According to the CDC, traumatic brain injury (TBI) is a leading cause of death and disability in the US. Each year an estimated 1.5 million Americans sustain a TBI. From 2006 to 2014, the number of TBI-related emergency department visits, hospitalizations, and deaths increased by 53%.1 According to the US Department of Defense, up to 75% of the armed forces that suffered a TBI reported visual changes.2

Based on these data, approximately 1.1 million Americans with TBI may visit eye care practitioners’ offices each year reporting significant changes to quality of life and requiring assistance with activities of daily living.

Several types of visual dysfunctions are common after effects of TBI. Blast injury, penetrating injuries, and blunt trauma may cause structural damage to the eye or lesions or swelling in the brain that can disrupt visual pathways.3 In communicating with patients and patient care teams, it is important to help non-eye care providers understand that the majority of the sequelae to TBI is not ocular related but related to changes in the brain and the pathways that control the eyes.

Between 2000 and early 2016, over 347,962 TBIs were diagnosed in the U.S. armed forces, with approximately 80% classified as mild TBIs (mTBI).3

In a study to determine the prevalence of vision dysfunctions after mTBI, 100 patients were examined, and 69% had 1 or more of the following vision diagnoses:

In all, 46% of patients had more than 1 vision diagnosis.4 For review of visual changes in moderate to severe brain injury including visual field loss, please refer to part 1 of this series (“Vision rehabilitation of patients with stroke,” November 2020).

Most mTBI symptoms resolve after 28 days.5 If a patient presents with lingering concerns, The national Vision Center of Excellence provides an evidence-based algorithm of care for ophthalmology and optometry in patients reporting visual changes post-mTBI.3 Often, these patients require 2 visits for the clinician to gather all pertinent data to provide optometric vision therapy. For the primary care clinician, the following protocol is useful.

A comprehensive eye exam is the foundation for a detailed functional vision assessment, all beginning with a detailed case history. The Brain Injury Vision Symptom Survey (Figure 1) can guide the new or unfamiliar clinician on the types of questions to ask.

Best-corrected visual acuity should be measured via traditional means. Dynamic visual acuity should follow to compare visual acuity while the head is in motion relative to the static baseline acuity. This assessment probes the ability of the vestibular ocular reflex (VOR) to maintain stable vision during head movement, known as gaze stabilization.

To perform, use the best corrected visual acuity as the smallest line, and present 4 lines of acuity above it. If best-corrected acuity is 20/20, the Snellen chart should show 20/50 progressing down to 20/20. While viewing the chart, ask the patient to move their head side to side (approximately 20˚ left and right of midline) at a frequency of 2 complete side-to-side cycles per second and to read to the lowest line that they can. A reduction in acuity to 2 lines worse than baseline indicates a defect in the responsiveness of the VOR.

Computerized visual fields should be performed to rule out ischemic or compressive events along the traditional sight pathway. A careful anterior and posterior segment evaluation will reassure the clinician that all visual complaints are related to visual cortical phenomenon.

To measure binocular function, start with a cover test at distance and near. While the patient is viewing the target with good posture and head position, ask the patient if the target moves side to side, up and down, or diagonal. This can clue the clinician to identify slight vertical heterophoria that can cause significant symptoms.

While performing a pursuit and saccade assessment, ask the patient if moving the eyes triggers symptoms and note hypermetric or hypometric function.

In addition to a traditional near-point of convergence (NPC) assessment, a red lens NPC test can pick up subtle deficiencies in sensory fusion. To perform, ask the patient to put on red/green glasses over their habitual near correction and use a penlight. Starting outside the range of dissociation noted on the traditional NPC, move the penlight inward until diplopia is reported, and repeat 3 times. Diplopia at 7 cm or beyond is a failure.

A small study showed that 76% of mTBI sufferers complained of photophobia.6 Evidence also shows that mTBI sufferers have a lower critical flicker frequency,7 indicating this patient population is more sensitive to the frequency at which an intermittent light stimulus appears to be completely steady. Therefore, due to the amount of screen time in this era, mTBI patients often are more comfortable wearing the highest level of ophthalmic grade blue-blocking lenses. These are a readily available tool in the primary care clinician’s arsenal that can provide dramatic relief.

