The irony is that some older steroids have made a resurgence to help with inflammation on the anterior surface.
One such example—Eyevance’s Flarex 0.1% (fluorometholone acetate ophthalmic suspension)—provides a better penetration of the acetate formulation, which allows the steroid to access the anterior surface in all areas needed.
Whereas Bausch + Lomb’s Zylet (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) works as a compliment for patients with both a bacterial infection and inflammation, Flarex proves to be an effective tool for when inflammation on the ocular surface needs to be quelled.
Another area where steroids have made an impact is in the way refractive and cataract refractive surgical patients are managed.
In the late 1990s—when photorefractive keratectomy (PRK) and laser-assisted in situ keratomileusis (LASIK) were a burgeoning surgery—ODs relied on prednisolone acetate to be the work horse.
Yet, for patients who developed corneal haze secondary to PRK/epi-LASIK, ODs also had to work with an increased intraocular pressure (IOP) and potential glaucomatous damage.
LASIK is also prone to the sequelae of steroids. In fact, there have been cases of secondary glaucoma reported due to an increase in IOP from a steroid.
Extreme elevation induced fluid to fill under the flap. Subsequently, these patients had IOP measurements within normal limits, since the tonometer was bouncing off the fluid under the flap.
The Ocular Response Analyzer ([ORA] Reichert) can be used to avoid mistaking IOP post-surgery. This tightrope was balanced by the addition of loteprednol (Lotemax, Alrex; Baush + Lomb). The ester-based steroid was able to be broken down faster and showed fewer IOP spikes.
Because refractive surgery induces inflammation that can limit visual acuity potential or have transient effects on the cornea, steroids are a necessity.
This is also true of modern-day cataract surgery. The use of the femtosecond laser has placed a safety net of predictability for cataract patients—particularly those with a more dense lens. The laser takes away unnecessary phacoemulsification that can induce a greater internal inflammation.
Yet ODs continue to look for opportunities to make this healing process faster and safer.
Bausch + Lomb took lotprednol to submicron particle size and put Lotemax SM (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) on the market.
Lotemax SM was also designed to be patient-friendly with the moisturizing ingredients glycerin and propylene glycol, a pH close to that of human tears and the lowest preservative percentage (0.003% benzalkonium chloride), in a loteprednol etabonate formulation.
The same was done by Kala Pharmaceuticals with the introduction of its steroid Inveltys (loteprednol etabonate ophthalmic suspension 1%), which utilized Kala’s proprietary AMPPLIFY Drug Delivery Technology to enhance penetration into target tissues of the eye.
Inveltys boasts a bid dosing, which can be a benefit for patient compliance. This does not take into account tried-and-true steroids such as Pred Forte and Durezol (difluprednate ophthalmic emulsion, Novartis).
There are now more drugs to personalize the anti-inflammatory drop of choice. This is exemplified when looking at a procedure such as the Kamra Inlay (CorneaGen). This inlay works best when the cornea is free of edema or inflammation.
However, it is known that subclinical and clinical inflammation follows patients in their daily activities, especially after surgery. ODs can now use effective penetrating steroids, less IOP spiking, and better dosing for these patients for a more prolonged taper.