Using Topical Steroids

How do you use steroid drops to treat ocular surface disease?

ESEN K. AKPEK, MD: I frequently use topical steroids in the treatment of inflammatory ocular surface diseases, including but not limited to dry eye syndrome, particularly in the setting of Sjögren’s syndrome, thyroid eye disease, graft versus host disease, allergic keratoconjunctivitis and significant anterior blepharitis. I usually place the patient on a high-dose regimen at the beginning of the course, rather than escalate treatment, to quickly induce remission of the inflammation. I almost always pair topical steroids with topical cyclosporine 0.05% or 1% as a steroid-sparing agent. My goal in doing this is to be able to taper the steroid over 4 to 6 weeks and use the topical cyclosporine as a maintenance treatment. I prefer a topical steroid eye drop or ointment that doesn’t contain the preservative benzalkonium chloride (BAK). I worry about the toxicity of BAK in these cases, which could be interpreted falsely as “no response” to treatment. Also, checking intraocular pressure frequently is part of the regimen to make sure we don’t get pressure spikes.

JOSEPH TAUBER, MD: Topical steroids have an important place in the treatment of ocular surface disease, and clinical judgment is required to make optimal use of the therapeutic benefits these medications provide. I use low-dose loteprednol 0.2% often to bring active allergic disease under control, and I find that higher-potency steroids are rarely needed. I rarely use steroids in the treatment of aqueous tear underproduction and find that topical cyclosporine is quite well tolerated, particularly when my patients are informed to expect transient burning after instillation of the eye drop. Topical steroids are often useful to suppress active meibomian gland disease and occasionally necessary for long-term control of inflammation. Of course, many forms of inflammatory keratitis that are related to ocular surface disease require moderate- to higher-dose prednisolone acetate 1% to preserve corneal clarity and vision, and I find a distinct advantage to the brand-name preparation. I have found a limited role for difluprednate, in settings of more severe inflammation not complicated by elevated IOP. I have experienced several cases of marked IOP elevation with difluprednate, limiting me from increased utilization of this potent steroid preparation. All clinicians should be familiar with the nuances of different steroid eye drops to properly manage ocular surface disease.

STEPHEN C. PFLUGFELDER, MD: I routinely use corticosteroids to treat ocular irritation symptoms and corneal epithelial disease in patients with tear dysfunction. Corticosteroids are potent broad-spectrum anti-inflammatory mediators that inhibit production of inflammatory cytokines, lipid mediators and matrix metalloproteinases. Patients treated with steroid eye drops often have a rapid improvement in ocular irritation symptoms and severity of corneal epithelial disease. Steroids can jump-start therapy when they are combined with other therapies, such as topical cyclosporine or oral n-3 essential fatty acid supplements that require weeks to show improvement. Preservative-free dexamethasone 0.01% to 0.1% is my corticosteroid of choice. Because this medication has to be made by a formulation pharmacy and is not covered by prescription drug plans, I often use loteprednol 0.5% or fluorometholone 0.1%, both of which are commercially available. I typically start steroid eye drops 4 times daily for 2 weeks and taper to twice daily for another 2 weeks. At that point, I recommend stopping the drop. If the patient requires topical steroids to be functional, I may continue the eye drop once daily, closely observing for steroid-related complications.

BENNIE H. JENG, MD: Topical steroid drops are definitely in my armamentarium for treating ocular surface disease that is inflammatory in origin, most commonly for dry eyes secondary to etiologies such as graft-versus-host disease. I prefer preservative-free dexamethasone 0.1%. Since this compounded medication may be difficult for some patients to obtain, I will offer prednisolone phosphate 1%, if necessary. However, if any sign of preservative toxicity appears, I will insist on the compounded medication. I start my dosing at 4 times daily and titrate down as I see the effect. If a low dose of topical steroids seems to be necessary for chronic maintenance therapy, then I will switch to cyclosporine A 1% (also compounded). As a final thought, anytime steroids are used, I will monitor IOP carefully.

ELMER TU, MD: Short courses of topical corticosteroids for ocular surface disorders can be beneficial both therapeutically and diagnostically. In patients who have responded either poorly or paradoxically to a variety of other therapies, the use of compounded preservative-free topical methylprednisolone 1% as little as 3 to 4 times per day can quickly demonstrate whether inflammation is playing a prominent role in the patient’s signs and symptoms without the background toxicity integral to most other preparations. Once inflammation is identified and suppressed and the viscous cycle of the ocular surface reset, other immunosuppressive agents or lowest-dose topical corticosteroids can be used for long term maintenance.