Approximately 28 days or more after injury, the presence of reduced dynamic visual acuity, a cover test outside clinical norms and/or with the presence of a vertical heterophoria, symptoms during eye movements, and/or reduced NPC indicate a referral to a colleague who can offer optometric vision therapy.

Working with patients who have suffered from TBI is a rewarding aspect of optometric care. For more information on how to work with this patient population, visit https://visionhelp.com/concussion/ or www.noravisionrehab.com.

TBI: get the facts. CDC. Updated March 11, 2019. Accessed February 28, 2021. https://www.cdc.gov/traumaticbraininjury/ get_the_facts.html

Goodrich GL, Kirby J, Cockerham G, et al. Visual function in patients of a polytrauma rehabilitation center: a descriptive study. 

. 2007;44(7):929-36. doi: 10.1682/ jrrd.2007.01.0003

Eye and vision care followomg blast exposure and/or possible traumatic brain injury. Vision Center of Excellence. Updated 24 November 2015. Accessed February 28, 2021. https://vce. health.mil/Products/Additional-Resources/TBI-CR-Photo

Master CL, Scheiman M, Gallaway M, et al. Vision diagnoses are common after concussion in adolescents. 

(Phila). 2016;55(3):260-267. doi: 10.1177/0009922815594367

McCrory P, Meeuwisse W, Dvořák J, Divine J. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. 

. 2017;51:838-847. doi:10.1136/ bjsports-2017-097699

Clark J, Hasselfeld K, Bigsby K, et al. Colored glasses to mitigate photophobia symptoms posttraumatic brain injury. 

. 2017;52(8): 725-729. doi: 10.4085/1062-6050-52.4.04

Chang TTL, Ciuffreda KJ, Kapoor N. Critical flicker frequency and related symptoms in mild traumatic brain injury. 

. 2007;21(10):1055-1062. doi: 10.1080/02699050701591437

Articles

A protocol of patient questions and clinical measurements can show a need for therapy

Vision rehabilitation of patients with traumatic brain injury

The use of scleral contact lenses has grown significantly in the past year with an associated increase in research.

This type of lens can be classified as corneo-scleral or fully scleral depending on the presence or absence of corneal bearing.

One of the main advantages of this option for refractive correction is that the tear reservoir between the posterior surface of the contact lens and the anterior corneal surface allows a significant neutralization of anterior corneal aberrations, which are relevant considering the contribution of this optical surface to the total power of the eye.

Because these lenses are fitted with minimal or no corneal bear, the fitting process can be simplified in patients with highly irregular anterior corneal profiles.

 For this reason, the use of these contact lenses has been intensively investigated for the correction of irregular astigmatism in post-corneal refractive surgery4,5 and postkeratoplasty corneas

 as well as in ectatic corneal disorders.

Although there is a consensus among practitioners with more than 5 years of scleral lens experience about most aspects of contact lens management,

 some factors require more research, such as the management of multifocality for presbyopia correction.

To date, only the outcomes of conventional soft or rigid gas permeable corneal contact lenses have been evaluated,

 despite the availability of some multifocal scleral contact lens designs.

Recently, a new model of multifocal corneo-scleral contact lens has been commercially released, called Presbycustom, which provides the option of customizing not only the fitting parameters to adjust the lens over the cornea and sclera, but also the type of multifocality induced. What follows are the results obtained with this new modality of contact lens in eyes with previous refractive surgery and significant high-order corneal aberrations.

The Presbycustom contact lens (paflufocon D, Dk 100 Fatt units) is the result of a proof-of-concept research project developed by Laboratorios Lenticon SA in collaboration with the Group of Optics and Visual Perception of the University of Alicante in Spain.

 It is a corneo-scleral contact lens made of highly gas-permeable material.

The lens is customized according to the anterior corneal geometry, the level of ocular high-order aberrations, and the peculiarities of pupil dynamics. It comprises 3 different areas: corneal, limbal, and scleral (Figure 1).

The corneal area has a variable diameter with fixed back-surface asphericity and central anterior surface asphericity that is modified according to the aberrometric induction required. Specifically, the depth of focus achieved with the contact lens is set by customizing the induction of primary and secondary spherical aberration. It has been demonstrated that combining primary and secondary spherical aberrations of opposite sign is significantly more effective for expanding the depth of focus than other aberrometric options.

