Locally administered ocular corticosteroids: benefits and risks

Contact lenses as drug reservoirs & delivery systems: the successes & challenges

Although conventional eye drops comprise over 90% of the marketed ocular dosage forms, they do have limitations, such as poor ocular drug bioavailability and systemic side effects; contact lenses are amongst the new delivery systems and devices that could overcome some of these problems. The most common approach to load drug molecules into contact lenses includes soaking in a drug solution. This approach had some success, but failed to achieve controlled/sustained drug release to the eye. On the other hand, nanoreservoir systems comprising nanoparticles, cyclodextrins, liposomes or surfactant aggregates being incorporated into the contact lenses could offer a plausible solution. This review highlights the status quo with contact lenses as ocular drug-delivery carriers and identifies possible future directions.

Soluble vascular endothelial growth factor receptor-3 suppresses allosensitization and promotes corneal allograft survival

PURPOSE

To investigate the effect of VEGF-C and VEGF-D blockade via soluble VEGFR-3 (sVEGFR-3) on T cell allosensitization, corneal neovascularization, and transplant survival.

METHODS

Corneal intrastromal suture placement and allogeneic transplantation were performed on BALB/c mice to evaluate the effect of sVEGFR-3 on corneal neovascularization. Soluble VEGFR-3 trap was injected intraperitoneally to block VEGF-C/D (every other day starting the day of surgery). Immunohistochemical staining of corneal whole mounts was performed using anti-CD31 (PECAM-1) and anti-LYVE-1 antibodies to quantify the levels of hem- and lymphangiogenesis, respectively. Mixed lymphocyte reaction (MLR) was performed to assess indirect and direct host T cell allosensitization and the frequencies of IFN-γ-producing T cells in the draining lymph nodes were assessed using flow cytometry. Graft opacity and survival was evaluated by slit-lamp biomicroscopy.

RESULTS

Treatment with sVEGFR-3 resulted in a significant blockade of lymphangiogenesis 2 weeks post-transplantation and significantly prolonged corneal allograft survival compared to the control group at 8 weeks post-transplantation (87.5 % vs. 50 %), and this was associated with significant reduction in the frequencies of allosensitized T cells and decreased frequencies of IFN-γ-producing CD4 T cells.

CONCLUSIONS

Soluble VEGFR-3 suppresses corneal lymphangiogenesis and allograft rejection and may offer a viable therapeutic modality for corneal neovascularization and corneal transplantation.

Corneal lymphangiogenesis in herpetic stromal keratitis

Corneal lymphangiogenesis is the extension of lymphatic vessels into the normally alymphatic cornea, a process that compromises the cornea's immune-privileged state and facilitates herpetic stromal keratitis (HSK). HSK results most commonly from infection by herpes simplex virus-1 (HSV-1) and is characterized by immune- and inflammation-mediated damage to the deep layers of the cornea. Current research demonstrates the potential of anti-lymphangiogenic therapy to decrease and prevent herpes-induced lymphangiogenesis.

Corneal nerves in health and disease

Corneal nerves are responsible for the sensations of touch, pain, and temperature and play an important role in the blink reflex, wound healing, and tear production and secretion. Corneal nerve dysfunction is a frequent feature of diseases that cause opacities and result in corneal blindness. Corneal opacities rank as the second most frequent cause of blindness. Technological advances in in vivo corneal nerve imaging, such as optical coherence tomography and confocal scanning, have generated new knowledge regarding the phenomenological events that occur during reinnervation of the cornea following disease, injury, or surgery. The recent availability of transgenic neurofluorescent murine models has stimulated the search for molecular modulators of corneal nerve regeneration. New evidence suggests that neuroregenerative and inflammatory pathways in the cornea are intertwined. Evidence-based treatment of neurotrophic corneal diseases includes using neuroregenerative (blood component-based and neurotrophic factors), neuroprotective, and ensconcing (bandage contact lens and amniotic membrane) strategies and avoiding anti-inflammatory therapies, such as cyclosporine and corticosteroids.

[Cataracts related to the extended application of dermocorticosteroids. A study of 8 cases in Abidjan]

INTRODUCTION

Cataract induced by corticosteroids is an entity, which has been well described for a relatively long time, but this eventuality caused by the cutaneous application of corticosteroids remains inadequately reported. The purpose of this study was to describe cataract as one of the complications of the misuse of cutaneous application of corticosteroids.

MATERIALS AND METHODS

In eight patients seen for visual loss, bilateral cataract was discovered. The only probable etiology in these cases appeared to be the cutaneous application of corticosteroids. Indeed, the work-up and careful history performed did not uncover any other etiology.

RESULTS

Eight patients, six women and two men, exhibited cataracts related to the application of topical corticosteroids. The age of the patients ranged between 39 and 45 years. The cataracts were bilateral and posterior subcapsular alone or combined. The period of use of corticosteroids ranged from 5 to 10 years. The products used consisted of a variety of chemicals including corticosteroids mainly in the form of traditionally manufactured soap, but also as ointment or other types of mixtures.

CONCLUSION

Topical corticosteroids induce posterior subcapsular cataract. The mechanism of action is direct access to the eye without any hepatic-first pass effect on the corticosteroid in question. The increasingly frequent use of corticosteroids in African blacks for skin lightening raises concern regarding the risk of epidemic cataracts in young women attempting to lighten their skin to be beautiful. Increased public awareness should be undertaken to prevent this growing and harmful phenomenon.

Comparison of the effects of topical cyclosporine a 0.05%, cyclosporine a 2%, epinastine hydrochloride 0.05%, and prednisolone acetate 1% on allergic inflammation in an experimental allergic conjunctivitis model

PURPOSE

To investigate the effects of topical cyclosporine A 0.05%, cyclosporine A 2%, epinastine hydrochloride 0.05%, and prednisolone acetate 1% in an experimental allergic conjunctivitis model.

METHODS

Forty Wistar albino male rats were randomly divided into 5 groups. All the rats were immunized by an intraperitoneal injection of 100 μg of ovalbumin. After 2 weeks, topical treatment was administered: cyclosporine A 0.05% 4 times a day to group 1, cyclosporine A 2% 4 times a day to group 2, epinastine HCl 0.05% 2 times a day to group 3, and prednisolone acetate 1% 4 times a day to group 4 for the following 7 days. Group 5 was designated as the control group. Both eyes of the rats were enucleated on the 22nd day of the study. The excised sections were stained by toluidine blue for mast cell count and by hematoxylin-eosin for histopathological evaluation.

RESULTS

The 2 solutions of cyclosporine A and epinastine were more effective than prednisolone acetate (P < 0.05) when compared with the control in histopathological scoring. There were statistically significant differences between the treatment groups and the control group (P < 0.05); however, no differences were observed between the treatment groups in the mast cell number.

