Speaker sees little value in use of NSAIDs for dry eye, corneal melt
NEW ORLEANS — While NSAIDs may be useful for treating corneal transplant rejection, they should not be used in dry eyes or cases of corneal melt, a speaker said here.
Graft rejection detected early in a low-risk patient may be reversible in 75% of cases, Reza Dana, MD, said at Cornea Subspecialty Day preceding the American Academy of Ophthalmology meeting.
“Our current approach in patients at high risk of rejection (three or more quadrants of neovascularization) is we prophylax intraoperatively with subconjunctival and intravenous steroid, then 3 to 6 weeks of prednisone,” Dana said. “If they do reject, they go on oral cyclosporine.
However, “No consensus has been established yet,” he added.
“With dry eye disease, the approach is to enhance lubrication, support the epithelium, treat lid disease and control inflammation,” Dana said.
The surface wetness can be increased with tear supplements and tear preservation, and sometimes oral secretagogues are used, he said.
“Treat concurrent lid disease with oral tetracycline or macrolides along with lid hygiene and hot compresses,” Dana said.
Some practitioners are using the LipiFlow by TearScience and performing meibomian gland probing.
“Some have responded, some have not,” he said.
Mucolytic therapy can be used for filamentary keratitis, as can diluted 20% autologous serum tears four to six times daily.
“Do not use NSAIDs in dry eyes,” he added.
Topical immunomodulatory treatments are also useful, Dana said.
“Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) is extremely safe, but there is a distinct minority who has burning,” he said. “Many have to be on the drug for 4 months or longer.”
Dana noted that he rules out a family history of glaucoma before starting a dry eye patient on corticosteroids, and he only uses them to control flares.
Lifitegrast, a T-cell agonist, is being studied for treatment of dry eye.
“Corneal melt is the rapidly progressive thinning of the stromal matrix, with or without epithelial defect,” Dana explained. “Rule out underlying disease, such as infection. Do cultures at baseline and then from time to time to gauge response to therapy.”
In patients with Sjögren’s syndrome or rheumatoid arthritis, the fellow eye must be ruled out.
He recommended suppressing collagen breakdown with the use of oral tetracyclines.
“We also use medroxyprogesterone 1%, autologous serum tears and high-dose oral ascorbate,” Dana said.
“Minimize the use of preservative-containing medications,” he added. “These are very problematic. I often see patients come in with epithelial defect, and they’re on one or two preserved antibiotics.”
Therapeutic bandage contact lenses, scleral contact lenses and amniotic membranes can also be used.
Disclosure: Dana is a consultant for and has received grant support from Allergan.