The scleral area of the contact lens allows a smooth bearing over the sclero-conjunctival surface, facilitating comfortable wearing (Figure 2). The distribution of the tear film below the different areas of the contact lens generates a characteristic fluorogram consisting of central tear pooling with paracentral alignment and significant edge clearing (Figure 3).

We recently conducted a prospective pilot study in the Department of Ophthalmology of the Vithas Medimar International Hospital in Alicante, Spain, and in the Optometry Clinic of the University of Alicante. The study included 8 eyes of 8 patients (age 45 to 56 years) with previous LASIK surgery requiring presbyopia correction. All cases had reduced corrected distance visual acuity (CDVA) and significant corneal irregularity.

A complete ocular examination was performed before and 1 month after fitting the customized multifocal scleral contract lens, including visual and refractive analysis, corneal topography, pachymetry and evaluation of corneal and ocular aberrations with the VX120 multidiagnostic system (Luneau Technology, Inc). The contact lens was customized according to the anterior corneal geometry, level of ocular higher-order aberrations and pupil diameter.

The mean corneal radius of the lens fitted was 8.06 ± 0.47 mm; the mean scleral radius was 7.68 ± 0.20 mm. The mean central eccentricity used for the lenses was 0.44 ± 0.33, whereas a fixed posterior eccentricity of 0.63 was used in all contact lenses fitted.

Mean monocular logMAR CDVA changed from 0.21 ± 0.08 with spectacles before fitting to 0.08 ± 0.08 with the contact lens fitted (

=.04). Mean logMAR binocular distance and near visual acuity values with the contact lens were 0.02 ± 0.03 and 0.14 ± 0.11, respectively. Mean logMAR-corrected visual acuities for defocus levels of -0.50 D, -1.00 D, -1.50 D, -2.00 D, and -2.50 D were 0.03 ± 0.06, 0.08 ± 0.08, 0.19 ± 0.17, 0.24 ± 0.10 and 0.31 ± 0.12, respectively (Figure 4).

All patients reported spectacle independence for reading and high levels of contact lens tolerance and satisfaction. No complications were reported during the first year of follow-up.

The selection of an appropriate combination of primary and secondary spherical aberration of opposite sign according to the aberrometric status of the eye can be useful to optimize the depth of focus required for presbyopia correction. This approach can be used to correct presbyopia in irregular corneas with a scleral contact lens.

This pilot study showed that complete visual rehabilitation can be achieved with a customized multifocal scleral lens in presbyopic eyes with previous unsuccessful corneal refractive surgery. These preliminary results should be corroborated in the long term as well as in a larger population.

Originally appeared in the November 2020 issue of Ophthalmology Times Europe®

Davies I. Scleral publications & contact lens category growth. 

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2014;37:240-250. doi: 10.1016/j.clae.2014.02.002

Piñero DP. Management of keratoconus with scleral contact lenses. In: Barbara A, ed. 

Controversies in the Management of Keratoconus

. Springer International Publishing; 2019.

Porcar E, España E, Montalt JC, et al. Post-LASIK visual quality with a corneoscleral contact lens to treat irregular corneas. 

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Piñero DP. Full scleral lens fitting in an eye with high corneal astigmatism after radial keratotomy and several retreatments. 

. February 2017. Accessed March 2, 2020. http:// netherlens.com/february_2017

Barnett M, Lien V, Li JY, Durbin-Johnson B, Mannis MJ. Use of scleral lenses and miniscleral lenses after penetrating keratoplasty. 

2016;42:185-189. doi: 10.1097/ ICL.0000000000000163

Serramito-Blanco M, Carpena-Torres C, Carballo J, et al. Anterior corneal curvature and aberration changes after scleral lens wear in keratoconus patients with and without ring segments. 

. 2019;45:141-148. doi: 10.1097/ICL.0000000000000534

Piñero DP. Fitting of a new design of full scleral contact lens in advanced keratoconus with previous implantation of intracorneal ring segments. 

. 2015;4(2):56-59. doi: 10.5005/jp-journals-10025-1099

Harthan J, Nau CB, Barr J, et al. Scleral lens prescription and management practices: the SCOPE study. 

. 2018;44 (suppl 1):S228-S232. doi: 10.1097/ ICL.0000000000000387

. Pérez-Prados R, Piñero DP, Pérez-Cambrodí RJ, Madrid-Costa D. Soft multifocal simultaneous image contact lenses: a review. 