CONCLUSIONS

Topical 0.05% cyclosporine A is as effective as 2% cyclosporine A and epinastine in suppressing mast cell-mediated type I allergic conjunctivitis in an experimental allergic conjunctivitis model.

Resolution of idiopathic granulomatous orbital inflammation with intraorbital triamcinolone

A 77-year-old man presented with a right lower eyelid swelling. Biopsy and histopathology of the lesion identified idiopathic granulomatous orbital inflammation. Clinical resolution of this patient's orbital mass was achieved with injection of 40 mg triamcinolone acetonide, perilesionally, at three sites in the right orbit. Such treatment may thus form an alternative to oral corticosteroid therapy in the management of granulomatous orbital inflammation.

A nanoparticle formulation reduces the corneal toxicity of indomethacin eye drops and enhances its corneal permeability

Indomethacin (IMC) has been shown to reduce post-operative inflammation and to decrease intraocular irritation after cataract extraction and in cystoid macular edema; however, the clinical use of its most commonly used eye drops is limited due to topical side-effects that include burning sensation, irritation and epithelial keratitis. It is known that decreasing direct cell stimulation and reducing the amount applied via increasing bioavailability are useful for improving these issues. In this study, we designed ophthalmic formulations containing 0.5% IMC nanoparticles using zirconia beads and Bead Smash 12 (IMCnano eye drops; particle size 76 ± 59 nm, mean ± S.D.), and investigated the corneal toxicity of these IMCnano eye drops. IMCnano eye drops are tolerated better by a human cornea epithelial cell line (HCE-T) than commercially available NDSAIDs preparations (IMC, pranoprofen, diclofenac, bromfenac and nepafenac eye drops), and corneal wound healing in rat eyes with debrided corneal epithelium instilled with IMCnano eye drops is significantly better than that of eyes instilled with commercially available IMC eye drops. In addition, the accumulation of IMC in HCE-T cells treated with the IMCnano eye drops for 30 min was 19.9% that of the accumulation from commercially available IMC eye drops. On the other hand, the corneal penetration of IMC from IMCnano eye drops was significantly greater than in the case of the commercially available IMC eye drops in both in vivo and in vitro studies using rabbit corneas. Taken together, we hypothesize that a nanoparticle formulation reduces the corneal toxicity of IMC eye drops, probably because the accumulation of IMC from IMCnano eye drops in the eye is lower than that from commercially available IMC eye drops. In addition, the nanoparticle formulation may allow a decrease in the amount of IMC used due to the increase in bioavailability, resulting in reduced drug toxicity. These findings provide significant information that can be used to design further studies aimed at developing less toxic eye drops.

Prolonged exposure to loteprednol etabonate in human tear fluid and rabbit ocular tissues following topical ocular administration of Lotemax gel, 0.5%

PURPOSE

A new gel formulation containing loteprednol etabonate (LE), a C-20 ester corticosteroid used to treat ocular inflammation, was developed to provide increased retention on the ocular surface for improved drug delivery to intraocular tissues. This investigation evaluated concentrations of LE in tear fluid following topical instillation of LE gel to humans and the ocular and systemic pharmacokinetics of LE following administration to rabbits.

METHODS

LE ophthalmic gel 0.5% was administered as a single topical dose to human volunteers (n=12) and Dutch Belted rabbits (n=40). In the human study, tear sampling was performed at 6, 9, 12, and 24 h after instillation. In the rabbit study, tears and ocular tissues were collected from 5 min through 24 h postdose. Serial blood samples were collected from one cohort of rabbits for plasma analysis. Concentrations of LE were determined by high performance liquid chromatography tandem mass spectrometry.

RESULTS

In humans, LE was detected in tears at all the time points assessed with mean concentrations of 114 μg/g at 6 h declining to 2.41 μg/g at 24 h postdose. In rabbits, LE was detected in all ocular tissues within 5 min after dosing. Maximum concentrations of LE were achieved within 0.5 h and were highest in tear fluid (1560 μg/g), followed by bulbar conjunctiva (4.03 μg/g), cornea, (2.18 μg/g), iris/ciliary body (0.162 μg/g), and aqueous humor (0.0138 μg/mL). LE remained measurable in all ocular tissues through 24 h with the exception of aqueous humor. In contrast, plasma levels of LE were low with no detectable levels after 4 h.

CONCLUSIONS

The gel formulation of LE provided prolonged exposure to LE on the ocular surface, with measurable levels in tears through 24 h in both humans and rabbits, for delivery of LE to anterior segment tissues, as evidenced by sustained levels of LE in rabbit conjunctiva, cornea, and iris/ciliary body.

Dose uniformity of loteprednol etabonate ophthalmic gel (0.5%) compared with branded and generic prednisolone acetate ophthalmic suspension (1%)

Introduction

Loteprednol etabonate (LE) ophthalmic gel 0.5% (Lotemax®) is a new polycarbophil-based, nonsettling topical ophthalmic formulation. The formulation is a semisolid gel at rest and a shear thinning fluid when expressed through a dropper tip. The present study was undertaken to determine how the nonsettling character of LE ophthalmic gel affects dose uniformity. Prednisolone acetate ophthalmic suspension 1% (Pred Forte®) and a generic prednisolone acetate suspension 1% were used as comparators.

Methods

Drug concentrations of LE ophthalmic gel, Pred Forte, and a generic prednisolone acetate suspension were determined following simulated dosing – consisting of 2 drops, expressed four times daily for 2 weeks, with bottles that were shaken or not shaken immediately prior to expressing the drops. Drug concentrations were determined using a reverse-phase high-performance liquid chromatography (HPLC) method and reported as a percentage of the declared (labeled) concentration. Comparative kinetics of drug particle sedimentation were also determined for each formulation, using dispersion analysis under gravity.

Results

Mean drug concentrations in drops of all three formulations were within a few percentage points of the declared concentration when the bottles were shaken for 5 seconds prior to dispensing. Only LE ophthalmic gel showed consistent and on-target concentrations when the bottles were unshaken prior to dispensing, with a mean (standard deviation [SD]) percent declared concentration of 102% (1.92%) over the 2-week dosing regimen. Drug concentrations for the branded and generic prednisolone acetate suspensions following expression from unshaken bottles were highly variable (overall relative SDs of 16.8% and 20.3%, respectively), with mean concentrations for both falling significantly below the declared concentration for drops expressed at the beginning of the 2-week dosing regimen and significantly above the declared concentration for drops expressed near the end of the dosing regimen. Dispersion analysis at 120× g showed no drug particle sedimentation for LE ophthalmic gel over the 24-hour testing period, whereas the prednisolone acetate suspensions settled in less than 6 hours.

Conclusion

LE ophthalmic gel 0.5% provided consistent dose uniformity at the declared concentration whether or not the bottle was shaken prior to dispensing, whereas Pred Forte® and the generic prednisolone acetate required shaking to provide consistent drug concentrations. LE ophthalmic gel may be beneficial to patients because it eliminates the potential impact on the clinical response of both under- and overdosing.

