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Inflammation remains most common condition that ophthalmologists treat
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 Richard L. Lindstrom |
Inflammation is the most commonly treated pathology in any ophthalmologist’s office.
Inflammation is associated with infection, injury, ocular surface disease, surgery, contact lens wear and autoimmune disease. It is estimated that at least 30% of office visits to a comprehensive ophthalmologist are for ocular surface disease: dry eye, blepharitis or allergy. The pathophysiology of all three of these includes inflammation, and anti-inflammatory drugs are a mainstay in their therapy.
Forty-five million patients in the U.S. wear contact lenses, and most suffer at least occasionally from secondary inflammation. At least 6 million undergo surgery every year in America, and every case is associated with inflammation. Add in conjunctivitis, keratitis, episcleritis, scleritis, uveitis, vitreitis, retinitis, dacryocystitis, hordeolum and chalazion, cellulitis, trauma, autoimmune and systemic disease, and a number of idiopathic cases, and it is clear we are treating inflammation not just every day in practice, but every hour.
While inflammation can be benign and self-limited, it can also be devastating and destructive to the eye and vision, including the impact of secondary problems such as corneal scarring, vascularization, damage to the corneal endothelium and trabecular meshwork, secondary cataract and, of course, cystoid macular edema.
The most effective drug for the therapy of inflammation on, in and around the eye is a corticosteroid. Fortunately, we have several corticosteroids available and multiple routes of administration that can be therapeutically effective.
Important issues to consider when selecting which steroid and method of delivery to use include potency, penetration, dosage frequency required, compliance and potential side effects. Traditionally, we have considered Pred Forte (1% prednisolone acetate, Allergan) our big gun as a topical steroid. A new guy in town, Durezol (difluprednate ophthalmic emulsion 0.05%, Alcon), appears to be ready to bump prednisolone acetate to second place. I am finding myself recommending this drug more frequently every week when I need a potent steroid with good penetration into the eye. It is a powerful agent. Risks such as secondary cataract and steroid-induced glaucoma appear similar to prednisolone acetate and dexamethasone.
When longer-term therapy is indicated, I remain a fan of Lotemax (loteprednol ophthalmic suspension 0.5%, Bausch + Lomb). This steroid, for me, is excellent for ocular surface disease and other long-term indications such as prophylaxis against graft rejection in keratoplasty. Secondary cataract and steroid-induced glaucoma are rare.
Considering the costs and long timelines involved in obtaining regulatory approval for a new drug, I suspect our current armamentarium of steroids will remain the same for years, if not decades. Still, we can look forward to exciting advances in delivery vehicles that will reduce dosage frequency, enhancing compliance. In addition, many new forms of extended-release steroid treatments for surface, anterior segment and especially posterior segment disease are likely to come on the market in the next few years. All in all, including the advances in topical NSAID therapeutic agents and immune modulators such as cyclosporine, our ability to treat the most common pathology we encounter in daily practice, inflammation, continues to advance.