. 2017;100:107-127. doi: 10.1111/cxo.12488

. Piñero DP, Carracedo G, Ruiz-Fortes P, Pérez-Cambrodí RJ. Comparative analysis of the visual performance and aberrometric outcomes with a new hybrid and two silicone hydrogel multifocal contact lenses: a pilot study. 

. 2015;98:451-458. doi: 10.1111/cxo.12299

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. Yi F, Iskander R, Collins M. Depth of focus and visual acuity with primary and secondary spherical aberration. 

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. Benard Y, Lopez-Gil N, Legras R. Optimizing the subjective depth-of-focus with combinations of fourth- and sixth-order spherical aberration. 

. 2011;51:2471-2477. doi: 10.1016/j. visres.2011.10.003

Novel corneo-scleral contact lens offers visual rehabilitation in irregular corneas

Multifocal lenses for presbyopia in eyes with previous corneal surgery

Ophthalmic corticosteroids provide ODs with the opportunity to treat complex ocular conditions. Conditions that are rooted in inflammation and require acute alleviation respond well to corticosteroids.

Steroids have been embraced as postoperative therapy, in particular cataract surgery, to manage both pain and inflammation. Additionally, several conditions including dry eye, lid inflammation, allergic conjunctivitis, non-infectious infiltrative keratitis, and anterior uveitis, can benefit from temporary use of a topical corticosteroid. Although the information included in this article is not a comprehensive list of all indications for topical corticosteroids, conditions that would benefit from inflammation reduction may benefit from topical corticosteroids.

It is important to understand the risks with topical corticosteroid use. Corticosteroids can increase intraocular pressure (IOP), so it is critically important for practitioners to regularly assess IOPs while patients are using topical corticosteroids.

Although corticosteroids are frequently used on a short-term basis and then discontinued after the ocular condition is alleviated, it is critical to manage IOP elevations during treatment if the corticosteroid cannot be discontinued. This can be effectively performed by temporarily adding a topical ocular hypotensive agent that is not a prostaglandin analogue.

Additionally, patients who may require long-term corticosteroid therapy, such as corneal transplant patients, need to be monitored and managed if IOP elevates. Long-term corticosteroid use also increases the risk of developing posterior subcapsular cataract formation.

Corticosteroids should be used cautiously, and prolonged use can create susceptibility to bacterial, viral, and fungal infections. Additionally, usage can cause delayed healing. Topical corticosteroids are contraindicated in active viral disease, mycobacterial infection, and fungal infection. No corticosteroids are approved to be used while wearing contact lenses.

ODs must ensure that their understanding of the adverse effects of ophthalmic corticosteroids do not hinder appropriate use when indicated. Clinically, there are times that uncontrolled inflammatory ocular disease can cause significant damage, and corticosteroids—when used appropriately— optimize outcomes in these patients. As ODs reach for this class of pharmaceuticals, it is critical to understand advancements in the technologies available.

Next, we will review corticosteroids’ mechanism of action and recent advancements.

Ophthalmic corticosteroids provide tremendous anti-inflammatory activity when used to treat ocular inflammatory conditions. They work early on in the inflammatory cascade, resulting in a broad spectrum of anti-inflammatory activity.

The knowledge base of their mechanism of action is ongoing. When practitioners understand more about the way steroids work, they can appreciate mechanisms of action to help guide most appropriate use. Additionally, understanding the underlying mechanism of action will often make way for new pharmaceutical treatments to be developed within the category.

Harnessing the power of appropriate topical corticosteroid use for ocular conditions requires a deeper understanding of their mechanism of action. To date, it has been understood that they affect gene expression, resulting in anti-inflammatory, immunosuppressive, and anti-mitogenic effects. Steroids enter the cell via the cell membrane and bind to a glucocorticoid receptor (GR) within the cell, forming a corticosteroid-GR complex. This causes a conformational change, which allows the drug to enter the nucleus of the cell.

The cell’s DNA resides within the cell nucleus. The corticosteroid-GR complex requires access to the cell’s DNA to ultimately suppress the cell’s inflammatory response. The corticosteroid-GR complex allows for its entry into the cell nucleus, where it ultimately binds to the DNA. Corticosteroids act to suppress or stimulate gene transcription of DNA to messenger (mRNA) and translation of mRNA to protein. Steroids are known to stimulate production of lipocortin, an anti-inflammatory glycoprotein. Lipocortin inhibits Phospholipase A2, which releases arachidonic acid, the precursor of prostaglandins and leukotrienes. Corticosteroids also inhibit IL-1 production. Cumulatively, the steroids’ actions result in anti-inflammatory, immunosuppressive and anti-mitogenic effects.

