A series of patients present for consultation, all with the same basic need. The first is a 50-year-old white female with severely dry eyes. She has used numerous artificial tears with moderate success, but the dryness is now particularly bothersome. She believes that her vision is compromised and fluctuates slightly day-to-day. Best-corrected visual acuity is 20/25-, and the vision reduction is attributable to a very poor ocular surface. She has significant punctate epitheliopathy in each eye and her tear-film breakup time (TFBUT) is very rapid: three seconds in each eye. There is mild underlying redness O.U.

The second patient is a 38-year-old white male, an avid outdoorsman who recently presented with red eyes following a camping and fishing trip. The problem began in his right eye and progressed to his left eye over the course of one day. He describes it as a combination of itching, irritation and foreign-body sensation. He also reports a yellow discharge accumulating bilaterally in the nasal canthus. This morning, three days later, it was so thick that it was difficult to open his eyes. In fact, he had to wash away the glue-like accumulation in order to fully open his eyes, prompting his visit.

The third patient is a 19-year-old black female who recently adopted a new kitten. She complains of intense itching and redness of both eyes since the feline addition to her family. Her eyes tear continuously, and the constant rubbing makes her tear even more.  Also, her eyelids have become puffy. She has been using an over-the-counter allergy drop, but reports that it has only helped modestly.

The fourth patient is a 58-year-old Hispanic man with Crohns disease who presents with sectoral redness in his right eye. He says that the problem is recurrent and can afflict either eye, but that it has never happened in both eyes simultaneously. He mentions that during the last episode, he had to use a medication for several weeks and the prescribing doctor became concerned because the pressure in his eye elevated; that doctor subsequently prescribed another medication to bring down the pressure.

The final patient is a 49-year-old black woman who presents with an acute red, painful, photophobic eye thats lasted for two days. Her vision is modestly compromised; she sees 20/40 out of the affected eye. This has never happened to her before. In addition to a circumlimbal flush, there is a moderate cell and flare reaction and numerous keratic precipitates on the corneal endothelium. Notably, there is also posterior synechiae formation. There is no hypopyon at this time.

The diagnoses in these situations are different, but the underlying pathophysiologic process is the same: inflammation. Each patient has redness of the eyes, and in virtually every case of red eye, inflammation with subsequent vasodilation is the reason. Each patient here needs anti-inflammatory therapy. Clearly, the most effective anti-inflammatory therapy is a topical corticosteroid. But, there are many corticosteroids available, as are agents combined in a single bottle with various antibiotics.

In this months column, we sort out the steroids and identify appropriate options for each scenario.

 

In a case of episcleritis in a steroid responder, treatment may vary from the normal regimen.

Different Diagnoses

The first patient clearly has severe keratitis sicca. Replacement lubrication is the main therapy for this condition, but the inflammatory component should also be addressed. In cases this severe, we often opt for a short steroid course, such as 1% prednisolone acetate, 0.1% fluorometholone or 0.5% loteprednol etabonate. These can be used q.i.d. for seven to 14 days before being tapered and replaced with lubrication and/or topical cyclosporine A.

The second patient has bacterial conjunctivitis. While antibiotic therapy with broad-spectrum action, such as a fourth-generation fluoroquinolone, is typically used to remove the offending bacteria, anti-inflammatory therapy can be used in addition to reduce the redness. In such cases, deep penetration of ocular tissues is unnecessary, so low-cost generic 1% prednisolone acetate or 1% prednisolone phosphate at q.i.d. dosing are our preferences, though loteprednol is an acceptable option as well. Or, q.i.d. therapy with a combination antibiotic/steroid medication, such as Zylet (loteprednol/tobramycin, Bausch & Lomb), TobraDex (dexamethasone/tobramycin, Alcon) or Maxitrol (neomycin, polymyxin B/ dexamethasone, Alcon), is an excellent option.

The third patient is suffering from severe allergies related to her new kitten. The allergic response is best managed by medications that both block histamine and stabilize mast cell membranes, such as Pataday (olopatadine, Alcon) or Zaditor (ketotifen fumarate, Novartis). For severe situations, however, a short course of a topical steroid will quiet the inflammation associated with the acute allergic response.

