An Alternative Treatment
Decreased tear meniscus in dry eye.
As an alternative to steroids—or as an adjunctive therapy—topical cyclosporine can also be used to control inflammation in dry eye disease. While cyclosporine does not demonstrate the rapid anti-inflammatory effect of steroids, it carries fewer risks and is safe for long-term use.
Because of their complementary efficacy and safety profiles, many practitioners often begin dry eye treatment by prescribing both topical steroids and cyclosporine. Following the recommendation of the Asclepius Panel, the use of combination therapy is instituted with the topical corticosteroid, Lotemax (loteprednol etabonate ophthalmic suspension %, Bausch + Lomb) and Restasis (cyclosporine ophthalmic emulsion %, Allergan). 24 The Asclepius Panel recommends practitioners begin early treatment with an anti-inflammatory agent (such as Lotemax) four times a day to improve symptoms and to prevent disease progression. After two weeks, the frequency of the corticosteroid is reduced to twice daily and supplemented with Restasis twice a day. Treatment with loteprednol was stopped after day 60, while cyclosporine treatment is continued.
Corticosteroids will inhibit phospholipase A2 thereby preventing the generation of substances which mediate inflammation, for example, prostaglandins. Corticosteroids also produce a marked, though transient, lymphocytopaenia. This depletion is due to redistribution of the cells, the T lymphocytes being affected to a greater degree than the B lymphocytes. Lymphokine production is reduced, as is the sensitivity of macrophages to activation by lymphokines. Corticosteroids also retard epithelial regeneration, diminish post-inflammatory neo- vascularisation and reduce towards normal levels the excessive permeability of inflamed capillaries.
Contact lens wear can be an inflammatory influence under normal circumstances, but an alreadysensitized cornea can show rebound inflammation if proper steps aren’t taken. It is imperative to use the immunosuppressive benefits of steroids with a slow taper as contact lens wear is resumed, or the patient will suffer setbacks and require multiple office visits. We typically restart limited contact lens wear when the rehabilitating cornea can tolerate a limited steroid dosage of once to twice daily.