Currently, several corticosteroid ophthalmic options are available. They are powerful, have manageable adverse effect profiles, and should not be overlooked when considering treatment options for ocular inflammation.

PRED FORTE - ALLERGAN (PREDNISOLONE ACETATE 1% OPHTHALMIC SUSPENSION) AND GENERICS

OMNIPRED (PREDNISOLONE ACETATE 1% OPHTHALMIC SUSPENSION)

PREDNISOLONE SODIUM PHOSPHATE (PREDNISOLONE SODIUM PHOSPHATE 1% OPHTHALMIC SOLUTION)

PRED MILD - ALLERGAN (PREDNISOLONE ACETATE 0.12% OPHTHALMIC SUSPENSION)

Prednisolone is a synthetic glucocorticoid structurally related to the naturally occurring glucocorticoid cortisol.

 With the prednisolone family of medications, one important thing to remember is that the acetate formation are suspensions—so patients must be counselled to vigorously shake bottles every time to resuspend the particles for dose uniformity.

Health care providers face ongoing challenges in providing their patients with intended prescribed medications without generic substitution. It is too common that a prescriber writes a brand-name prescription that is then automatically substituted in the pharmacy with a generic medication. The brand-to-generic substitution may allow for cost savings and equal efficacy, or the substitution may result in reduced treatment efficacy—potentially requiring additional office visits and an increased overall cost to health care. Watching for substituted ophthalmic medications is important because the size of particles, how the medications are manufactured, and inactive ingredients within the drops can influence medication penetration into the ocular surface and thus clinical efficacy.

Eyecare practitioners must continue to advocate for their patients and watch for potential switches that can occur at the pharmacy. Make sure to include “DAW” or “dispense as written” if the name brand product must be dispensed. Additionally, when patients return for follow-up visits, have them bring the product they are using to ensure it is the intended medications.

Research has shown that the particle size of Pred Forte, EconoPred Plus (Alcon), and generic prednisolone acetate 1% played a factor in dose consistency and concentration.

The generic form of prednisolone acetate had larger particle size and tended to agglomerate. Investigators also noted that the larger particle size could lead to clogging of the medication bottle, ultimately affecting the medication dosing. The particle sizes in Pred Forte were smaller and more uniform, allowing them to be properly suspended and more accurately dosed.

It has also been demonstrated that with appropriate shaking prior to use, generic prednisolone eyedrops deliver less of the intended concentration of prednisolone out of the bottle than the branded steroid.

Difluprednate is a synthetic derivative of prednisolone with structural differences including fluorine molecules on both C6 and C9.

 These differences result in difluprednate having a higher binding affinity to the glucocorticoid receptor compared to prednisolone.

Difluprednate 0.05% dosed 4 times a day was shown to be as effective as prednisolone acetate 1% dosed 8 times a day to treat anterior uveitis.

Although difluprednate offers an increased efficacy, this must be balanced with its higher likelihood of increasing IOP. Additionally, if IOP does increase with difluprednate use, it is likely to be higher than IOP increases seen with other topical corticosteroids.

Closely watch IOP with all topical corticosteroid use and manage these elevations. If medication use can be discontinued, it is the first recommendation.

 When discontinuing therapy is not an option because of the inflammatory condition being treated, the addition of an IOP-reducing agent is warranted. Prostaglandin analogues should be avoided for this purpose because they have been shown to induce uveitis.

Difluprednate 0.05% is packaged in an emulsion vehicle that provides consistent medication concentration throughout the bottle. This provides the benefit of no shaking required prior to medication instillation.

 Difluprednate 0.05% is not available as a generic, eliminating the possibility of generic substitution.

FLAREX (EYEVANCE - FLUOROMETHOLONE ACETATE 0.1% OPHTHALMIC SUSPENSION)

FLUOROMETHOLONE (ALLERGAN - FLUOROMETHOLONE 0.1% OPHTHALMIC SUSPENSION) AND GENERICS

FML (ALLERGAN - FLUOROMETHOLONE 0.1% OPHTHALMIC OINTMENT; OPHTHALMIC SUSPENSION)

FML FORTE (FLUOROMETHOLONE 0.25% OPHTHALMIC SUSPENSION)

Fluorometholone is a fluorinated structural analogue of progesterone.