Loteprednol etabonate ophthalmic gel 0.5% following cataract surgery: integrated analysis of two clinical studies

INTRODUCTION

We aimed to evaluate the safety and efficacy of loteprednol etabonate (LE) gel 0.5% compared with vehicle in the treatment of postoperative inflammation and pain following cataract surgery, using the integrated analysis of data from two identical, prospective, multicenter, randomized, double-masked, parallel-group, vehicle-controlled trials.

METHODS

Patients with anterior chamber cell (ACC) inflammation ≥ grade 2 (6-15 cells) 1 day post-surgery were randomized to receive 1 or 2 drops of LE gel 0.5% or vehicle 4 times per day instilled in the study eye for 14 days. Primary outcome measures included the proportion of patients with complete resolution of ACC and grade 0 (no) pain on postoperative Day 8. Safety endpoints included adverse events (AEs), changes from baseline in intraocular pressure (IOP) and visual acuity (VA), biomicroscopy, and funduscopy findings. Gel comfort was graded by patients according to drop sensation.

RESULTS

The intent-to-treat population included 813 patients (409 LE gel 0.5% and 404 vehicle). At postoperative Day 8, 30.8% and 15.1% of patients randomized to LE gel 0.5% or vehicle, respectively, had complete resolution of ACC, while 74.3% and 43.8% of patients, respectively, had grade 0 pain (P < 0.001 for both). Tolerability assessments for ocular itching, photophobia, and tearing favored LE gel 0.5% compared with vehicle at different time points beginning at Day 3. Two patients in the LE gel 0.5% group and 1 patient in the vehicle group exhibited a transient treatment-emergent increase in IOP ≥ 10 mmHg. Treatment-related AEs were generally mild to moderate and occurred less frequently with LE gel 0.5% than with vehicle. Reports of treatment-related blurred vision were rare (n = 2, vehicle).

CONCLUSION

LE gel 0.5% was efficacious and well tolerated in the treatment of postoperative pain and inflammation following ocular surgery, with minimal risk of IOP elevation.

Neuroprotectin D1 reduces the severity of herpes simplex virus-induced corneal immunopathology

PURPOSE

Neuroprotectin D1 (NPD1) is an anti-inflammatory and proresolving lipid mediator biosynthesized from the omega-3-polyunsaturated fatty acid docosahexaenoic acid (DHA). The purpose of this study is to test the therapeutic potential of NPD1 for the treatment of herpes simplex virus (HSV)-induced stromal keratitis (SK) using a mouse model.

METHODS

C57BL/6 mice were infected ocularly with HSV-1 strain RE. Infected animals were treated topically with methyl ester prodrug NPD1 (300 ng/eye, 5-μL drop). Development of SK lesions, infiltration of inflammatory cells into the cornea, and production of proinflammatory cytokines, chemokines, and angiogenic factors were compared to untreated animals using slit-lamp biomicroscopy, flow cytometry, ELISA, and quantitative PCR (qPCR).

RESULTS

Topical administration of NPD1 resulted in a significant reduction in the severity and incidence of SK, as well as the extent of corneal neovascularization in the NPD1-treated animals compared to their untreated counterparts. Infiltration of fewer neutrophils and pathogenic CD4⁺ T cells into the cornea, along with a lower number of cells that could be induced ex vivo to produce IFN-γ and IL-17, occurred with NPD1 treatment. Additionally, treatment with NPD1 diminished the production of proinflammatory cytokines, chemokines, and angiogenic factors, such as IL-6, CXCL1, CXCL-10, CCL-20, VEGF-A, MMP-2, and MMP-9 in the corneas of infected animals. Importantly, treatment with NPD1 increased the production of the anti-inflammatory cytokine, IL-10.

CONCLUSIONS

Our novel findings demonstrate that NPD1 treatment could represent a valuable therapeutic approach to control SK lesions.

Intraocular pressure effects of common topical steroids for post-cataract inflammation: are they all the same?

The efficacy of topical corticosteroids as ocular anti-inflammatory agents following cataract surgery is well-documented. They also help to prevent a number of complications associated with post-operative ocular inflammation, including corneal edema and cystoid macular edema. However, topical corticosteroids are associated with side effects, such as increased intraocular pressure (IOP). Indeed, corticosteroid-induced ocular hypertension and the potential for steroid-induced glaucoma remain the leading drawbacks of topical corticosteroid therapy. Some individuals are known to experience a high degree of IOP elevation with low doses or short durations of treatment with topical corticosteroids. Careful monitoring of IOP in such individuals is essential. Few randomized, controlled studies are available on the comparative safety and efficacy of common topical corticosteroids in the treatment of post-operative ocular inflammation. Furthermore, the lack of consistent reporting criteria for clinically significant IOP increases across clinical studies makes meaningful comparisons among corticosteroids difficult. This review aims to examine data from available published studies, including studies in steroid responders, to determine whether topical corticosteroids are the same in terms of their effect on IOP. Early generation corticosteroids, such as dexamethasone and prednisolone, are more likely to result in clinically significant increases in IOP. Newer corticosteroids, such as rimexolone and the retro-metabolically designed corticosteroid, loteprednol etabonate, offer similar anti-inflammatory efficacy to older corticosteroids with less effect on IOP. However, randomized controlled trials of newer corticosteroids are needed. The proportion of patients exhibiting an increase of ≥10 mmHg IOP in clinical studies has emerged as the most clinically relevant parameter for ophthalmologists to consider when deciding on which topical corticosteroid to use.

Management of vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a relatively rare, chronic form of ocular allergy that can potentially cause severe visual complications. Affecting mainly children and young adults, it is an IgE- and T cell-mediated disease, leading to a chronic inflammation in which eosinophil, lymphocyte and structural cell activation are involved. Treatment of VKC requires a multiple approach that includes conservative measures and pharmacologic treatment. Patients and parents should be made aware of the long duration of disease, its chronic evolution and possible complications. Treatment should be based on the duration and frequency of symptoms and the severity of corneal involvement. Mast cell stabilizers and antihistamines have been proven to be effective for the treatment of mild to moderate forms of VKC. In the most severe cases, topical steroids can be used as rescue medication to reduce conjunctival and corneal inflammation. Immunomodulators that have been investigated for VKC treatment include topical ocular preparations of cyclosporine A and tacrolimus. Topical cyclosporine A has been proven to be effective in the long-term treatment of VKC, significantly improving signs and symptoms without significant side effects.

Comparative evaluation of topical pranoprofen and fluorometholone in cases with chronic allergic conjunctivitis

PURPOSE

This study was conducted to compare the efficacy of 0.1% fluorometholone and 0.1% pranoprofen in cases with chronic allergic conjunctivitis.

