[Perioperative/Postoperative Anti-Inflammatory Therapy During/After Corneal Surgery/Transplantation]. / Perioperative/postoperative antientzündliche Therapie bei/nach Hornhautchirurgie/Hornhauttransplantation.

Surgical trauma, and foreign material - such as sutures or implants or antigens during tissue transplantation - may cause inflammatory reactions. Inflammatory reactions after surgical interventions distant from the vascularised limbus and without opening of the anterior chamber of the eye are usually very muted, because of the corneal immune and angiogenic privilege. A milestone in the therapy and prophylaxis of inflammation after corneal surgery has been the use of topical glucocorticoids since the 1950s. When these are used, it is important to consider the cataractogenic effect of long-term use, the possibility of steroid-induced increase in intraocular pressure (so-called steroid response), the increased risk for microbial infection and the inhibition of epithelialisation. The available glucocorticoids differ in their ability to penetrate into the eye (prednisolone best), their immunosuppressive activity (dexamethasone best) and their ability to induce a steroid response (loteprednol etabonate and fluorometholone least). Preservative-free formulations are only available for dexamethasone. The different properties must be taken into account when choosing the "best" glucocorticoid: If there is a risk of delay in epithelialisation of the wound, topical steroids should be avoided or if necessary, phosphate- and preservative-free dexamethasone should be used with caution. If efficiency in the posterior cornea or in the anterior chamber is important, e.g. after penetrating keratoplasty, prednisolone acetate should be used. If a steroid response is known, loteprednol etabonate or fluorometholone should be used. When allogeneic tissue is transplanted, long-term topical glucocorticoid use over 24 months or longer is necessary. After high-risk keratoplasty with allogeneic donor tissue, supplemental systemic immunosuppressive therapy with calcineurin inhibitors or mycophenolate mofetil over 6 to 12 months is recommended.

Panscleritis as an Unusual Complication of Gonioscopy-assisted Transluminal Trabeculotomy.

PURPOSE: The main purpose of this study was to report a case of panscleritis after gonioscopy-assisted transluminal trabeculotomy (GATT). METHODS: We describe the case of a 33-year-old man with a history of unilateral anterior uveitis and glaucoma, who developed panscleritis after GATT surgery. RESULTS: Uneventful GATT surgery was performed in a glaucomatous left eye. On the second postoperative day, the patient developed tenderness on palpation of the eye. Ophthalmic examination revealed significant diffuse hyperemia, elongated and tortuous upper bulbar conjunctival/scleral vessels, and exudative retinal detachment at the superior nasal quadrant, with diffuse scleral thickening. The patient was diagnosed as having panscleritis, which was attributed to the GATT surgery. Although the scleritis resolved completely with intravenous and oral methylprednisolone treatment, localized retinal detachment persisted. CONCLUSIONS: Surgery-induced posterior scleritis may occur following minimally invasive glaucoma surgeries such as GATT. Control of uveitis for at least 3 months before surgery is indicated in patients with uveitis if GATT surgery is planned.

Non-glaucoma periocular allergic, atopic, and irritant dermatitis at an academic institution: A retrospective review.

PURPOSE: To better understand the nature of periocular dermatitis (PD) patient presentation, treatment, time-to-cure, and referral pattern for allergy testing in an ophthalmic academic center. METHODS: A retrospective chart review of 344 patients diagnosed with PD between January 1, 2000 and November 30, 2016 at the Edward S. Harkness Eye Institute was performed. Eighty patients were eligible for the study. The primary endpoint was the time-to-cure. Cox proportional hazards regression was performed to assess if there was a significant difference between time-to-cure in patients treated with: 1) combination topical steroid/antibiotic (n = 6) vs. topical steroid alone (n = 40) and 2) combination topical steroid and oral antihistamine (n = 5) vs. topical steroid alone (n = 40). RESULTS: The median age of eligible patients was 57.69 years old, 66.25% of patients were female, and 41.25% had a history of atopy. Seven patients in total were referred for allergy testing. A significant difference was found in likelihood of cure when comparing combination topical steroid and oral antihistamine versus topical steroid alone, adjusting for age and gender (aHR = 3.97, 95% CI: 1.40-11.25). No significance was found when comparing combination topical steroid/antibiotic versus topical steroid alone (aHR = 1.96, 95% CI: 0.72-5.27). CONCLUSION: Patients treated with topical steroid and oral antihistamine were approximately 4 times more likely to experience cure in comparison to patients treated with topical steroids alone. While the majority of patients were not referred for formal allergy testing, this would likely be of benefit.