 Fluorometholone is available in 2 forms: acetate and alcohol derivatives.20 It has been shown that the acetate derivative improves inflammation at a higher rate compared to the alcohol base.

 The acetate derivative makes the fluorometholone compound more lipophilic, allowing it to more efficiently penetrate into tissues.

Fluorometholone in the acetate form has been compared to prednisolone acetate for efficacy. In a pivotal clinical trial, investigators found that external ocular inflammation reduction was statistically equal between prednisolone and fluorometholone acetate.

MAXIDEX (DEXAMETHASONE 0.1% OPHTHALMIC SUSPENSION)

DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OPHTHALMIC SOLUTION

DEXTENZA -DEXAMETHASONE OPHTHALMIC INSERT 0.4MG, OCULAR THERAPEUTIX

Dexamethasone is a synthetic glucocorticoid structurally related to cortisol.

Dextenza is an intracanalicular insert placed in the punctum and delivers dexamethasone to the ocular surface for up to 30 days after placement.

Dexamethasone has been shown to be effective in controlling inflammation after cataract surgery,

 and Dextenza is approved for the reduction of inflammation and pain following ophthalmic surgery.

 This technology may serve a role in treating ocular surface disease when non-compliance with eye drops is a concern.

INVELTYS (LOTEPREDNOL ETABONATE 1% OPHTHALMIC SUSPENSION)

ALREX (LOTEPREDNOL ETABONATE OPHTHALMIC SUSPENSION 0.2%)

LOTEMAX (LOTEPREDNOL ETABONATE 0.5% OPHTHALMIC GEL, 0.5% OPHTHALMIC OINTMENT, AND 0.5% OPHTHALMIC SUSPENSION)

LOTEMAX SM (LOTEPREDNOL ETABONATE 0.38% OPHTHALMIC GEL) EYSUVIS (LOTEPREDNOL ETABONATE 0.25% OPHTHALMIC SUSPENSION, KALA PHARMACEUTICALS)

Loteprednol etabonate was designed as an analogue of prednisolone. Loteprednol etabonate stands out from other ophthalmic corticosteroids due to its ester at carbon 20 opposed to a ketone group. It allows for rapid metabolism after activation and lowers risk of adverse effects. Loteprednol etabonate is highly lipophilic, which allows increased binding to the glucocorticoid receptor.

Many alterations to the loteprednol entity have taken place since it was introduced in 1998. Initially, it was available as a 0.5% ophthalmic suspension. The concentration of loteprednol was reduced to 0.2%, and it was approved for ocular allergies as Alrex.

 Years later, Bausch + Lomb evolved the vehicle that carried the loteprednol molecule in Lotemax and created Lotemax Gel, which provided longer ocular surface residence to facilitate greater tissue penetration.

New delivery mechanisms and changes in particle size have revolutionized the way topical corticosteroids are delivered to the ocular surface. Lotemax SM is loteprednol 0.38% gel and delivers a submicron particle size (0.4 μm to 0.6 μm) for faster drug dissolution in tears.

 Additionally, it offers 2-times greater penetration into the aqueous humor compared to its predecessor, Lotemax Gel.

Lotemax SM, similar to Lotemax Gel, has a consistent concentration throughout the bottle, eliminating the need to shake the bottle prior to instillation.

Inveltys is FDA approved as a twice-daily dosing regimen for postoperative inflammation and pain following ocular surgery.

 It incorporates a nanoparticle drug delivery technology. Nanoparticles 200 nm to 400 nm are mucous penetrating, allowing Inveltys to enhance penetration through the mucous barrier on the ocular surface.

The most recent introduction of topical corticosteroid is Eysuvis. This is approved for twice-daily dosing regimen for up to 2 weeks for the treatment of signs and symptoms of dry eye.

 Eyesuvis incorporates mucous-penetrating particle technology that enhances tissue penetration into the cornea and conjunctiva.

Ophthalmic corticosteroids provide an exceptional opportunity to alleviate ocular inflammatory conditions. Understanding these technologies will help position them best in the eye care practitioners’ treatment armamentarium.

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