Prophylaxis may be key in treating ocular surface disease, inflammation

Issue: February 10, 2012

ByRichard L. Lindstrom, MD

Richard L. Lindstrom

The most common uses of anti-inflammatory drugs by the anterior segment surgeon are to treat ocular surface disease and inflammation associated with surgery. As a corneal specialist and cataract surgeon, these two groups of patients are common in my practice. So, a few personal thoughts, some perhaps quite controversial.

Ocular surface disease, including dry eye, blepharitis/meibomian gland dysfunction and ocular allergy, comprises the most common diagnosis encountered on a daily basis by the comprehensive ophthalmologist. As many as 40% of patients seen each day in a typical ophthalmologist’s office carry one of these three diagnoses. Unfortunately, when surveying patient charts, these diagnoses are found in a much lower incidence. This suggests that we are not making these diagnoses as frequently as we should.

I am finding a simple screening test, tear film osmolarity, to be useful in screening for the patient with dry eye. This is especially important in patients about to undergo cataract or refractive corneal surgery. In addition, two quick questions for the patient — “Do your eyes ever itch?” to screen for allergy and “Do your eyes ever burn?” to screen for blepharitis/meibomian gland dysfunction — are quite useful to me.

While in most cases ocular surface disease is not sight-threatening, patients frequently suffer significantly reduced quality of life that could be eliminated with disease recognition and treatment. The pathophysiology of each of the three ocular surface diseases includes inflammation. While classical teaching is to begin treatment with palliative therapy such as artificial tears for ocular surface disease, I favor treating these patients more aggressively when I initiate therapy. None of us would initiate therapy for even a mild case of another common inflammatory anterior segment disease, iritis, with a trial of topical lubricants for a few weeks and then, only if treatment failed, initiate more aggressive anti-inflammatory therapy. We aggressively eradicate the inflammation and then taper to maintenance therapy. I believe that a similar approach is indicated in all but the mildest forms of ocular surface disease.

Usually patients with disease severe enough to be in my clinic chair fall into this category. Many of them have been seen by several other eye doctors without relief of their symptoms and signs. The solution for me is invariably aggressive topical steroids to tame the inflammatory cascade and then a rapid taper to long-term maintenance therapy, just like the patient with intraocular inflammation. I have suggested we use the term “ocular surface inflammatory disease” to remind us that the core issue in these diseases is inflammation and to lead us to consider more aggressive initial therapy.

Remissions and exacerbations are common, and occasionally these require another short course of topical steroids. I believe ophthalmologists as a whole are relatively “steroid shy” because of potentially serious complications including steroid-induced glaucoma and secondary cataract, but newer steroids such as loteprednol, which is now also available in an ointment form along with two strengths of suspension, reduce these risks significantly. For the patient who requires a generic alternative for economic reasons, I find fluorometholone is an effective drop with a similar safety profile. In more severe disease, I am even comfortable using our most powerful steroid, difluprednate, for a short course of treatment to generate remission and then transitioning to the softer steroids.

One more thought about allergy. I believe we are missing a great opportunity to teach our patients how to avoid the majority of their seasonal and acute allergic conjunctivitis problems. The missed opportunity is the use of an antihistamine/mast cell stabilizer for prophylaxis of symptoms. I am a perfect example of this opportunity. I have seasonal allergic conjunctivitis symptoms in the spring and am severely allergic to cats. A drop or two of an antihistamine/mast cell stabilizer before visiting a family member who owns cats can turn a miserable evening and day or two after into a totally asymptomatic experience. In addition, a daily dose of these drops begun a week before pollen counts rise in the spring can completely eliminate seasonal allergic conjunctivitis signs and symptoms for me. Prophylaxis of any disease usually is far superior to any treatment, and in the case of most ocular allergy, prophylaxis is extremely simple but rarely recommended. The next time a patient presents with significant allergic conjunctivitis, ask a little about the cause and suggest prophylaxis with drops before exposure to the eliciting allergens to prevent the next season or acute exposure episode of ocular allergy before it happens.

Now to the other most common indication for anti-inflammatory therapy: intraocular surgery. I believe this concept of inflammation prophylaxis is critical in treating the inflammation associated with surgery. This means anti-inflammatory drops, including both a topical steroid and a topical NSAID, should be started before surgery. If you only use a topical steroid, start it before the surgery. If you use both, start both before the surgery. I find this approach generates not only less postoperative intraocular inflammation, but also clearer corneas and more comfortable eyes. Those of us who do a lot of corneal surgery have observed that the stressed corneal endothelium often responds positively to a kiss of topical steroids. Early pseudophakic bullous keratopathy can clear with a soft steroid given once or twice daily. Perhaps, as Eric Donnenfeld, MD, has suggested, this is related to the neuroectodermal origin of the corneal endothelium, as neurologic studies suggest steroids are protective of neuronal damage after trauma.

Finally, combining these thoughts, I will suggest perhaps my most controversial current approach. Ocular surface disease/ocular surface inflammatory disease, at least in a mild form including any dry eye, blepharitis/meibomian gland dysfunction or ocular allergy is present in nearly every senior patient who I schedule for cataract surgery. Rather than screening for ocular surface disease/ocular surface inflammatory disease in these patients, I just treat them all. Recent studies by Steve Lane, MD, have shown that the signs and symptoms of blepharitis and meibomian gland dysfunction almost universally respond within 1 week to treatment with an antibiotic/steroid drop combined with eyelid hygiene. Dry eye and ocular allergy respond as well.

So, I treat 100% of my cataract surgical patients for 1 week before surgery with a tobramycin/dexamethasone or tobramycin/loteprednol combination drop. I call this preoperative ocular surface preparation. Over several years, my complication rate with this 1 week of therapy has been zero, avoiding patients with known tobramycin allergy and using loteprednol in known steroid responders. I then transition to my regular regimen of fluoroquinolone, steroid and NSAID on the day of surgery, giving all three before surgery for three to four doses with the dilating drops. It has worked so well that a couple of years ago I decided to just treat all my surgical patients — corneal, surface and intraocular — with the same preoperative regimen. I encourage others to give this approach a try and see if you as well find your patients have greater comfort, whiter eyes, clearer corneas and less inflammation after surgery.