Submicron loteprednol etabonate ophthalmic gel 0.38% for the treatment of inflammation and pain after cataract surgery.

PURPOSE: To assess the safety and efficacy of a 0.38% submicron formulation of loteprednol etabonate (LE) gel for the treatment of postoperative inflammation and pain after cataract surgery. SETTING: Forty-five United States ophthalmology practices. DESIGN: Double-masked vehicle-controlled randomized parallel group study. METHODS: Patients 18 years of age or older with anterior chamber cells grade 2 or higher on day 1 after uncomplicated cataract surgery were randomized to 14 days of treatment with LE gel 2 times a day, LE gel 3 times a day, or vehicle. Hierarchical primary endpoints were the proportion of patients with resolution of anterior chamber cells and grade 0 (no) pain at postoperative day 8. Safety outcomes included adverse events, intraocular pressure (IOP), biomicroscopy, visual acuity, ophthalmoscopy, and tolerability (drop comfort and ocular symptoms). RESULTS: The intent-to-treat population included 514 patients. Significantly more patients in the LE gel 2 times a day and 3 times a day groups compared with the vehicle group had complete resolution of anterior chamber cells (26.9% and 28.7% versus 9.3%) and reported grade 0 pain (73.7% and 73.1% versus 47.7%) on day 8 (P < .001 vs vehicle for all). The safety findings were unremarkable, with 1 patient experiencing an IOP increase of 10 mm Hg or higher while on LE gel. More than 75% of patients in each group reported no drop discomfort. CONCLUSION: In this study, submicron loteprednol etabonate gel 0.38% appeared safe and effective in the treatment of postoperative inflammation and pain whether instilled 2 times or 3 times a day.

Comparison of Efficacy of Difluprednate 0.05% and Loteprednol Gel 0.5% After Cataract Surgery.

PURPOSE: To compare the outcomes and complications of topical difluprednate 0.05% and loteprednol gel 0.5% after routine cataract surgery. METHODS: Subjects received either difluprednate emulsion 0.05% (n=30 eyes) or loteprednol gel 0.5% (n=30 eyes) after routine cataract surgery. Topical steroid drops were initiated 3 days before cataract surgery and continued for 2 weeks postoperatively. Anterior chamber (AC) cell grade, corneal edema, corneal pachymetry, visual acuity, ocular surface quality (Oxford scale), and intraocular pressure (IOP) were evaluated at 1 day, 1 week, and 1 month postoperatively. RESULTS: Patients treated with difluprednate or loteprednol had statistically similar resolution of their AC cell grade and corneal edema at 1 day, 1 week, and 1 month postoperatively (P>0.05 at each study visit). Difluprednate-treated and loteprednol-treated eyes achieved a mean best-corrected visual acuity of at least 20/25 by 1 week postoperatively (0.055 and 0.061 logarithm of the minimum angle of resolution, respectively; P=0.82). The nasal ocular surface quality at 1 week had improved in loteprednol-treated eyes compared with difluprednate-treated eyes (1.0 vs. 1.9 Oxford score, respectively; P<0.001), but similar at all other visits. There was no statistical difference between IOP levels between both treatment groups (P>0.05). In the difluprednate-treated group, one patient developed rebound inflammation and two patients developed cystoid macular edema at their 1-month postoperative visit. CONCLUSIONS: The anti-inflammatory effect, visual recovery, and IOP of patients using topical difluprednate or loteprednol gel after cataract surgery are equivalent. There may be an additional short-term benefit of loteprednol gel in protecting the ocular surface after cataract surgery.

