Corticosteroids still most effective treatment for ocular inflammation

Issue: January 1996

mugshot --- Siret D. Jaanus, PhD,

ANAHEIM, Calif.—When it comes to dealing with ocular inflammation, the treatment choices are still fairly straightforward.

"No matter what else is in our armamentarium," corticosteroids have remained the best drugs for treating inflammation, said Siret D. Jaanus, PhD, at a seminar here at the International Vision Expo. And for patients who suffer side effects from steroids, non-steroidal anti-inflammatory drugs (NSAIDs) are a good alternative.

Jaanus, co-editor of Clinical Ocular Pharmacology (3rd ed., 1995, Butterworth-Heinemann), said the secret for using these drugs is to rule out what the patient does not have and get a good history.

Use topical steroids first

While steroids can be used topically or systemically, Jaanus said, "use topical whenever possible. Try to stay away from oral steroids for as long as you can. Topicals do just as well for anterior segment inflammations."

Primarily, four steroids are available: prednisolone, fluorometholone, dexamethasone and medrysone. On the horizon are two new "soft" steroids that have good anti-inflammatory effect but are metabolized quickly, thus reducing side effects and the likelihood of raising intraocular pressure (IOP): rimexolone (Vexol, Alcon); and loteprednol (Pharmos, Lotemax, should be available in 1996).

The individual steroids differ a bit, Jaanus said, but "Pred Forte (prednisolone, Allergan) is still the most potent anti-inflammatory steroid in our armamentarium."

Indications for corticosteroids include:

Any kind of allergic ocular disease--However, not minor ocular disease, which can effectively be treated with mast cell inhibitors, antihistamines or NSAIDs.
Contact dermatitis--"I don't know anything else that's better for contact dermatitis except avoiding the cause of it," Jaanus said.
Herpes zoster--But don't use for herpes simplex.
Chemical burns--While conventional wisdom may say to not use steroids when the epithelium is not intact, Jaanus said the drugs and a prophylactic topical antibiotic work very well here to prevent tissue damage.
Uveitis
Scleritis, episcleritis
Interstitial keratitis

Jaanus said that because research is revealing that almost everyone responds differently, "using steroids is more of an art than a science." Dosage is not controlled by giving higher concentrations, but instead by increasing the frequency of administration. Jaanus noted that suspension steroids must be shaken at least 20 times to ensure uniform dosage.

The timing is key. "The earlier you use them in the inflammatory process, the better effect you get," she said. "We don't pussyfoot around any more. Get in, get the inflammation under control and then get the patient off the steroid as quickly as possible."

Patient follow-up is important, she said. "Don't let them get away from you." Patients should never be suddenly taken off a steroid, particularly if they have been on it a while. They must be tapered.

There can also be side effects, although many follow chronic, long-term oral use. Jaanus warned that the primary concern with topical steroid use is glaucoma, as the steroids can impede aqueous outflow. Contraindications include fungal keratitis, diabetes, herpes ulcers and systemic hypertension. Steroids, when given orally, can also aggravate peptic ulcers.

NSAIDs for long-term use

Jaanus said NSAIDs, which have fewer side effects than steroids and do not affect IOP as much, are becoming increasingly popular, particularly in cases where anti-inflammatory agents must be administered for a long time.

NSAIDs have anti-inflammatory, anti-pyretic and analgesic effects, she said. The four NSAIDs and their treatment strengths are:

Diclofenac (Voltaren, CibaVision)--postoperative inflammation; corneal pain following refractive surgery.
Flurbiprofen (Ocufen, Allergan)--intraoperative miosis.
Ketorolac tromethamine (Acular, Allergan)--seasonal conjunctivitis; itching; allergies.
Suprofen (Profenal, Alcon)--intraoperative miosis; some indication for giant papillary conjunctivitis.

The NSAIDs do not exacerbate infections and do not block the effects of glaucoma medications, Jaanus said. Also, they do not need to be tapered.

She cautioned that NSAIDs can delay early healing of the cornea, and sometimes it is better to wait 24 hours before administering them after surgery, although she conceded that "this is not always practical."

The most common problem with NSAIDs is burning and stinging. Soft contact lens wear is contraindicated.