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In the past, clinicians have shied away from steroids because of the risks associated with the older ketone agents (prednisolone and dexamethasone), such as increased IOP and cataractogenesis, noted Dr. Dhaliwal, associate professor of ophthalmology, University of Pittsburgh School of Medicine, and director of the cornea and external disease service and the refractive surgery service, University of Pittsburgh Medical Center Eye Center, Pittsburgh.
"However, the newer ester steroids have increased safety," she said. "I typically use loteprednol etabonate 0.5% [Lotemax, Bausch & Lomb] or 0.2% [Alrex, Bausch & Lomb] or fluorometholone 0.1%."
Patients with a suboptimal ocular surface who undergo refractive surgery are at risk for severe dry eye, diffuse lamellar keratitis, and poor wound healing-all of which can lead to a negative result, warned Dr. Dhaliwal. Clinicians need to optimize the ocular surface before any refractive procedure, and a good approach is the use of short-term topical steroids to control the inflammatory component along with long-term therapeutic options, she continued.
"I typically start steroid drops q.i.d., followed by taper of 1 drop per week. This provides an immediate anti-inflammatory effect," she said. "I also concomitantly start cyclosporine 0.05% [Restasis, Allergan] b.i.d. If there is lid disease, I start with thermal eye massage and consider omega-3 fatty acids p.o. or low-dose doxycycline 20 to 50 mg b.i.d."
After a month, Dr. Dhaliwal said, she will re-examine the patient to determine whether the ocular surface is clear and therefore it's safe to proceed with refractive surgery. If the ocular surface is still compromised, she will try punctal plugs in patients who have aqueous deficiency.
Topical steroids are a useful part of the surgeon's armamentarium for treating the ocular surface. "The reason is that topical steroids reduce inflammation by increasing production of protein that inhibits phospholipase A. They also decrease prostaglandin and leukotriene formation," Dr. Dhaliwal said. "In addition, they block production and release of cytokines."
She warned surgeons of contraindications to steroid use, including a history of herpes simplex virus dendritic keratitis or contact lens-related keratitis, especially with the increased incidence of Fusarium infection.
"In summary, it is important to optimize the ocular surface preoperatively," Dr. Dhaliwal said. "Steroids are an underutilized tool."