The Comparison of Efficacies of Topical Corticosteroids
and Nonsteroidal Anti-inflammatory Drops On Dry Eye Patients:
A Clinical and Immunocytochemical Study
A.M. Avunduk, et. al, AJO, October 2003
Key Excerpts and Commentary
“The most important results of this study were that treatment
with topical corticosteroid drops significantly improved the
ocular signs and symptoms of moderate-to-severe dry eye patients,
and these improvements were associated with the reduction of
HLA-DR+ cells and an increase of PAS+ cells in conjunctival
impression cytology specimens. However, ATS (topical artificial
tears substitute) alone or ATS plus NSAID did not change the
parameters.”
“Our study provides evidence that TSD (topical corticosteroid
eye drops) treatment improved clinical signs and symptoms,
but topical ATS plus NSAID and ATS alone had no effect on these
subjective and objective clinical parameters. The beneficial
effect of corticosteroidal drops in the treatment of KCS has
been reported before. Marsh and Pflugfelder treated severe
KCS patients with Sjögren syndrome with nonpreserved topical
methylprednisolone and observed impressive improvement in clinical
parameters. They reported that 2 weeks of therapy with unpreserved
TSD significantly improved clinical parameters in severe KCS.”
“Topical steroids had a clear beneficial effect both on the
subjective and objective clinical parameters of moderate-to-severe
dry eye patients. These effects were associated with the reduction
of inflammation markers of conjunctival epithelial cells. Based
on the data provided, it may be speculated that conjunctival
inflammation is a primary event in the pathogenesis of KCS
rather than a secondary finding, because the decreasing surface
friction by ATS did not provide any beneficial effect. We think
that TSD might be a good alternative to topical CsA therapy
in the treatment of dry eye disease. A comparison of the two
drugs would clarify this hypothesis.”
M & T Commentary
We have all experienced patients who find great relief with
artificial tears, and those you find no relief. We were surprised
at the minimal benefit from artificial tears in this study.
It is not surprising to us at how poorly nonsteroidal anti-inflammatory
eyedrops performed. It is now well established that tissue
inflammation is at least partially responsible for the tear
film dysfunction seen in most patients with clinically significant
dry eyes. When it comes to inflammation, no drug class out-performs
a topical corticosteroid. Because of the greatly enhanced safety
profile of loteprednol, we use Lotemax as our dry eye steroid
of choice. Although all therapy must be individualized, we
would consider treating a “typical” moderate-to-severe dry
eye patient with Lotemax q.i.d. for a week, then t.i.d. for
a week, and then maintain the patient at b.i.d. for a month.
If Lotemax has significantly benefited the patient, we have
proven that inflammation is a treatable of component of the
ocular surface dryness in this patient, and we may opt to continue
the patient on cyclosporin eyedrops b.i.d. for a few months.
For perspective, many stromal herpes, chronic uveitis, and
corneal transplant patients are safely maintained on a drop
of Pred-Forte a day for years. Loteprednol enjoys a much enhanced
safety profile relative to prednisolone. It should be emphasized
that topical corticosteroid therapy is adjunctive to artificial
tears and gels, punctal plugs, oral doxycycline, oral omega-3
essential fatty acid supplementation, topical ophthalmic cyclosporin,
and other therapeutic interventions.
Regarding topical 0.05% cyclosporin, we are finding that those
patients who are helped with loteprednol can be well-maintained
on cyclosporin following four to six weeks of initial corticosteroid
treatment. It may be that the rapid onset of action of a highly
efficacious steroid sets the stage for more enhanced performance
of the cyclosporin. Furthermore, if a patient is helped by
the loteprednol, this is a strong indicator that cyclosporin
therapy will be beneficial. Conversely, if no real benefit
is obtained with loteprednol, then little response would be
expected from cyclosporin. Some doctors simply maintain these
patients on a drop on loteprednol daily, or every other day,
for a few months, or blend in Restasis over the final two weeks
of Lotemax therapy. Both of these approaches are rational.
Whether long-term use of cyclosporin twice daily, or loteprednol
once daily will best serve these patients is unknown. We would
love to see a good, sound, rigorously objective study reveal
this knowledge. Always follow scientific, peer-reviewed literature
to stay current.
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