METHODS

In an investigator-masked trial, patients with chronic allergic conjunctivitis were randomized to treatment with 4 times daily 0.1% pranoprofen (PN) or 0.1% fluorometholone (FL) eye drops for 4 weeks. A 4-point rating scale assessing the severity of 5 symptoms and 4 signs (0 = none, 1 = mild, 2 = moderate, and 3 = severe) was used. A linear mixed model was used to explore the rate of score changes. Regression analysis was used to evaluate the relation between clinical outcome and age.

RESULTS

A total of 75 patients were enrolled at the baseline. There were no significant differences in the demographics and baseline skin prick scores between both groups. Mean baseline scores in PN and FL group were 6.71 ± 2.28 and 6.41 ± 2.06, respectively. The scores rapidly decreased to 3.35 ± 1.58 and 2.91 ± 1.71 on day 7, respectively. Fluorometholone showed a more rapid effect compared with pranoprofen during the first week of treatment (P < 0.05) but not later. Regression analysis showed that age was negatively associated with response to fluorometholone (younger than 29 years). The intraocular pressure increased by 0.7 mm Hg in the FL group and decreased by 0.5 mm Hg in the PN group on day 28 (P > 0.05).

CONCLUSIONS

Both fluorometholone and pranoprofen were effective for management of cases with chronic allergic conjunctivitis. Fluorometholone provided more rapid relief as compared with pranoprofen. The effect of fluorometholone was more pronounced in younger patients.

Anterior chamber flare after femtosecond laser-assisted cataract surgery

PURPOSE

To determine whether postoperative ocular inflammation is less after femtosecond laser-assisted cataract surgery than after conventional phacoemulsification (manual) cataract surgery.

SETTING

Private clinic, Launceston, Tasmania, Australia.

DESIGN

Prospective consecutive investigator-masked nonrandomized parallel cohort study.

METHODS

Consecutive cataract patients who had femtosecond laser-assisted cataract surgery or manual cataract surgery by the same surgeon at a single center were assessed. The primary endpoint was postoperative aqueous flare measured by laser flare photometry at 1 day and 4 weeks. Secondary endpoints included retinal thickness measured by optical coherence tomography and slitlamp examination findings at 4 weeks.

RESULTS

The per-protocol population comprised 176 patients (100 in laser group; 76 in manual group). Postoperative aqueous flare was significantly greater in the manual cataract surgery group at 1 day (P=.0089) and at 4 weeks (P=.003). There was a significant correlation between effective phacoemulsification time and 1-day postoperative aqueous flare (r = 0.35, P<.0001). The increase in outer zone thickness measured by optical coherence tomography was less in the laser group (P=.007).

CONCLUSION

Anterior segment inflammation was less after femtosecond laser-assisted cataract surgery than after manual cataract surgery, and this appeared to be due to a reduction in phacoemulsification energy.

The artemisinin derivative artesunate inhibits corneal neovascularization by inducing ROS-dependent apoptosis in vascular endothelial cells

PURPOSE

Without therapeutic intervention, corneal neovascularization rapidly compromises visual acuity, and is a leading cause of blindness. Artesunate was reported to inhibit angiogenesis in tumors, although, the effects of artesunate on nontumor angiogenesis have not been investigated. This study was designed to investigate the effect of artesunate on corneal neovascularization and delineate its underlying mechanism of action.

METHODS

Rats with alkali-burned corneas were treated with artesunate for 11 days. Corneal neovascularization was evaluated by measuring the length and area of corneal vasculature in the rats. Apoptotic cells were stained with AnnexinV and propidine iodide (PI), and measured with flow cytometry analysis. Apoptosis-related and p38 mitogen-activated protein kinases (p38MAPK) signaling were evaluated by Western blot analysis.

RESULTS

Artesunate significantly inhibited corneal neovascularization and inflammation via specifically inducing apoptosis of vascular endothelial cells. In vascular endothelial cells, artesunate increased the Bax/Bcl-2 ratio, reduced mitochondrial membrane potential, stimulated release of cytochrome C, and cleavage of caspase 9 and 3, suggesting that the mitochondrial apoptotic pathway was involved. Artesunate activated p38MAPK, and specific p38MAPK inhibitors suppressed artesunate-induced apoptosis in endothelial cells. Reactive oxygen species (ROS) levels were increased by artesunate. N-acetyl-L-cysteine blocked p38MAPK activation and protected endothelial cells from artesunate-induced apoptosis. Ferrous salt increased ROS levels and elevated the cytotoxic effect of artesunate on endothelial cells, while the iron chelating agent deferoxamine decreased ROS levels and artesunate-induced apoptosis. Artesunate had no effect on expression of Fas, Fas Ligand, or caspase 8 cleavage.

CONCLUSIONS

These results suggest that artesunate induces apoptosis of endothelial cells via an iron/ROS-dependent p38MAPK-mitochondrial pathway.

Efficacy and safety of indomethacin 0.1% eye drops compared with ketorolac 0.5% eye drops in the management of ocular inflammation after cataract surgery

PURPOSE

To determine whether indomethacin 0.1% eye drops are at least as effective as ketorolac 0.5% eye drops in treating ocular inflammation following cataract surgery.

METHODS

Prospective, multicenter, investigator-masked, parallel-group, randomized, active-controlled clinical trial. Cataract patients were randomized in a 1:1 ratio to receive indomethacin or ketorolac administered QID for 3 weeks beginning 1 day before surgery. The primary end-point was aqueous flare measured by laser flare meter at postoperative Days 1 and 7. Secondary end-points included retinal thickness, slit lamp and funduscopic examinations and postsurgical pain ratings. Safety and tolerability were also assessed.

RESULTS

A total of 86 patients were included in the per protocol population (n = 43 per treatment group). Indomethacin was found non-inferior to ketorolac for comparison of aqueous flare at postoperative Days 1 and 7 (Day 1: 95% CI: -2.37, 5.50; non-inferiority upper margin, 15 ph/ms and Day 7: 95% CI: -7.83, -0.94; non-inferiority upper margin, 8 ph/ms) and statistically better than ketorolac at Day 7 (p = 0.013). There were no significant between-group differences in aqueous flare and change from baseline in retinal thickness at postoperative Days 30 and 90. Indomethacin showed a higher subjective tolerance rating than ketorolac at postoperative Days 7 and 30 (p ≤ 0.044).

CONCLUSION

Indomethacin 0.1% was at least as effective as ketorolac 0.5% at Day 1 and more effective than ketorolac 0.5% at Day 7 in treating ocular inflammation after uncomplicated cataract surgery. Indomethacin was better tolerated than ketorolac. There were no clinically meaningful safety concerns with either treatment.

Ocular graft-versus-host disease

PURPOSE OF REVIEW

This review was carried out to study the frequency, and severity of ocular surface involvement at the setting of allogeneic hematopoietic stem cell transplantation and subsequent graft-versus-host disease (GVHD) and evaluate the clinical outcomes of newer treatments.

