Isolate the Source
A protective steroid quiets inflammation -- and changes the way doctors treat dry eye.

The realization that dry eye is an inflammatory disease has influenced how clinicians think about and treat this condition. Artificial tears can alleviate symptoms temporarily, but patients will achieve long-term relief only by addressing the primary cause of dry eye discomfort -- inflammation.

Recently, a panel of experts met to discuss the role of corticosteroid therapy in managing ocular inflammation. This article and those that follow will recap the highlights of that meeting.

Dry eye patients treated with loteprednol etabonate 0.5% (Lotemax) for 2 weeks showed statistically positive improvement in signs, symptoms and test results compared with baseline measurements.
Improvement was even more dramatic in dry eye patients who had a significant amount of corneal staining.

Isolating inflammation

External ocular disease is one of the most common disorders treated by eye doctors. Up to 40% of the general population suffers from dry eye and irritation secondary to meibomian gland dysfunction, but as panel members found out, this condition is more common in some areas of the country than in others.

Marc R. Bloomenstein, O.D., F.A.A.O., estimates that 90% of his patients in Phoenix have meibomian gland dysfunction. Their dry eye problems don't end there, however. "Our patients have meibomitis, aqueous deficiency and evaporative problems combined with a significant amount of allergy," he says. Like many of his colleagues, Dr. Bloomenstein is prescribing more steroids, such as loteprednol etabonate 0.5% (Lotemax) to bring his patients relief.

"Loteprednol 0.5% has revolutionized the way we treat dry eye," says Ron Melton, O.D., F.A.A.O., Charlotte, N.C. "This agent helps us manage the inflammatory component of dry eye and offer our patients greater comfort."

Other panel members share Dr. Melton's enthusiasm for loteprednol and report receiving positive feedback from their patients. "The number of dry eye patients my colleagues and I have treated over the past year and a half has increased, probably because they've heard about the good results we're getting from early loteprednol use," says Paul M. Karpecki, O.D., F.A.A.O., Overland Park, Kan.

When a patient complains that artificial tears aren't working, Dr. Karpecki immediately prescribes lote-prednol and cyclosporine ophthalmic emulsion 0.05% (Restasis). "The loteprednol seems to decrease burning and stinging sensations that patients sometimes report with cyclosporine monotherapy to about 1 in 50 patients instead of 1 in 5. And best of all, loteprednol works immediately," Dr. Karpecki says.

Randall K. Thomas, O.D., M.P.H., F.A.A.O., Concord, N.C., explains: "If you're going to suppress the T-cell response, you don't want to wait 3 to 6 months to know if a drug is working. If I anticipate placing a dry eye patient on cyclosporine, I first prescribe loteprednol four times a day for a month. If the patient says, 'That stuff is great!' I'll continue loteprednol b.i.d. to control inflammation for another month and concurrently start cyclosporine for several months to maintain inflammatory control."

Dr. Bloomenstein also advocates early anti-inflammatory therapy. "I want to give dry eye patients who are experiencing significant vision fluctuation a medication that works immediately," he says. "They've already tried several dry eye remedies, and they want something different that will give them relief."

In addition to fast results, loteprednol therapy helps provide clinical insight into the nature of dry eye. After starting patients on loteprednol, most of the panel members transition these patients to cyclo-sporine, as Dr. Thomas does, or to artificial tears. Two-stage therapy isn't just effective, they say, it's also less expensive than cyclosporine alone.

Walter S. Ramsey, O.D., F.A.A.O., Charleston, W. Va., says the results he's seen with loteprednol prompted him to address dry eye sooner.

"I used to wait until patients developed moderate to severe dry eye before initiating treatment, but now I treat even the mildest cases," he says. "Everything we've learned about this condition tells us that 'mild' often means the dry eye signs and symptoms we know don't seem to correlate as well as we expect."

Dr. Karpecki adds that comfortable application is another feature that sets loteprednol apart from similar drugs. "Perhaps the glycerin base in this drop works well as a lubricating agent for dry eyes," he says. "Loteprednol's soothing properties mean that patients don't complain about applying this medication like they do with some other drops."

Moderate to severe dry eye

What's the best therapy for patients with moderate to severe dry eye and possible superficial punctate keratitis? The roundtable participants prefer to enhance the precorneal tear film by starting with steroids alone, rather than a combined steroid and anti-infective.

"I look at the lid margins to make sure the patient doesn't have overriding blepharitis that could induce punctate keratitis," Dr. Bloomenstein says. "If he doesn't, I go straight to a steroid. This approach works very well."

Dr. Karpecki also uses a straight steroid. "I've treated hundreds of patients with a similar regimen, and I have yet to see an infection in any dry eye patient," he says.

Dr. Karpecki is more likely to use loteprednol 0.5%, but will taper to loteprednol 0.2% for long-term treatment. "I typically use loteprednol 0.5% four times a day for the first month then taper to two times a day in the second month," he says. "Beyond that, patients can use it as needed when they experience ocular discomfort. I use cyclosporine and loteprednol 0.2% for longer-term therapy."

Fewer punctal plugs

The participants report their success with loteprednol has eclipsed that of punctal occlusion, which until recently, was their traditional therapy for moderate to severe dry eye.

"Lately, I've removed more plugs than I've put in," Dr. Bloomenstein says. "I think patients are more comfortable with pharmaceutical treatment. The steroid response calms the eye and stabilizes the tear film."

Dr. Karpecki still uses punctal plugs for dry eye patients, but he's more selective. "Sometimes placing plugs makes the patient worse, especially if he has significant dry eye with blepharitis," he says. "I used to start with artificial tears and environmental management, then go to punctal plugs. Now, I begin with artificial tears followed by loteprednol before trying punctal occlusion. Initial corticosteroid treatment addresses the inflammatory component of dry eye disease, setting the stage for more successful punctal occlusion."

New perspective

Left untreated, ocular inflammation can trigger a self-perpetuating cycle of dry eye and irritation. Lote-prednol's anti-inflammatory properties can break this cycle, bringing relief for external ocular disease.