EyeWorld India September 2016 Issue

September 2016 54 EWAP refractive Loteprednol following LASIK and PRK by Maxine Lipner EyeWorld Senior Contributing Writer Physician discusses loteprednol as a viable option for refractive surgery patients U se of loteprednol etabonate gel (Lotemax, Bausch + Lomb, Bridgewater, New Jersey) is safe and effective for postoperative treatment following PRK or LASIK, according to Clifford Salinger, MD , medical director, Dry Eye Spa and VIP Laser Eye Center, Palm Beach Gardens, Florida. Dr. Salinger and colleagues published a study in the November 2015 issue of Clinical Ophthalmology 1 that showed patients taking loteprednol after LASIK and PRK had a very low incidence of elevated pressure, while attaining acuities consistent with the use of other steroids. Prior to FDA approval of Lotemax gel, Dr. Salinger was using Lotemax suspension off-label for perioperative and postoperative inflammation and pain following surgery. “I felt strongly that it was appropriate to use for LASIK, PRK, and corneal procedures, as well as conjunctival procedures,” he said. While he knew many of his colleagues also thought this, there were those who doubted that the newer form of Lotemax gel was potent enough for refractive and other ocular surgery. Post-refractive study Dr. Salinger and other proponents decided to undertake a study considering how loteprednol fared for refractive surgery. “Several of us decided to go back through our files for PRK and LASIK and compile our data in order to see if we could show not only the safety—the very few adverse events—but also the potency and the good visual outcomes for patients after LASIK and PRK,” Dr. Salinger said. They thought that loteprednol could have benefits for refractive surgery patients over other steroids, particularly for PRK patients. “Many of us have patients on steroids for an extended period of time (for PRK), often up to 3 or 4 months,” Dr. Salinger said. They wanted to consider if loteprednol had a better side effect profile with respect to causing IOP elevation than other ocular steroids. “It is the only ester steroid,” he said. “All the rest are ketone steroids.” Although steroids such as fluorometholone are being used by some who think they are milder and safer, they are still ketone steroids and have an increased risk of elevated IOP, he pointed out. Included in the study were patients who had undergone either primary PRK or LASIK and then exclusively received loteprednol as the steroid used postoperatively. Investigators found that the visual results were in line with results from other LASIK and PRK studies. They reported that in 189 LASIK eyes, the mean uncorrected distance acuity was 20/24, and for the 209 eyes that underwent PRK, the mean acuity was 20/30. For those who underwent either LASIK or PRK, the mean postoperative IOP did not increase over time. In only three eyes of two PRK patients was IOP found to be significantly elevated from baseline. “One patient with elevated IOP was lost to follow-up, so we can’t say if the patient had a normalization of IOP, but the other eyes that showed elevated IOP did return to baseline,” Dr. Salinger said. “There was also a very low incidence of corneal haze or scar in our PRK patients.” There were no complications, Dr. Salinger reported, adding that the only adverse events were stinging and irritation, with a couple of patients switching to a different steroid as a result. Clinical considerations From a clinical perspective, Dr. Salinger hopes that practitioners take away from the study the understanding that loteprednol is a viable option for refractive surgery patients. “We can safely use loteprednol for extended periods of time on our post-PRK patients and in our short-term steroid-using LASIK patients,” he said, adding that for LASIK patients there may even be an additional benefit to loteprednol use. Dr. Salinger pointed out that there are emollients in the gel that are not in any other steroid drops that lubricate the ocular surface. “For our LASIK patients, I think it is important to consider the use of loteprednol not only for the safety profile but also because it’s a better dry eye type of eye drop,” Dr. Salinger said. He also views the fact that the medication is in gel form as a benefit. “It has uniform dosing and uniform delivery from the first drop to the last, whereas almost all of the other steroids are suspensions,” Dr. Salinger said. Too often such suspensions do not get shaken enough. “The first third of the bottle, patients are getting a lower amount of the medication, the middle third we hope they are getting approximately what they should be getting, and by the last third they are getting a stronger steroid dose,” he said, adding that the stronger dose at the end may be why those on prednisolone show increased IOP elevation after using it for 6 weeks or more. When using loteprednol, which is a thicker drop, Dr. Salinger advises patients to wait 8 to 10 minutes after instillation before taking other drops to allow for better absorption, to maximize effectiveness. Overall, Dr. Salinger urges practitioners to consider loteprednol as a valuable asset for refractive surgery patients. “Loteprednol should be on our collective therapeutic radar for all ocular inflammation from the posterior capsule forward,” he said. “We all realize this does not penetrate into the vitreous and does not treat CME well, but for anterior segment and ocular surface inflammation, it is a wonderful drop that should be considered.” In addition to refractive surgery, this is true for cataract surgery, corneal transplant, DSEK or DMEK, as well as removal of pterygium or conjunctival tumors or growths, Dr. Salinger concluded. EWAP Reference 1. Salinger CL, et al. A retrospective analy- sis of the postoperative use of loteprednol etabonate gel 0.5% following laser-assist- ed in situ keratomileusis or photorefrac- tive keratectomy surgery. Clin Ophthalmol . 2015;9:2089–97. Editors’ note: Dr. Salinger has financial interests with Bausch + Lomb. Contact information Salinger: drsalinger@comcast.net