RECENT FINDINGS

Ocular involvement has been reported in 60-90% of patients with chronic GVHD. Although dry eye is the most frequent finding occurring in the great majority of patients (up to 90%), posterior segment complications are also not infrequent, seen in 12.8% of patients after bone marrow transplantation. Anti-inflammatory treatments particularly T-cell suppressants seem to have a beneficial effect in managing GVHD. Corticoteroids, calcineurin inhibitors, such as cyclosporine and tacrolimus, as well as antifibrotic agents such as tranilast are available options for topical application. Cyclosporine ophthalmic drop seems to be a well tolerated and effective treatment modality; favorable results have been demonstrated with increased dosage.

SUMMARY

GVHD is an increasingly frequent cause of ocular surface morbidity with the potential of visual loss from corneal involvement. Early diagnosis and aggressive local as well as systemic treatment can be vision saving.

A Prospective, Open-label Study to Compare the Efficacy and the Safety of Topical Loteprednol Etabonate and Topical Flurbiprofen Sodium in Patients with Post-Operative Inflammation after Cataract Extraction

PURPOSE

To study the effect of the topical Non-Steroidal Anti Inflammatory Drug (NSAID), Flurbiprofen 0.03%, as an alternative to the topical steroids for the postoperative control of inflammation in cataract surgeries.

METHODS

The effect of the topical NSAID, flurbiprofen sodium 0.03%, was studied and compared with that of the topical steroid - Loteprednol etabonate 0.5% suspension (as eye drops) in a prospective, open labelled study. Both the groups (20 patients each) were similar in the baseline parameters. The postoperative inflammatory response following the standard, small incision, extra capsular cataract extraction was assessed in both the groups for 28 post-operative days. The parameters which were considered for the study were conjunctival hyperaemia, ciliary congestion, corneal oedema, cells in the anterior chamber, aqueous flare and ocular pain. The severity of the postoperative inflammatory responses for both the drugs was graded on the post-operative days 1, 7, 14, 21 and 28 and it was statistically analyzed.

RESULTS

The 2 groups did not differ statistically in the effect of the treatment for any of the variables, which included aqueous cells, flare, ciliary congestion and conjunctival congestion (p< 0.001). Both the drugs were well tolerated and no severe adverse Drug Reactions (ADRs) were caused by the topical NSAID and the topical steroid.

CONCLUSION

The topical NSAID, Flurbiprofen, is as effective as the topical corticosteroid, Loteprednol and it can be used as an alternative in the routine postoperative treatment following uncomplicated cataract surgeries.

Management of seasonal allergic conjunctivitis: guide to therapy

Seasonal allergic conjunctivitis (SAC) is an inflammatory response of the conjunctiva triggered by exposure to seasonal allergens. Treatment options for SAC include artificial tears, antihistamines, decongestants, mast cell stabilizers, nonsteroidal anti-inflammatory drugs, dual antihistamine/mast cell stabilizers, immunotherapy and corticosteroids. Topical, intranasal and systemic formulations of corticosteroids have traditionally provided the most effective relief of the inflammation and signs and symptoms associated with severe, acute exacerbations of SAC. However, steroid-induced ocular and systemic side-effects have limited the prescribing of these agents. This limitation of traditional corticosteroids led to the development of modified corticosteroids that retain the anti-inflammatory mechanism of action of traditional corticosteroids with a much-improved safety profile because of their rapid breakdown to inactive metabolites after exerting their activity. The development of one such novel corticosteroid, loteprednol etabonate (LE), led to the insertion of an ester (instead of a ketone) group at the carbon-20 (C-20) position of the basic corticosteroid structure. Clinical trials assessing this C-20 ester corticosteroid have demonstrated similar efficacy to C-20 ketone corticosteroids in the prevention or treatment of the signs and symptoms of SAC but with a greatly improved safety profile, as the C-20 ester corticosteroid is less likely to elevate intraocular pressure. In addition, the ketone at the C-20 position has been implicated in the formation of cataract, while nonketolic corticosteroids do not form Schiff base intermediates with lens proteins, which is a common first step in cataractogenesis. The clinical relevance of the C-20 ester corticosteroid class, as modelled by LE, is that they provide both effective and safe treatment of the inflammation associated with SAC and relief of its signs and symptoms. Loteprednol etabonate offers a well-tolerated treatment option for patients with debilitating acute exacerbations as well as chronic forms of the disease.

Loteprednol etabonate ophthalmic suspension 0.5 %: efficacy and safety for postoperative anti-inflammatory use

Topical corticosteroids are routinely used as postoperative ocular anti-inflammatory drugs; however, adverse effects such as increased intraocular pressure (IOP) are observed with their use. While older corticosteroids such as dexamethasone and prednisolone acetate offer good anti-inflammatory efficacy, clinically significant increases in IOP (≥10 mmHg) are often associated with their use. Loteprednol etabonate, a novel C-20 ester-based corticosteroid, was retrometabolically designed to offer potent anti-inflammatory efficacy but with decreased impact on IOP. After exerting its therapeutic effects on the site of action, loteprednol etabonate is rapidly converted to inactive metabolites, resulting in fewer adverse effects. Randomized controlled studies have demonstrated the clinical efficacy and safety of loteprednol etabonate ophthalmic suspension 0.5 % for the treatment of postoperative inflammation in post-cataract patients with few patients, if any, exhibiting clinically significant increases (≥10 mmHg) in IOP. Furthermore, safety studies demonstrated a minimal effect of loteprednol etabonate on IOP with long-term use or in steroid responders with a much lower propensity to increase IOP relative to prednisolone acetate or dexamethasone. The anti-inflammatory treatment effect of loteprednol etabonate appears to be similar to that of rimexolone and difluprednate with less impact on IOP compared to difluprednate, although confirmatory comparative studies are needed. The available clinical data suggest that loteprednol etabonate is an efficacious and safe corticosteroid for the treatment of postoperative inflammation.

Safety and tolerability of loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension in pediatric subjects

BACKGROUND

Loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension (LE/T) is indicated for steroid-responsive inflammatory ocular conditions where superficial bacterial ocular infection or a risk of bacterial ocular infection exists. LE/T was shown to be safe in healthy volunteers and patients aged 18 years and older with minimal effect on intraocular pressure (IOP).

OBJECTIVE

The aim of the study was to evaluate the safety of LE/T in pediatric subjects by examining data from two clinical studies.