In this situation, we rely on Alrex (loteprednol etabonate 0.2%, Bausch & Lomb), a topical steroid approved for the management of allergic conjunctivitis. In fact, some have recommended this medication for long-term allergic conjunctivitis management, as it has a low propensity toward cataractogenesis or elevation of IOP.1

The fourth patient has episcleritis, presumably associated with Crohns disease. In typical cases of episcleritis, deep penetration of ocular tissues is not necessary. In these instances, we often opt for generic 1% prednisolone acetate or 1% prednisolone phosphatebut, his history is significant for an IOP elevation from topical steroid use.

In such a case of a known steroid responder, our preference is Lotemax (loteprednol etabonate 0.5%, Bausch & Lomb). This corticosteroid has a high therapeutic index and contains an ester-based, rather than a ketone-based, steroid. This steroid is quickly metabolized in the eye with a lower propensity to elevate IOP.2

The final patient has acute anterior uveitis. For this patient, we want a potent steroid with excellent ocular penetrance. So, we typically prescribe Pred Forte (prednisolone acetate 1%, Allergan) with dosing as often as every hour (or more frequently, in some cases) in the initial phase.

These steroids need to be shaken vigorously in order to get the proper suspension, and generic versions tend to need even more shaking; patients simply do not accomplish this properly much of the time.3 The prednisolone particles in Pred Forte are smaller and more uniform, allowing them to stay in suspension longer than in the generic formulation.3 So, we tend to avoid the generic version, as patients often dont shake the bottle enough to get a full 1% in suspension and are effectively getting only partial therapy.

IOP elevation is a concern with prednisolone acetate, but we dont shy away in cases of anterior uveitis due to its clinical potency. We will, however, monitor the patients IOP carefully and add an aqueous suppressant should clinically significant elevation occur.

If topical anti-glaucoma medications dont adequately lower the IOP and anti-inflammatory therapy is still needed, we will often switch to Lotemax, which has clinical anti-inflammatory action similar to prednisolone acetate, but with a lower propensity to affect IOP.4,5 Both Pred Forte and Lotemax have been shown effective in the management of patients with anterior uveitis.4,5 While Pred Forte has been shown to be somewhat more effective in reducing the signs and symptoms caused by anterior uveitis, the IOP safety profile associated with Lotemax makes it an excellent option.5

When sorting out the steroids, keep in mind the clinical goals as well as the options. Combination steroid/antibiotics should not be used when only antibiosis or anti-inflammatory activity is desired. Rather, combination agents should be employed in cases of known infection when inflammation is a significant concern or in cases when anti-inflammatory therapy is needed, but there is a risk of bacterial infection. Medications, such as prednisolone acetate or loteprednol etabonate, should be used when clinically potent steroids with good ocular penetrance are needed. In cases of secondary elevation in IOP, such steroids as loteprednol etabonate have less pressure-elevating impact, though they still can cause significant IOP elevation.

When conditions are mild, therapy is expected to be short term and deep ocular penetrance is not needed, consider generic versions of prednisolone for cost-effective management.

Drs. Sowka and Kabat have no financial interest in any product mentioned in this article.

 

1. Howes JF. Loteprednol etabonate: a review of ophthalmic clinical studies. Pharmazie 2000 Mar;55(3):178-83.

2. Pavesio CE, Decory HH. Treatment of ocular inflammatory conditions with loteprednol etabonate. Br J Ophthalmol 2008 Apr;92(4):455-9.

3. Roberts CW, Nelson PL. Comparative analysis of prednisolone acetate suspensions. J Ocul Pharmacol Ther 2007 Apr;23(2):182-7.

4. Samudre SS, Lattanzio FA Jr, Williams PB, Sheppard JD Jr. Comparison of topical steroids for acute anterior uveitis. J Ocul Pharmacol Ther 2004 Dec;20(6):533-47.

5. Controlled evaluation of loteprednol etabonate and prednisolone acetate in the treatment of acute anterior uveitis. Loteprednol Etabonate US Uveitis Study Group. Am J Ophthalmol 1999 May;127(5):537-44.