The ability of a drug to penetrate into the ocular tissues is key to controlling inflammation.
“All fluorometholones are not the same,” said Beeran Meghpara, MD, and with good reason. Fluorometholone is the active steroid in formulations used to treat ocular inflammation- however, it is what doesn’t meet the eye that makes the difference, i.e., the vehicle.
If the vehicle prevents the drug from optimally penetrating through the ocular surface into the underlying tissue, the drug will not be as effective as if the penetration was at its potential peak, said Dr. Meghpara, co-director of Refractive Surgery, Wills Eye Hospital, and clinical assistant professor of ophthalmology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia.
What makes the difference for Dr. Meghpara in his practice is the acetate component of fluorometholone acetate ophthalmic suspension (Flarex, Eyevance Pharmaceuticals).
“The acetate in the formulation makes the drug more lipophilic, which facilitates better penetration into the ocular surface,” he explained, resulting in a more potent treatment effect compared with a regular fluorometholone, i.e., without acetate, with the same side effect profile.
The side effects of steroids used to treat ocular diseases have historically been the greatest concerns. These include elevated IOP leading to glaucoma, a higher incidence of cataract formation, worsening of concurrent infections, and delayed healing.
“Generally speaking, the higher the potency of the steroid, the more likely it is that side effects will develop and that they will be worse,” Dr. Meghpara explained.
Fluorometholone acetate, however, is considered one of the safer steroids. When side effects do occur, it is with a lower frequency and they are less severe, he noted.
Calming ocular surface disease
Probably the most common ocular surface disease of patients presenting to a cornea practice is dry eye syndrome, which results from inflammation of the ocular surface, tears, and lacrimal glands.
“The goal is to break the cycle of inflammation,” Dr. Meghpara said.
When treating these patients over the long term, he noted the “go-to” drugs that are safe for chronic use are cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan), lifitegrast ophthalmic solution 5% (Xiidra, Novartis), and cyclosporine A ophthalmic solution 0.09% (Cequa, Sun Pharmaceuticals).
“These are great drugs for treating dry eye,” Dr. Meghpara said. “However, the beneficial effects of these drugs require time to build up.”
Until those beneficial effects become apparent, he uses fluorometholone acetate for the short term in combination with one of the long-term therapies to obtain more immediate relief for his patients.
“This approach calms the inflammation, and the patients feel better and often see better,” he said.
For dry eye, Dr. Meghpara prescribes fluorometholone acetate ophthalmic suspension twice daily for about 4 to 6 weeks. By that time, the benefits of the chronic-use medication are beginning to kick in.
Allergic conjunctivitis is the second most common chronic offender seen in cornea practices, especially in the spring and fall when symptoms tend to become more severe.
In these patients, a short controlled course of fluorometholone acetate ophthalmic suspension can calm the ocular surface and provide relief from the characteristic symptoms of tear, itching, and discomfort.
Giant papillary conjunctivitis, or contact lens–induced papillary conjunctivitis, tends to appear less often in clinical practice, but it is a common complication associated with wearing of contact lenses. Despite the lower incidence, these patients seek treatment and can benefit from short-term treatment with fluorometholone acetate ophthalmic suspension, which allows them to resume wearing their lenses more quickly.
Steroids generally are not intended for use during contact lens wear.
Other less common ocular surface disorders include episcleritis, generally a self-resolving condition that respondes rapidly to treatment with fluorometholone acetate ophthalmic suspension, and marginal ulcers. The latter, while not technically an infection, is an inflammatory response to staphylococcal antigens on the eyelid surface.
Dr. Meghpara noted that a steroid in addition to an antibiotic is helpful in this scenario. In blepharitis, a related condition, the inflammation can spill over onto the ocular surface and cause blepharoconjunctivitis or blepharokeratoconjunctivitis, also responsive to a topical steroid.
“[Fluorometholone acetate ophthalmic suspension] provides the potency of a strong steroid, but the drug has the side effect profile of a milder steroid. The drug provides the best of both worlds. I am confident starting treatment with the drug and confident it is going to work. I am concerned about side effects, but not greatly,” Dr. Meghpara concluded.
Beeran Meghpara, MD
Dr. Meghpara is a speaker for Eyevance Pharmaceuticals.