METHODS

Two randomized, multicenter, double-masked, parallel-group (one two-arm, the other four-arm) studies were conducted in subjects aged 0-6 years (N = 245). One study assessed LE/T compared with vehicle in the management of lid inflammation (n = 108) and the other compared LE/T with loteprednol etabonate ophthalmic suspension 0.5% (LE), tobramycin ophthalmic solution 0.3% (tobramycin), and vehicle in the treatment of blepharoconjunctivitis (n = 137). In the first study, subjects were randomized to LE/T or vehicle administered four times daily (qid) for the first 7 days followed by twice daily (bid) for 7 days along with warm compresses bid for the entire 2 weeks. In the second study, subjects were randomized to LE/T, LE, tobramycin, or vehicle administered qid for 14 days. Treatment-emergent ocular and non-ocular adverse events (AEs) and bilateral vision were assessed at all study visits in both studies. In addition, in the lid inflammation study, IOP was assessed at all visits. The primary safety endpoint in both studies was the incidence of treatment-emergent AEs.

RESULTS

The incidence of LE/T treatment-emergent AEs was low. A total of four ocular AEs were reported for three LE/T-treated subjects in the first study (conjunctivitis [two events], meibomian gland dysfunction, and corneal staining), and one ocular AE was reported for an LE/T-treated subject in the second study (eye pain). A total of 13 non-ocular AEs were reported for eight LE/T-treated subjects in the two trials. The most prevalent non-ocular AEs were pyrexia (three events) and rash (two events). There were no differences in the incidence of specific ocular and non-ocular AEs between the LE/T group and the comparator treatment group. In both studies, there were no clinically meaningful reductions in vision at follow-up visits. Mean IOP and IOP changes from baseline, assessed in the lid inflammation study, were not different between LE/T and vehicle treatment groups at any study visits.

CONCLUSION

The results of these two clinical trials demonstrate the short-term safety of treatment with topical LE/T in pediatric subjects (0-6 years of age) with lid inflammation or blepharoconjunctivitis.

Advances in corticosteroid therapy for ocular inflammation: loteprednol etabonate

Topical corticosteroids are effective in reducing anterior segment inflammation but are associated with adverse drug reactions (ADRs) including elevation of intraocular pressure (IOP) and cataract formation. Retrometabolic drug design has advanced the development of new corticosteroids with improved therapeutic indices. Engineered from prednisolone, loteprednol etabonate (LE) has a 17α-chloromethyl ester, in lieu of a ketone group, and a 17β-etabonate group. LE is highly lipophilic and binds with high affinity to the glucocorticoid receptor; any unbound LE is metabolized to inactive metabolites. LE has been studied in several anterior segment inflammatory conditions (giant papillary conjunctivitis, allergic conjunctivitis, anterior uveitis, and keratoconjunctivitis sicca), and in postoperative ocular inflammation and pain. Combined with tobramycin, it is effective in blepharokeratoconjunctivitis. Elevations in IOP are infrequent with LE, and the absence of a C-20 ketone precludes formation of Schiff base intermediates with lens proteins, a common first step implicated in cataract formation with ketone steroids.

Comparison of intraocular pressure measurement using 4 different instruments following penetrating keratoplasty

PURPOSE

To compare intraocular pressure (IOP) measurements after penetrating keratoplasty (PK) using Goldmann applanation tonometry (GAT; Haag-Streit USA), TonoPen XL (Reichert Inc), Pascal Dynamic Contour tonometer (PDCT; Swiss Microtechnology AG), and Ocular Response Analyzer (ORA; Reichert Inc) and to analyze effects and correlation of corneal thickness and curvature on these measurements.

DESIGN

Prospective, cross-sectional study.

METHODS

SETTINGS

Departments of Ophthalmology, University of Auckland and Auckland District Health Board, New Zealand.

STUDY POPULATION

Thirty-one eyes of 31 participants with previous PK.

OBSERVATIONS

IOP measured using GAT, TonoPen, PDCT, and ORA. Central corneal thickness (CCT) and corneal astigmatism were assessed by Pentacam rotating Scheimpflug tomography.

MAIN OUTCOME MEASURE

Degree of agreement in IOP measures and correlation with CCT and corneal astigmatism.

RESULTS

Mean age was 44.5 ± 21.0 years and mean time since PK was 27.7 ± 28.2 months (range 3.0-122.4 months). Mean CCT was 585 ± 149 μm and mean corneal astigmatism 5.5 ± 3.8 diopters. There was no significant difference in IOP measured by GAT and TonoPen; however, both PDCT (2.12 mm Hg, P < .01) and ORA (6.29 mm Hg, P < .01) measured significantly higher IOPs compared to GAT. ORA showed the least agreement with GAT. Significant correlation was identified between each pair of measurement techniques. No instruments correlated significantly with CCT. Only PDCT showed no significant correlation with corneal astigmatism. However, no IOP measures correlated with corneal astigmatism if sutures in situ or less than 1 year post-PK.

CONCLUSIONS

TonoPen or PDCT are the most suitable alternatives for measuring IOP in PK eyes where GAT readings are difficult to obtain. PDCT also offers the advantage of being independent of both CCT and corneal astigmatism.

Controlling viral immuno-inflammatory lesions by modulating aryl hydrocarbon receptor signaling

Ocular herpes simplex virus infection can cause a blinding CD4⁺ T cell orchestrated immuno-inflammatory lesion in the cornea called Stromal Keratitis (SK). A key to controlling the severity of SK lesions is to suppress the activity of T cells that orchestrate lesions and enhance the representation of regulatory cells that inhibit effector cell function. In this report we show that a single administration of TCDD (2, 3, 7, 8- Tetrachlorodibenzo-p-dioxin), a non-physiological ligand for the AhR receptor, was an effective means of reducing the severity of SK lesions. It acted by causing apoptosis of Foxp3⁻ CD4⁺ T cells but had no effect on Foxp3⁺ CD4⁺ Tregs. TCDD also decreased the proliferation of Foxp3⁻ CD4⁺ T cells. The consequence was an increase in the ratio of Tregs to T effectors which likely accounted for the reduced inflammatory responses. In addition, in vitro studies revealed that TCDD addition to anti-CD3/CD28 stimulated naïve CD4⁺ T cells caused a significant induction of Tregs, but inhibited the differentiation of Th1 and Th17 cells. Since a single TCDD administration given after the disease process had been initiated generated long lasting anti-inflammatory effects, the approach holds promise as a therapeutic means of controlling virus induced inflammatory lesions.

Effect of menthol on ocular drug delivery

BACKGROUND

To assess how safe and effective it is to use menthol as a permeability enhancer in ophthalmic drug delivery systems.

METHODS

In this study, the effect of menthol on permeability of dexamethasone disodium phosphate in the cornea and sclera was investigated in vitro. Application of topical drops and subconjunctival injection of dexamethasone disodium phosphate with or without 0.1% menthol was administered to rabbit eyes, and the drug concentration was detected in aqueous humor, cornea, vitreous, and retinochoroidal tissues. The safety of menthol was assessed on the basis of corneal hydration level, Draize test, electroretinography (ERG), and histological examination.

