Steroids in the Treatment of Dry Eye Disease

Steroids in the Treatment of Dry Eye Disease

Steroids in the Treatment of Dry Eye Disease

Gary N. Foulks, MD, FACS

The connection between inflammation and the dry eye associated with Sjogrens syndrome was noted by Henrik Sjogren himself when he first described the condition. For decades afterwards, however, it was thought that, while inflammation was a significant aspect of Sjogrens syndrome dry eye, it was not important in other forms of keratoconjunctivitis sicca. It wasn’t until the last part of the 20th century that inflammatory markers were found in dry eye disease not associated with Sjogrens syndrome.

The DEWS Report, although it stops short of saying that inflammation causes dry eye, does make it clear that, like hyperosmolarity, inflammation is a global feature of dry eye disease and an important part of what initiates symptom formation.

Steroids

Steroids are attractive for controlling inflammation because they have a broad range of antiinflammatory effects. They inhibit inflammatory cells like T-lymphocytes, they act on blood vessel walls to limit transudation, and they inhibit a number of different cytokines or the receptors for those cytokines. This is in contradistinction to monoclonal antibodies or calcineurin inhibitors like cyclosporine and tacrolimus, which work on single targets.

Steroids are attractive, too, because they act quickly. Whereas cyclosporine can take weeks or months to have a noticeable effect, a steroid’s effects can be felt in hours or days.

Steroids can be considered whenever a strong antiinflammatory action is needed. This is typically the case when there is a significant inflammatory reaction—in Sjogrens syndrome, for example. Steroids can also be considered when a patient doesn’t respond to cyclosporine, during a flare-up of otherwise well controlled dry eye, or in cases of concomitant dry eye and allergic conjunctivitis—in this case, the steroid is useful because it can control inflammation irrespective of its etiology.
   
Steroid Selection

Three features determine steroid selection. The first is tolerance: Dry eye patients often don’t tolerate preservatives well, and some may need a drop that is formulated by a compounding pharmacy without preservative. This is inconvenient and limits the drop’s shelf life, but it is valuable for some patients.

Second, different steroids have different potencies. Dexamethasone, for example, is very potent but doesn’t penetrate ocular tissues as well as other steroids and has a strong side effect profile. By contrast, prednisolone is almost as potent and penetrates well. Other steroids, like loteprednol etabonate and fluorometholone, are less potent but have better safety profiles.

The third concern is side effects. The most worrisome steroid side effects are intraocular pressure (IOP) spikes and cataract formation. There is also, perhaps, some increased risk of superinfection because steroids suppress the eye’s natural defenses, but this is much less of a concern than cataracts and IOP spikes. Compared to dexamethasone and prednisolone, loteprednol and fluorometholone have lower rates of these complications.

Steroid use is contraindicated in patients with active infection. In addition, a developing cataract may be aggravated by the steroid and patients with glaucoma are more likely to be steroid responders and suffer IOP spikes—so glaucoma and cataract patients should avoid topical steroids if at all possible.

Using Steroids

Most practitioners will use steroids in pulses. That is, they may use a steroid when starting a patient on cyclosporine, taper the steroid once the inflammation is under control, and then not use it again unless the patient has a flare-up, when another pulse of steroid can be used to bring the flare-up under control.

It is much more difficult to maintain patients on continuous steroid. Doing so requires titrating to the lowest effective dose. Long-term steroid patients require frequent monitoring, and these patients can still break through with a flare-up, which will require increasing the dose. So in the choice between continuous and pulse therapy, the latter is usually the safer and simpler alternative. 

Gary N. Foulks, MD, FACS, is the Arthur and Virginia Keeney professor of ophthalmology, University of Louisville, Louisville, KY, 
and is editor-in-chief of The Ocular Surface.