BLOG: Topical steroids have role in dry eye disease treatment
“I quiver with fear.”
– Scar, The Lion King
Topical steroid therapy for pretty much any indication has historically invoked a Scar-like reaction among eye doctors of all kinds. Those of us who operate and routinely prescribe topical steroids most likely utter Scar’s famous line about his brother’s kingly wrath with the same degree of scorn and sarcasm. Why, then, the ongoing reluctance to use topical steroids for any symptomatic ocular surface disease, especially one as common and prone to episodic symptom flare-ups as dry eye disease (DED)? For better or worse, the answer is likely rooted in the long-standing belief that DED is somehow a lesser entity and we must therefore achieve a level of safety in its treatment that is one or two orders of magnitude greater than, say, cataract surgery.
Our patients would beg to differ.
KPI-121 0.25% is a formulation of loteprednol etabonate that is delivered to the ocular surface via Kala’s proprietary mucus-penetrating particle (MPP) technology. Korenfeld and colleagues present safety data of this particular topical steroid in nearly 1,500 subjects who used it four times a day over a 2- to 4-week course of therapy. This in itself is instructive, that it was necessary to show that the steroid that is arguably the least likely to cause an elevation in IOP over any time span whatsoever did not do so over 2 to 4 weeks. Nonetheless, in one of the least surprising outcomes in the entirety of the DED literature, only 0.6% of study subjects had a greater than 5 mm Hg rise in IOP and a pressure greater than 21 mm Hg. It should be noted 0.2% of subjects given the vehicle had similar results.
It can be argued, and heaven knows I have frequently argued, that topical steroids are severely underused in the treatment of DED symptoms. Whether a patient also uses chronic medication with an immunomodulator or not, the very nature of DED leads to periods in which symptoms are more problematic. In these instances, the prescription of a topical steroid can allow a patient to function without the annoyance of burning, itching and other typical DED symptoms. This study reminds us that topical steroids, in this case loteprednol etabonate, are safe to use, especially in short-term care situations.
Korenfeld and colleagues show us that loteprednol delivered in an MPP vehicle need not be feared; it belongs in our quiver of DED therapies.