RESULTS

0.05% and 0.1% menthol significantly enhanced the penetration of dexamethasone in the cornea, but did not change the dexamethasone penetration in sclera in vitro. When topical drops of dexamethasone containing 0.1% menthol were administered, a significantly increased concentration of dexamethasone in the cornea and aqueous humor tissues was reported, but dexamethasone concentrations remained unaffected in the retina-choroid tissues. On the other hand, increased drug concentration in aqueous humor, cornea, vitreous and retinochoroidal tissues was achieved through subconjunctival injection. No signs of irritation were observed when menthol was administered at concentrations ranging from 0.025%-0.1%; moreover, no substantial toxic reactions were observed in corneal hydration level, electrophysiological, or histological examinations after the addition of 0.1% menthol.

CONCLUSIONS

Menthol may improve the ocular penetration of a drug in a transcorneal and transscleral drug delivery system without causing toxic reactions.

Intraocular pressure elevations with loteprednol etabonate: a retrospective chart review

PURPOSE

Ocular corticosteroids can cause elevations in intraocular pressure (IOP). The purpose of this study was to characterize the timing and severity of IOP elevations in patients receiving loteprednol etabonate 0.5% or loteprednol etabonate 0.5%/tobramycin 0.3%.

METHODS

A retrospective chart review was conducted at 5 academic and private practices. Any patient who experienced an elevation in IOP ≥5 mm Hg while using loteprednol etabonate or loteprednol etabonate/tobramycin was eligible for inclusion in the study. Data collected included patient demographics, medical and ophthalmic history, concomitant medications, reason for treatment, IOP, and medical and surgical interventions.

RESULTS

Fifty patients experienced IOP elevations after use of topical loteprednol etabonate and were included in the study. The mean (standard deviation [SD]) patient age was 58.8 (20.3) years and 66% were women. The most common reasons for prescribing loteprednol etabonate were dry eye (30%), postoperative therapy (22%), and allergic conjunctivitis (16%). Before treatment, 28% of patients had a history of open-angle glaucoma or ocular hypertension. Mean (SD) IOP before treatment was 15.5 (3.2) mm Hg and increased to a mean (SD) of 24.7 (6.5) mm Hg, a statistically significant increase of 9.2 (SD: 5.8; range: 5-29) mm Hg (P<0.0001). The median duration of treatment with loteprednol etabonate at the time of observed IOP elevation was 55 days (range: 3 days to 3 years). Twenty-four percent of patients required IOP-lowering medications and 8% required surgery to control the elevated IOP.

CONCLUSIONS

Alternatives to corticosteroids should be considered when long-term treatment is required for an ocular surface condition.

An anti-inflammatory role of VEGFR2/Src kinase inhibitor in herpes simplex virus 1-induced immunopathology

Corneal neovascularization represents a key step in the blinding inflammatory stromal keratitis (SK) lesion caused by ocular infection with herpes simplex virus (HSV). In this report, we describe a novel approach for limiting the angiogenesis caused by HSV infection of the mouse eye. We show that topical or systemic administration of the Src kinase inhibitor (TG100572) that inhibits downstream molecules involved in the vascular endothelial growth factor (VEGF) signaling pathway resulted in markedly diminished levels of HSV-induced angiogenesis and significantly reduced the severity of SK lesions. Multiple mechanisms were involved in the inhibitory effects. These included blockade of IL-8/CXCL1 involved in inflammatory cells recruitment that are a source of VEGF, diminished cellular infiltration in the cornea, and reduced proliferation and migration of CD4(+) T cells into the corneas. As multiple angiogenic factors (VEGF and basic fibroblast growth factor [bFGF]) play a role in promoting angiogenesis during SK and since Src kinases are involved in signaling by many of them, the use of Src kinase inhibition represents a promising way of limiting the severity of SK lesions the most common cause of infectious blindness in the Western world.

Reducing peak corneal haze after photorefractive keratectomy in rabbits: prednisolone acetate 1.00% versus cyclosporine A 0.05%

PURPOSE

To compare the effects of topical cyclosporine A 0.05% (Restasis) with those of prednisolone acetate 1.00% (Pred Forte) on corneal haze after photorefractive keratectomy (PRK).

SETTING

Gavin Herbert Eye Institute, University of California, Irvine-Orange, California, USA.

DESIGN

Experimental study.

METHODS

After -9.00 diopter PRK, 15 rabbits were divided into 3 groups and treated for 4 weeks with prednisolone acetate 1.00% or cyclosporine A 0.05% or neither (control). Corneal haze was measured by in vivo confocal microscopy preoperatively and 2, 4, 6, 8, and 12 weeks postoperatively. At 12 weeks, the corneas were evaluated for collagen organization by ex vivo 2-photon second-harmonic generation and stromal cell density.

RESULTS

Corneal haze was significantly less in the prednisolone acetate group than in the cyclosporine and control groups during the first 6 weeks postoperatively (P<.02). At 8 weeks, there was no significant difference between the 3 groups. There was no significant difference in haze between the cyclosporine and control groups at any time. The stroma was also significantly thinner in the prednisolone acetate group than in the other groups for the first 4 weeks postoperatively (P<.02). Second-harmonic generation scar thickness measurements at 12 weeks were not significantly different between the groups, although the prednisolone acetate group tended to have lower stromal cell density.

CONCLUSION

Cyclosporine A 0.05% had no effect on wound healing after PRK, while prednisolone acetate 1.00% significantly reduced peak corneal haze but had no effect on long-term corneal haze after discontinuation of the drug.

Growth suppression caused by corticosteroid eye drops

Scarce data on systemic activity of corticosteroid eye drops are available in children. Two weeks treatment with fluorometholone eye drops in a case series of five children caused growth suppression detected by knemometry. The suppression had no impact on height growth during the following year.

Controlling herpes simplex virus-induced ocular inflammatory lesions with the lipid-derived mediator resolvin E1

Stromal keratitis (SK) is a chronic immunopathological lesion of the eye caused by HSV-1 infection and a common cause of blindness in humans. The inflammatory lesions are primarily perpetuated by neutrophils with the active participation of CD4(+) T cells. Therefore, targeting these immune cell types represents a potentially valuable form of therapy to reduce the severity of disease. Resolvin E1 (RvE1), an endogenous lipid mediator, was shown to promote resolution in several inflammatory disease models. In the current report, we determined whether RvE1 administration begun at different times after ocular infection of mice with HSV could influence the severity of SK lesions. Treatment with RvE1 significantly reduced the extent of angiogenesis and SK lesions that occurred. RvE1-treated mice had fewer numbers of inflammatory cells that included Th1 and Th17 cells as well as neutrophils in the cornea. The mechanisms by which RvE1 acts appear to be multiple. These included reducing the influx of neutrophils and pathogenic CD4(+) T cells, increasing production of the anti-inflammatory cytokine IL-10, and inhibitory effects on the production of proinflammatory mediators and molecules, such as IL-6, IFN-γ, IL-17, KC, VEGF-A, MMP-2, and MMP-9, that are involved in corneal neovascularization and SK pathogenesis. These findings are, to our knowledge, the first to show that RvE1 treatment could represent a novel approach to control lesion severity in a virally induced immunopathological disease.