Effect of topical loteprednol etabonate with lid hygiene on tear cytokines and meibomian gland dysfunction in prosthetic eye wearers.

PurposeTo assess tear cytokine levels and clinical outcomes in meibomian gland dysfunction (MGD) in the blind eye of patients wearing an ocular prosthesis after 2 months of treatment with topical loteprednol etabonate and eyelid scrubs with warm compresses.Patients and methodsThis study included patients with MGD wearing a unilateral ocular prosthesis for more than 1 year. All patients topically received 0.5% loteprednol etabonate and were instructed to scrub their eyelids with warm compresses on the prosthetic eye for 2 months. We evaluated tear cytokine levels using Multiplex Bead Immunoassays, performed biomicroscopic examination of the lid margins and meibomian gland, conducted meibography imaging, and assessed MGD-related ocular symptoms using a questionnaire for the prosthetic eye before and 2 months after treatment.ResultsThirty consecutive patients were included. There were significant reductions in the levels of interleukin (IL)-6, interferon-γ, monocyte chemotactic protein-1, IL-8, tumor necrosis factor-α, and IL-1ß (P<0.001 for each cytokine). Moreover, there were improvements in ocular symptoms (P=0.001), lid margin abnormalities (P<0.001), meibomian gland expressibility (P<0.001) and meibography findings (P=0.037).ConclusionTopical loteprednol etabonate in conjunction with eyelid scrubs and warm compresses were effective in treating MGD in prosthetic eye wearers. Furthermore, tear cytokine measurements may serve as an additional approach for evaluating the efficacy of anti-inflammatory treatment for MGD in prosthetic eye wearers.

Symptomatic Treatment of Subepithelial Infiltrates after Viral Conjunctivitis: Loteprednol or Dexamethasone?

PURPOSE: To compare the efficiency and ocular side-effect profile of topical loteprednol applied to one eye and topical dexamethasone applied to the other eye in the early period on the same patient who has subepithelial infiltrates (SEI). METHODS: The patients who developed bilateral SEI following epidemic keratoconjunctivitis (EKC) were applied topical loteprednol on one eye (group 2) and topical dexamethasone on the other (group 1). RESULTS: Decrease in the symptoms was faster in the dexamethasone group, but this difference between the groups was not statistically significant (p = 0.073). Both groups were found to have substantial recurrence. However, the difference between the groups was not statistically significant (p = 0.131). CONCLUSIONS: The study has found that in the treatment of SEI, which developed after EKC, statistically similar results can be obtained with loteprednol, which is known to have fewer adverse effects.

Effect of 0.1% diclofenac ophthalmic solution on inflammatory response and macular thickness following phacoemulsification cataract surgery. / [Wplyw 0,1% kropli diklofenaku na odczyn zapalny w komorze przedniej oka i stan plamki po operacji fakoemulsyfikacji zacmy].

Purpose: To evaluate 0.1% diclofenac sodium as an adjunctive therapy with loteprednol etabonate on postoperative inflammation in the anterior chamber and on foveal and parafoveal retinal thickness. Material and methods: Eighty eyes eligible for phacoemulsification were enrolled in a randomized clinical trial. Patients in group I (N = 40) received anti-inflammatory treatment consisting of 0.1% diclofenac with 0.5% loteprednol; group II (N = 40) patients received 0.5% loteprednol alone. Best corrected visual acuity and intraocular pressure were measured, and laser flarephotometry was done. Foveal and parafoveal thickness were assessed by optical coherence tomography. Results: Median flare values decreased more rapidly in group I at 7 and 14 days (7.9 and 7.4 ph/ms, respectively) than in group II (13.7 and 11.8 ph/ms, respectively; p < 0.0001). Group II had significantly increased parafoveal thickness at 14 and 42 days (median 285.59 µm, p = 0.001 and 288.38 µm, p < 0.001, respectively). Parafoveal thickness differed significantly between groups at 14 and 42 days (p = 0.0085, p = 0.0004, respectively). Conclusions: Eyes treated with both diclofenac sodium and loteprednol etabonate showed less inflammatory response and were less likely to develop foveal and parafoveal thickening than those treated with steroid only.