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Encourage patients to do the ‘eye drop shake’
OK, colleagues. Thinking back to your boards, answer this easy question:
How long do pressure spikes typically take to develop after starting a topical ophthalmic steroid?
a. 1 day
b. 2 to 5 days
c. Around 2 weeks
d. After 3 to 4 weeks
If we believe our classic teaching, the correct answer is, “c. Around 2 weeks.”
However, a recent, better understanding about steroid delivery though eye drops has helped us to realize that, with a consistently delivered steroid, pressure spikes frequently occur much sooner — as early as 3 days.
Prednisolone acetate, the most commonly used eye steroid, is a suspension that requires vigorous shaking at least 20 times to thoroughly mix the bottle contents. Several studies have shown that if a patient fails to do this, the first drops out of the bottle have a much lower concentration of steroid, and the last, delivered right around 2 weeks into therapy, have much more. Aha! Now we know why a “steroid response” was thought to occur at least 2 weeks into therapy. By the way, this very same effect occurs whether brand-name or generic prednisolone acetate is used, although the effect may be more pronounced in the case of generics.
The fact is, our patients just don’t shake these medications as they should. How ironic is it that when a steroid is needed most, shortly after surgery is performed, the least drug is actually delivered. Moreover, when a tapering dose is desired, heavy doses are inadvertently administered.
Thankfully, newer steroid formulations such as Durezol (difluprednate ophthalmic solution 0.05%, Alcon) and Lotemax (loteprednol etabonate ophthalmic gel 0.5%, Bausch + Lomb) don’t require shaking and provide a much more consistent delivery of medication per drop. I applaud these manufacturers for producing drops that are people-proof, because most of us just can’t get our patients consistently to shake any bottle of drops adequately.
Or, maybe we should ask our patients to take their eye drops while they are doing the Harlem Shake.
Disclosure: Hovanesian is a consultant to Allergan, Bausch & Lomb, Fera, and Sarcode pharmaceuticals.