Holland: mredmond@CincinnatiEye.com Lee: lee0003@aol.com Perry: hperry@ocli.net the topical cyclosporine takes effect. Now that topical lifitegrast is on the market, I will likely not need the steroids as often, since it seems to work faster than topical cyclosporine in improving symptoms of dry eye disease," Dr. Lee said. Dr. Lee will often use cyclo- sporine and lifitegrast in off-label conditions that involve T-cell mediated inflammatory reactions on the ocular surface, which often also require concurrent topical cortico- steroids, such as for Thygeson's, al- lergic eye disease, atopic and vernal conjunctivitis, giant papillary con- junctivitis, Terrien's degeneration, superior limbic keratoconjunctivitis, post-surgical in patients undergoing keratolimbal allografts, keratoplas- ty, or severe dry eyes after cataract or refractive procedures. He begins dosing b.i.d. and increases to q.i.d. if he cannot get the inflammation under control. Neovascularization "We have an increasing amount of experience with off-label use of bev- acizumab for the treatment of corne- al neovascularization in the last few years," Dr. Lee said. "I have delivered the drug via topical application (1%) q.i.d. Compounding pharmacies that can make the topical solution have become harder to find with increasing government regulations so I have switched to either subcon- junctival or intracameral injection. Bevacizumab use avoids the side ef- fects of topical steroids, but as soon as treatment is discontinued, the corneal neovascularization recurs." The occurrence of ocular and systemic adverse events, particularly in the neovascular area and the area of the corneal vessels, vessel caliber and diameter, and the fraction of the total corneal area invaded by vessels were greatly reduced in a prospec- tive open label study that gave 1.0% bevacizumab for 3 weeks in 10 eyes with stable corneal neovasculariza- tion. The patients were followed for 24 weeks, and the study concluded that short-term topical bevacizum- ab therapy reduced the severity of corneal neovascularization without local or systemic side effects. 4 Approaches to the treatment of corneal neovascularization may dif- fer among specialists. According to Dr. Holland, the current use of beva- cizumab for corneal neovasculariza- tion is a trend, effective in resolving the signs of neovascularization, but not in addressing the underlying cause. "Corneal neovascularization is never the primary disease—it is secondary to something such as inflammation or chronic epithelial problems. I see many patients who have recurrent anti-VEGF injections, but anti-VEGF does nothing to deal with the etiology of neovascular- ization. Aggressive treatment with anti-inflammatories will get the neovascularization to regress, and in cases with epithelial problems, aggressive therapy for epithelial dis- ease will get the neovascularization to regress. In a very rare case, we will have addressed the etiology and still have a persistent leaky vessel, and that is one indication for an anti-VEGF injection. But what I see is that patients get recurrent anti- VEGF therapy, but they don't have the etiology addressed. I think it is a rare case where you can't control the neovascularization by pinpointing your therapy to the etiology. The vessel will regress with anti-VEGF, but the inflammation is still there. Stopping the neovascularization is not going to stop the corneal scarring. I do think there is often a disconnect in the way that clinicians are approaching corneal neovascu- larization," he said. Delivery Dr. Holland administers steroids topically and will occasionally penetrates more rapidly, as a solu- tion, however, it can burn and leave patients with a metallic taste in their mouth. Restasis can also burn but does not have an after taste. It has a positive effect for meibomian gland disease due to the anti-inflammatory effect, but also has a direct physical effect, with the emulsion helping pull out secretions from the meibo- mian glands. "Since both of these compounds can be irritating, in very symptomat- ic patients, it is better to use a mild steroid, such as loteprednol [Lote- max, Bausch + Lomb, Bridgewater, New Jersey], a synthetic steroid," Dr. Perry said. "We use it anywhere from 2 to 4 weeks and then taper. This regimen will quiet the anterior segment in most dry eye patients and allow us to give the Restasis and/or lifitegrast more of a chance to work in a better situation. To use them concurrently would be the best method. The use of either alone would not work as well and not be as user friendly, meaning pa- tients would discontinue the drugs more frequently, without the use of steroids beforehand. In this use, Lotemax is used off-label." According to Barry Lee, MD, Eye Consultants of Atlanta, combin- ing agents for best efficacy is a huge advantage. "I will often use topical ester steroids in concert with topical cyclosporine for decreasing the inflammation associated with dry eyes or meibomian gland disease. This often helps patients feel better in terms of dry eye symptoms since it may take several months to see improvement with topical cyclospo- rine. I think that ester steroids have less risk of inducing complications of ketone steroids, such as cataract and increased intraocular pressure. I typically use the gel formulation of ester steroids b.i.d. for 4 to 6 weeks and decrease to once a day for 2 to 3 weeks, and then discontinue once Off-label continued from page 48 ascrs.org/macrahotline

• Blank Page
• Blank Page (1)