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Treat the root causes of red eye and infiltrative keratitis while relieving discomfort.

Two of the more common conditions treated by eye doctors -- red eye and infiltrative keratitis -- have inflammatory and infective characteristics that make them prime candidates for a combination drug. The result: Faster healing time and more comfortable (and grateful) patients.

Treat red eyes

"We use combination steroids and antibiotics most frequently to treat generic red eye, particularly if we see corneal staining," says Randall K. Thomas, O.D., M.P.H, F.A.A.O.

Ron Melton, O.D., F.A.A.O, agrees. "In my practice, I see many contact lens patients who have peripheral infiltrates. Others may have contact lens-associated red eye with inflamed conjunctiva and occasionally, corneal stippling," he says. "Because these patients have a higher risk of infection, I often use combination steroid and antibiotic agents to treat their condition."

Combination therapy is particularly well-suited to treat bacterial conjunctivitis because this condition has an infectious and inflammatory component. "I rarely use straight antibiotics to treat bacterial conjunctivitis because this condition usually includes secondary inflammation," Dr. Melton says. "Experience has shown me that patients improve faster with a combination steroid/antibiotic than with antibiotics alone. Plus, patients on antibiotic monotherapy who suddenly discontinue treatment can remain symptomatic for quite some time because of underlying secondary inflammation. Once we control the bacterial infection, patients treated with combination therapy are symptom-free, compared with patients who continue to feel irritation after discontinuing a straight antibiotic."

Panel members follow similar combination drug strategies for treating red eye. They begin aggressively, eventually tapering treatment to fewer doses per day. Dr. Thomas, Dr. Melton and Walter S. Ramsey, O.D., F.A.A.O, prescribe one drop every 2 hours for about 2 days. For the next 3 or 4 days, patients reduce the dose to one drop four times a day.

Dr. Ramsey adjusts treatment as needed. "My patients who are in pain use combination drugs once an hour for the first day and once every 2 hours the second day," he says. These patients return for evaluation the third day.

Marc R. Bloomenstein, O.D., F.A.A.O., keeps patients on the starting regimen of one drop every 2 hours for 4 or 5 days instead of 2. "As their condition begins to resolve, I taper their dose to four, three, two, and finally one drop per day, which avoids discontinuing therapy too suddenly," he says.

Resolve infiltrative keratitis

Another indication for combination steroid/antibiotics is infiltrative keratitis. "After years of experience treating contact lens wearers who develop limbal infiltrates, I typically choose a combination steroid and anti-infective as first-line therapy," says Jimmy D. Bartlett, O.D., F.A.A.O. "Combination agents are particularly effective if I suspect the patient has a small, typical limbal-type lesion that doesn't appear infected. Patients feel and look much better after 2 or 3 days -- and they love you because they can start wearing their contact lenses sooner than they could with other drugs."

Dr. Thomas agrees, but warns that combination therapy is controversial among doctors who don't fully understand the nature of the problem. "At least 99% of infiltrative keratitis cases involve inflammatory white blood cell infiltrates, which resolve faster with a topical steroid and antibiotic," he says. "Prescribing a drug that combines a good antibiotic with a good steroid is paramount to helping patients get better faster."

Paul M. Karpecki, O.D., F.A.A.O., suggests combination drugs improve outcomes because they respond to the condition's specific nature. "Infiltrative keratitis is a cellular response in which the immune system reacts to the presence of harmful organisms or agents," he says. "It's not infectious, but I use a combination drug for added protection."

Nevertheless, lingering misconceptions may prevent some doctors from treating infiltrative keratitis with combination steroids and antibiotics. "Some argue lesions will improve if you just stop wearing the contact lens," Dr. Melton says. "But what patient who comes to you with a painful, inflamed eye wants to hear 'You'll feel better in a few days or maybe a week. You just have to wait?' Prescribing a combination product with a steroid will speed healing and resolve inflammation sooner."

Get comfortable with your choice

"Surveys reveal we're still prescribing a lot of straight antibiotic eye drops as a default therapy for general inflammation," Dr. Melton says. "But some conditions respond better to combination steroids and anti-infectives, or even a straight steroid."

Although eye doctors frequently prescribe combination drugs, they still haven't realized the full therapeutic potential of these agents. As they continue to share knowledge and strategies with their colleagues, these practitioners will become more comfortable using combination agents, a change that will be reflected by the treatment decisions they make.

A	B
These fluorescein photographs show a marginal corneal ulcer before (A) and after (B) treatment with combination loteprednol and tobramycin (Zylet). Photographs courtesy Ron Melton, O.D., F.A.A.O.