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Pred Forte: The big gun anti-inflammatory drop
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Pred Forte 1% (prednisolone acetate, Allergan) has been the steroid ophthalmic drop of choice for moderate to severe anterior segment inflammation for many years. It has an excellent track record for treatment of anterior uveitis and as a postoperative anti-inflammatory for cataract surgery patients. If you want a steroid proven to reduce inflammation, Pred Forte should be considered.
Pred Forte 1% is a suspension that also contains benzalkonium chloride, poly sorbate 80, boric acid, sodium citrate, sodium bisulfite, sodium chloride, edetate disodium, hydroxypropyl methylcellulose and purified water. These preservatives, buffers and lubricants have proven to be effective and provide a comfortable drop for the patient to use. It is supplied in bottle sizes of 1 mL, 5 mL and 15 mL. Because it is a suspension, the patient must shake the bottle before drops are instilled.
Prednisolone acetate works as an anti-inflammatory by inhibiting capillary dilation, fibrin deposition, phagocytic migration and deposition of collagen. This action helps reduce scar formation and edema caused by inflammation. These inflammations can be caused by auto-immune reactions, injuries, surgery and some infections.
Correct diagnosis is still the key to how and when Pred Forte should be used for treatment. It is contraindicated with purulent bacterial infections, superficial herpes simplex, most other viral infections of the eye, ocular tuberculosis and fungal diseases of the eye.
Prednisolone acetate is indicated for the following: anterior uveitis, postoperative cataract care, noninfectious anterior segment inflammation, prevention of scarring after injury and treatment for some severe allergic reactions.
Treating anterior uveitis
To treat moderate to severe anterior uveitis (grade 2 or greater cells and flare, ciliary flush, keratitic precipitates, photophobia), Pred Forte 1% should be given every 2 hours when awake for 2 days, homatropine 5% should be given four times daily and 600 mg of ibuprofen should be given every 4 hours (maximum ibuprofen dose is 3,200 to 3,600 mg per day depending on weight, health and age).
Check again on day 3; if cells, flare and ciliary flush have decreased, taper Pred Forte 1% to four times a day, continue homatropine 5% four times a day and reduce ibuprofen to 400 mg every 4 hours. Check again on day 6 or 7, and determine if the uveitis is improving. Monitor for posterior synechiae and increase in intraocular pressure (IOP). Taper the course of treatment slowly as the anterior chamber clears.
To treat mild anterior uveitis (few cells, limited flare, few — if any — keratitic precipitates, mild photophobia), Pred Forte 1% should be given four times daily, homatropine 2% should be given twice daily and 600 mg of ibuprofen should be given four times daily. Check within 3 to 5 days. When the anterior chamber is clear, gradually taper the drops and ibuprofen.
For postoperative cataract care, TobraDex (tobramycin dexamethasone, Alcon) or Maxitrol (neomycin, polymyxin b sulfates, dexamethasone, Alcon) should be given four times daily for the first 7 days. Begin Pred Forte 1% four times daily starting on day 8 for 2 weeks, then twice daily for 2 weeks. This treatment varies with the amount of inflammation after the surgery. With clear cornea and no-stitch cataract surgery, the postoperative treatment with Pred Forte may not need to be as intensive as the above treatment plan.
Noninfectious conditions
To treat noninfectious anterior segment inflammation (episcleritis, nodular episcleritis, ultraviolet burns, chemical burns), Pred Forte 1% should be given four times daily. Check in 5 to 7 days to determine if drops should be tapered. With burns, an antibiotic is usually added to help prevent infection. Homatropine may be appropriate to reduce ciliary spasm and the risk of traumatic uveitis.
Day one: To treat acute allergic reaction, a pulse dose of Pred Forte 1% should be given every 2 hours while awake on day one. Over-the-counter Benadryl Allergy (diphenhydramine HCl, Warner-Lambert) 25 mg and Naphcon A (pheniramine maleate, naphazoline HCl, Alcon) should be given four times a day, cold compresses should be used four times a day and saline rinses should be used four times a day. Check on day 2 to determine how to taper the medications.
Vernal conjunctivitis
To treat vernal conjunctivitis, a pulse dose of Pred Forte 1% should be given every 2 hours while awake on day one, then four times daily for 6 days. Livostin (levocabastine HCl, Ciba Vision), cold compresses and saline rinses should be used four times a day for 7 days. After 1 week, check for improvement of symptoms, and consider tapering the Pred Forte 1% and starting Alomide (lodoxamide tromethamine, Alcon) four times daily.
Pred Forte 1% is an excellent topical medication with a proven track record for the treatment of anterior uveitis. It is not an absolute that the listed treatment plans will calm uveitis. Some cases will require injections, oral steroids and other heroic efforts. If the inflammation is not getting better with aggressive treatment, do not hesitate to refer the patient to an anterior segment specialist.
When treating noninfectious anterior surface inflammations with Pred Forte 1%, improvement is likely with a relatively small chance of complications. Remember to monitor IOP and always be concerned about herpes simplex. Patients with a history of fever blister, especially those with an active fever blister or past herpetic keratitis, should be treated cautiously. Consider nonsteroidal anti-inflammatory drugs or decongestants as an alternative treatment.
Pred Forte 1% is a comfortable, inexpensive treatment for uveitis and other anterior segment inflammations. Respect and use its strengths, but be cautious of the complications, even when used appropriately.
For Your Information:
- Pred Forte 1% is available from Allergan, 2525 DuPont Drive, Irvine, CA 92612; (800) 366-6554; fax: (800) 752-7006.