EyeWorld India September 2019 Issue

60 EWAP SEPTEMBER 2019 CORNEA O cular surface disease has many different etiologies, LÕÌ ˆ˜y>““>̈œ˜ ˆÃ > Vœ““œ˜ Vœ“«œ˜i˜Ì ˆ˜ ̅i “>œÀˆÌÞ œv «>̈i˜ÌÃ]» Ã>ˆ` `Ü>À` œ>˜`] ° º"ÛiÀ ̅i Þi>Àà Üi½Ûi developed treatment strategies ̜ ˆ˜VÕ`i >˜Ìˆ‡ˆ˜y>““>̜Àˆið» Ƃ˜Ìˆ‡ˆ˜y>““>̜ÀÞ >}i˜Ìà currently in use for ocular surface management broadly fall into two categories: steroids, mainly œÌi«Ài`˜œ iÌ>Lœ˜>Ìi] ܅ˆV…º>Ài immediate and work consistently,” Ã>ˆ` œ…˜ œÛ>˜iÈ>˜] Æ and immunomodulators, encompassing cyclosporines and ˆwÌi}À>ÃÌ 8ˆˆ`À>] -…ˆÀi®] ܅ˆV…] according to Vincent de Luise, MD, do not have the side effect «Àœwi œv ̅i ̜«ˆV> ÃÌiÀœˆ`𠜘ÃÌiÀœˆ`> >˜Ìˆ‡ˆ˜y>““>̜ÀÞ drugs (NSAIDs) are no longer used in the management of `ÀÞ iÞi LÞ À° œ>˜`] À° œÛ>˜iÈ>˜] >˜` -Ìi«…i˜ *yÕ}vi`iÀ] ]…>ۈ˜} v>i˜ œÕÌ œv v>ۜÀ ȘVi ºÌ…i Vœ“«ˆV>̈œ˜ of scleral and corneal melts that are associated with NSAIDs, especially the generics, make this class of drug less ideal for chronic ÕÃi vœÀ `ÀÞ iÞi]» À° œ>˜` Ã>ˆ`° º/…i “iÌ Vœ“«ˆV>̈œ˜ ˆÃ > greater risk in dry eye patients.” Àð `i ՈÃi] œ>˜`] œÛ>˜iÈ>˜] >˜` *yÕ}vi`iÀ shared their expertise on the VÕÀÀi˜Ì ÕÃi œv >˜Ìˆ‡ˆ˜y>““>̜ÀÞ therapeutics for ocular surface management. Steroid use º v ޜսÛi }œÌ > ÛiÀÞ ˆ˜y>“i`] red eye that needs quieting down, there’s nothing that substitutes a steroid for doing ̅>Ì]» À° œÛ>˜iÈ>˜ Ã>ˆ`° *ÀˆœÀ to cataract surgery, for instance, many doctors prefer steroids ºLiV>ÕÃi ̅iÞ >Ài Ü À>«ˆ`] ̅iÞ work fairly universally, they’re well-tolerated by patients. They do have the side effect of causing intraocular pressure increases and the long-term risk of cataract, but in the short term, in a patient being monitored, those are pretty small risks.” À° œÛ>˜iÈ>˜ ÈÌÕ>Ìià ÃÌiÀœˆ` pulses in the context of dry eye. º ÀÞ iÞi ˆÃ > V…Àœ˜ˆV `ˆÃi>Ãi that has acute exacerbations, and during those exacerbations, nothing substitutes for a steroid,” he reiterated. º/…i ÕÃi œv ̜«ˆV> ÃÌiÀœˆ`à depends on diagnosis,” Dr. de Luise said, adding there is no ºœ˜i‡Ãˆâi‡wÌÇ>» Ài}ˆ“i˜° º œÀ ÀœṎ˜i «œÃ̜«iÀ>̈Ûi care, for example after uncomplicated cataract and IOL surgery, a TID or QID regimen for a week with a rapid taper is one effective strategy,” Dr. de ՈÃi Ã>ˆ`° º"vÌi˜] ˆv > ̜«ˆV> NSAID is used concomitantly with the topical steroid in the postoperative