Periocular corticosteroid injection in the management of uveitis in children

PURPOSE

To report the outcome of orbital floor corticosteroid injection (OFCI) in the management of uveitis in children.

METHODS

  A retrospective noncomparative interventional case series. The medical records of 15 consecutive children (19 eyes) with various forms of uveitis treated with OFCI of 40 mg/ml methylprednisolone acetate or a combination of 20 mg/0.5 ml Triamcinolone and 2 mg/0.5 ml dexamethasone were reviewed. Data were collected 6 months postinjection and included details of uveitis, best corrected visual acuity (BCVA), ocular inflammation, systemic therapy required and potential complications of OFCI.

RESULTS

The mean BCVA improvement was 0.18 logarithm of the minimum angle of resolution (p < 0.001), at a mean of 6 weeks (range, 4-20). Fourteen eyes (74%) had significant improvement in inflammation, 4-7 weeks post-OFCI, with a median of 4 weeks. Anterior uveitis was treated effectively in all eyes, vitritis resolved in all but one case and resolution of cystoid macular oedema was achieved in six eyes (55%). Uveitis relapsed in seven eyes (50%) after a median time of 4 months (range, 2-5 months). Four eyes (21%) underwent more than one injection. The dosage of immunosuppressive systemic therapy was reduced or able to be stopped in three patients (50%). Steroid-induced cataract was observed in four eyes (21%), 5 months post-OFCI. One patient developed cushingoid features 6 weeks post his second OFCI.

CONCLUSION

Corticosteroid orbital floor injections resulted in control of active uveitis and visual acuity improvement in most children. However, the effect might be transient and induce cataract formation.

The effectiveness of an improved combination therapy for experimental Staphylococcus aureus keratitis

INTRODUCTION

antibiotic and steroid combination therapies, such as tobramycin with dexamethasone, are often used in ophthalmology to treat or prevent infection and inflammation. The purpose of this study was to use a model of Staphylococcus aureus keratitis to quantify and compare the effectiveness of a standard tobramycin and dexamethasone combined therapy, with each drug individually, and with a new formulation of the two drugs in a xanthan gum vehicle.

METHODS

rabbit corneas were intrastromally injected with a methicillin-sensitive S. aureus (MSSA) or a methicillin-resistant S. aureus (MRSA) strain. Rabbit eyes were treated every hour from 10 to 15 hours postinfection (PI) with 0.1% dexamethasone, 0.3% tobramycin, 0.3% tobramycin with 0.1% dexamethasone, or 0.3% tobramycin with 0.05% dexamethasone in a xanthan gum vehicle (ST). Slit lamp examinations (SLE) were performed on infected eyes and pathology scored at 15 hours PI. At 16 hours PI, colony forming units (CFUs) per cornea were quantified.

RESULTS

the CFUs in eyes treated with dexamethasone alone were similar to untreated control eyes for MSSA or MRSA infections. All other treatment groups had significantly less CFUs per cornea than untreated eyes. The eyes treated with the ST formulation had significantly fewer CFUs per cornea than all other treatment groups when infected with MSSA or MRSA. The SLE scores of MSSA or MRSA infected eyes treated with tobramycin alone were similar to untreated control eyes. All other treatment groups had significantly lower SLE scores than untreated controls eyes, but were not significantly different from each other.

CONCLUSION

the results of this study demonstrated that the tobramycin and dexamethasone combination therapy with a xanthan gum vehicle has an improved bactericidal effectiveness compared to the commercially available formulation, and maintains a similar anti-inflammatory effect while containing half the amount of steroid.

Efficacy and safety of bromfenac for the treatment of corneal ulcer pain

PURPOSE

To evaluate the efficacy and safety of bromfenac ophthalmic solution 0.09% (Xibrom™, ISTA Pharmaceuticals Inc., Irvine, CA, USA) for treating pain associated with corneal ulcers.

METHODS

Twenty-five eyes of 24 patients with corneal infiltrates (bacterial or fungal) were treated with appropriate anti-infective agents along with bromfenac twice daily for up to 102 days to treat the pain caused by the infection. Follow-up visits were frequent in the first 2 weeks upon initiation of treatment, then at least weekly until infections were resolved. The best corrected visual acuity, location, size, and density of corneal infiltrates, the size and presence of a corneal epithelial defect, subjective eye pain (scale of 0-4) and time to pain resolution, the ability to conduct daily activities, and adverse events were recorded at each follow-up visit. The results of these treated patients were compared with those of 10 control eyes with corneal infiltrates (bacterial or fungal) where appropriate anti-infectives were used without adjunct medications.

RESULTS

Fifty-two percent of bromfenac-treated patients reported no pain by day 3, compared with 0% of untreated controls (P=0.023). Most of the treated patients' epithelium healed by day 20 (68%) compared with only 10% of controls (P=0.040). Most bromfenac-treated patients (71%) returned to normal activities within 2 days of starting treatment with bromfenac, compared with 0% of controls (P=0.018). No adverse events were recorded.

CONCLUSION

Bromfenac was effective in treating pain associated with infectious keratitis and did not delay corneal epithelialization nor cause any corneal adverse events in this group of 25 eyes.

Loteprednol and tobramycin in combination: a review of their impact on current treatment regimens

IMPORTANCE OF THE FIELD

The treatment of ocular inflammation continues to be a challenge. Topical corticosteroids are effective in reducing ocular inflammation but are limited by adverse events including elevation of intraocular pressure, development of cataracts, glaucoma and inhibition of wound healing with associated risk of infection. Loteprednol etabonate (LE) is a unique C-20 ester corticosteroid designed to produce a predictable therapeutic effect with a low incidence of side effects. Zylet (LE/T) a combination of LE and tobramycin (T) is indicated for the treatment of steroid-responsive ocular inflammatory conditions in which there exists either superficial bacterial ocular infection or a potential risk of bacterial infection.

AREAS COVERED IN THIS REVIEW

The current review of the literature (Medline and the Cochrane Library, 1996 - 2009) examines the safety and efficacy of LE/T in the treatment of ocular inflammation.

WHAT THE READER WILL GAIN

Studies with either LE or LE/T indicate that LE has a lower risk of IOP elevation compared with C-20 ketone corticosteroids owing to its rapid de-esterification to inactive metabolites. LE also lacks the ability to form Schiff base intermediates with lens proteins, a common first step in cataractogenesis. LE/T was noninferior to dexamethasone 0.1%/tobramycin 0.3% in the treatment of blepharokeratoconjunctivitis.

TAKE HOME MESSAGE

LE/T may be a safer treatment option for ocular inflammation in which there is risk of superficial bacterial infections.