Eyeworld

55 EW FEATURE August 2017 • Steroids roundup Tapering steroids Dr. Mah said that sometimes ophthalmologists think they must get the patient off steroids entirely when treating stromal keratitis with an antiviral prophylactic cover, but this does not necessarily have to be the case. As a cornea specialist, he said, trying to do a transplant on someone who is neurotrophic from HSV or varicella zoster virus is more difficult to manage than a cataract or secondary glaucoma. "You may not get the patient off steroids, and that's OK," Dr. Mah said. First, he will try a typical taper. If the patient is using steroids four times a day, Dr. Mah will go down one drop per week, moving to three times a day, and then after another week, two times a day, and so on. If this is unsuccessful, try doing a slower taper, even using a drop several times a week, then once a week, and then attempt to com- pletely stop. However, some patients may still require steroids, even if it's just once a week. "The patient and corneal reaction during the slow taper guides you, and the goal is to try to get them off the steroid," he said. "But sometimes, you must continue using the lowest dose with the lowest potency steroid that will keep the cornea quiet along with the antiviral cover." He added that it's important to prevent scarring, or if there already is a scar, you want to prevent it from getting worse. Dr. de Luise shared his specific plan for tapering in immune stromal HSV without ulceration. Those pa- tients are usually on topical steroids four times a day and oral antivirals in prophylactic doses, he said. He stressed the importance of tapering over a long period of time. Once you start the steroid, you have to keep it up for a couple of weeks, he said. He added that the oral antivirals also need to be ta- pered down "one piece at a time." If you're starting out at four times a day, Dr. de Luise said this should be continued for 2–3 weeks, after which time the patient would switch to three times a day. After an- other few weeks, they would move to two times a day, and so on. Dr. de Luise stressed that the ophthal- mologist needs to see the patient a number of times throughout this taper process. Some patients may be main- tained on their oral antiviral med- ications for years, he said, so after 6 months, he recommended that patients have renal function checks as oral antivirals can be toxic to the kidneys. It may become necessary to decrease the amount of oral antivi- rals depending on kidney function, in consultation with the patient's internist or nephrologist, he said. Dr. de Luise added that topical cyclosporine 2% has been evaluated in several uncontrolled studies in the treatment of herpetic stromal disease without the use of cortico- steroids. A role may exist for this medication in those patients unable to use corticosteroids. EW Editors' note: Dr. Mah has financial interests with Bausch + Lomb (Bridge- water, New Jersey), Allergan (Dublin, Ireland), and Alcon (Fort Worth, Texas). Drs. de Luise and Jeng have no financial interests related to their comments. Contact information de Luise: vdeluisemd@gmail.com Jeng: BJeng@som.umaryland.edu Mah: Mah.Francis@scrippshealth.org positively impact your patients' perception of care improve satisfaction scores reduce patient anxiety increase referrals What if a few changes to your practice's waiting room could... Learn how to navigate the surprisingly complex do's and don'ts of medical practice waiting rooms with our newest eBook How to Design the Perfect Waiting Room for Patients get.rendia.com • 877.321.5481 • 1820 Lancaster St., Ste. #110, Baltimore, MD 21231 Download your free copy today! Go to http://go.rendia.com/ophthalmology-waiting-room

• Blank Page
• Blank Page (1)