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A short course of a low-dose corticosteroid eye drop can relieve inflammation with only a low increase in intraocular pressure.
Dry eye disease (DED) is a multifactorial condition, with the two main pathways being decreased healthy tear production or increased tear evaporation from the ocular surface. If any one of several instigating factors is collectively added, a heightened inflammatory response on the ocular surface can occur, which can affect both DED pathways and lead to the exacerbation of DED.1-4
A dry eye flare is defined as an acute episode of worsening symptoms characterised by inflammation that has disrupted the homeostatic balance within the tear film. This acute worsening of symptoms can last from a few days to a few weeks. Most commonly, a dry eye flare is caused by a trigger that activates a pro-inflammatory cascade on the ocular surface.1-4
Seasonal allergies are likely to trigger an exacerbation or flare of DED symptoms. These patients often complain of runny or teary eyes, redness, itchiness, burning and a gritty sensation, as well as symptoms that affect the adjacent regions such as sinus tenderness and a stuffy, runny nose.
In my clinical experience, most people have these allergy-induced dry eye flares during the spring and summer when pollen, the biggest inciting factor, is being dispersed by blooming flowers and trees. Along with seasonal allergies, other triggers include perennial allergens (such as pet dander, dust and mould); excessive screen time; excessive wearing of contact lenses; and vented air from heat or air conditioning.5-13
When Ieducate patients about dry eye flares, I let them know that a flare is a symptomaticacute episode during apreviously quiescent period. Many of my patients with more severe dry eye are on baseline therapysuch as ciclosporinor lifitegrastophthalmic solution (Xiidra,Novartis), and for the most part, their symptoms are well controlled.
However, when a trigger such as seasonal allergyinduces a pro-inflammatory state, they develop a sudden onset of acute symptoms.In other words, these patients are quite miserable. They do not say: “Doctor, I think I’m experiencing a dry eye flare,” but they do say “My medications don’t seem to be working anymore, and I’m getting these symptoms again." So, I take the opportunity to educate them, reminding them that althoughthere is no cure for DED, we can manage it with therapy and that it is normal to experience fluctuations in symptoms.
I say: “Your seasonal allergies are pushing your eyes into overdrive or a pro-inflammatory state, and medication is needed to control this acute flare.” Treatment with an approved, fast-acting, low-dose topical corticosteroid can provide rapid relief of symptoms—exactly what these patients are looking for.
Loteprednol etabonate ophthalmic suspension 0.25% (Eysuvis, Kala Pharmaceuticals) isthe first United States Food and Drug Administration-approved corticosteroid for short-term treatment of the signs and symptoms associated with DED. The drop has a novel formulation that utilises Ampplify, Kala’s proprietary mucus-penetrating particle technology.
Nanoparticles of approximately 300 nmin diameter are coated to facilitate their penetration through the mucus barrier. This controlled delivery system enables the drop to spread more uniformly across the ocular surface.
I like to use this dropin patients with DED because the quick onset of action means noticeable, rapid relief, plus the patients only need to use it for a short period of time—no more than 2 weeks. Those patients with DED who are on chronic medication can continue while supplementing with loteprednol etabonate ophthalmic suspension 0.25%.
Patients should be educated that seasonal changesor other triggers mentioned earlier may cause them to have recurrent episodes of dry eye flares that need to be treated with a short course of a low-dose corticosteroid. Many of us worry about intraocular pressure (IOP) elevation secondary to corticosteroid use. I reassure patients that the drop has a favourableadverseeffect profile and that because of its low concentration, I am comfortable with episodic dosing throughout the year.
In fact, loteprednol etabonate ophthalmic suspension 0.25% was studied in more than 2,800 patients with DED.14-16 The drop was well tolerated and, similar to the vehicle, illustrated a low incidence of IOP increase.
In the treatment and vehicle groups, respectively, 0.2% and 0% of subjects experienced an equal-to or greater-than-10 mm Hg increase from baseline, resulting in an IOP measurement of equal-to or greater-than-21 mm Hg at any post-baseline visit up to 29 days.These IOP safety data provide me with a boost in confidenceto prescribe this drop to my patients with DED.
For compliant patients with DED who have a good understanding of the disease, I have them keep their loteprednol etabonate ophthalmic suspension 0.25% handy andI advise them to re-start it for a short course when they notice a dry eye flare.
It is normal for patients to experience multiple flares throughout the year. For some, it may be more (or less) frequent. These inflammatory spikes of acute exacerbation occur in approximately eight out of ten patients with dry eye, and approximately half of patients with DED experience flares only, without continuous symptoms, four to six times per year.17-20
Many allergy patients aretaking oral antihistamines. If I see that they are having signs and symptoms of ocular surface disease, I tell them to hold off on their oral antihistamine because the drugcan worsen DED.
Depending on the severity of their systemic allergy symptoms, I may talk to their allergy specialist to determine if they can switch to a nasal decongestant or other non-systemic therapy. The best solution, though, is always to avoid the allergy trigger and make other appropriate environmental and/or lifestyle changes.
I advise contact lens wearers to discontinue use when they are experiencing a dry eye flare. I prefer that they do not use eye drops with contact lenses, to avoid problems such as build-up, debris or denaturing of the lens material. In addition, lens wear can add to, or be a culprit of, their dry eye flare due to the mechanical rubbing on their eyes and oxygen deprivation.
While they take a contact lens holiday, they can also start a short course of loteprednol etabonate ophthalmic suspension 0.25% for rapid relief of their symptoms. They can then consider slowly going back to using their contact lenses; however, I recommend decreasing wear time as much as possible (so that it totals no more than 8 hours per day). In addition, we should always ensure that patients are wearing lenses with optimal oxygen permeability, with daily disposables as an ideal option.
For most of our patients with DED, it is not a matter of if, but when, they will have an acute exacerbation of symptoms—dry eye flares. Fortunately, we have a fast-acting treatment to lessen their misery.