period, it is begun and tapered in similar or identical frequency.” œÀ ºi«ˆÃœ`ˆV `ÀÞ iÞi»p> term Dr. de Luise considers >“Lˆ}՜Õà >˜` º˜œÜ…iÀi ˜i>À as common” as chronic dry eye—an ester steroid such as loteprednol can be employed as a pulse topical steroid. ºƂà > }i˜iÀ> ÀՏi] «ÕÃˆ˜} topical steroids is better than using them long term in low- dose daily use, but even here there are exceptions,” Dr. de Luise said. One exception is when using very low-dose topical steroids at one drop a day for chronic recalcitrant …iÀ«ià âœÃÌiÀ ŽiÀ>̜ÕÛiˆÌˆÃ° º v this one drop a day is summarily Ã̜««i`] ̅i ˆ˜y>““>̈œ˜ recurs. Thus, this is a scenario where a taper down to a low daily dosage for a chronic period …>à ÃVˆi˜ÌˆwV Ãi˜Ãi >˜` V>˜ Li > community standard for chronic ÀiV>VˆÌÀ>˜Ì < ŽiÀ>̜ÕÛiˆÌˆÃ°» À° œ>˜` ÌÞ«ˆV>Þ ÃÌ>ÀÌà with loteprednol for induction ̅iÀ>«Þ] vœœÜi` LÞ ˆwÌi}À>ÃÌ] shifting to cyclosporine if ՘Ài뜘ÈÛi ̜ ˆwÌi}À>ÃÌ° º ˆŽi œÌi«Ài`˜œ LiV>ÕÃi it has a lower risk of elevating intraocular pressure, and I have not seen cataract formation with loteprednol in using it with patients over the years, even with long-term therapy,” he Ã>ˆ`° º Ì ˆÃ >˜ iÃÌiÀ ÃÌiÀœˆ`] ̅i only ester steroid that we have, which makes it safer than all the other steroids, which are ketone steroids.” À° œ>˜` >Ãœ ÕÃià ÃÌiÀœˆ` by Chiles Aedam R. Samaniego EyeWorld æÈ>‡*>VˆwV Senior Staff Writer #PVK KPƃCOOCVQT[ VJGTCRGWVKEU HQT ocular surface management Contact information de Luise: vdeluisemd@gmail.com Holland: eholland@holprovision.com Hovanesian: …œÛ>˜iÈ>˜J…>ÀÛ>À`iÞi°Vœ“ 2ƃWIHGNFGT stevenp@bcm.edu This article originally appeared in the June 2019 issue of EyeWorld . It has been UNKIJVN[ OQFKƂGF CPF CRRGCTU JGTG YKVJ permission from the ASCRS Ophthalmic Services Corp. At a glance • č˜Ìˆ‡ˆ˜y>““>̜ÀÞ >}i˜Ìà VÕÀÀi˜ÌÞ ˆ˜ ÕÃi >Ài ÃÌiÀœˆ`à >˜` ˆ““Õ˜œ“œ`Տ>̜ÀÃ] ܅ˆi -č Å>Ûi v>i˜ œÕÌ œv v>ۜÀ `Õi ̜ ̅i ÀˆÃŽ œv ÃViÀ> >˜` VœÀ˜i> “iÌð • 7…ˆi ̅iÀi ˆÃ ˜œ ºœ˜i‡Ãˆâi‡ wÌÇ>» Ài}ˆ“i˜] ÃÌiÀœˆ`à >Ài LiÃÌ vœÀ ˆ““i`ˆ>Ìi Àiˆiv >˜` Ü >Ài œvÌi˜ ÕÃi` ̜ ˆ˜ˆÌˆ>Ìi ÌÀi>̓i˜Ì° • iÜiÀ vœÀ“Տ>̈œ˜Ã œv i݈Ã̈˜} >}i˜Ìà œvviÀ LiÌÌiÀ `ÀÕ} «i˜iÌÀ>̈œ˜ >˜` ˆ“«ÀœÛi` ̜iÀ>˜Vi] LÕÌ iÝ«iÀˆi˜Vi ˆÃ VÕÀÀi˜ÌÞ ˆ“ˆÌi`° #SWGQWU FGƂEKGPV FT[ G[G FKUGCUG UJQYKPI FGETGCUGF VGCT ƂNO OGPKUEWU CPF RQUKVKXG NKUUCOKPG UVCKPKPI QH EQTPGC CPF EQPLWPEVKXC Source: Vincent de Luise, MD