Topical Corticosteroids

Topical administration is commonly the route of choice for ocular disorders. Most ocular inflammation manifests itself in the anterior segment of the eye: the conjunctiva, cornea, anterior chamber, and anterior uveal tract. In addition, topical administration decreases potential risks and side effects associated with these drugs.

In topical form, corticosteroids are the mainstay of therapy for inflammation involving the anterior segment of the eye. In addition to use after cataract or refractive surgery, there are many other uses for these agents. Topical corticosteroids work best in cases of acute inflammation and less well for chronic diseases. They have little, if any, effect on degenerative diseases.

Topical ophthalmic corticosteroids are available for administration as suspensions, solutions, and ointments. In some types, suspensions are more effective than solutions. Ointments are the least effective. Though they increase contact time with the ocular surface, ointments seem to bind the drug, decreasing availability for its intended use.

Each steroid base, such as prednisolone or dexamethasone, may be available in more than 1 form; for example, dexamethasone is available as dexamethasone alcohol or dexamethasone sodium phosphate. The alcohol or phosphate form is known as its derivative. The derivative of the corticosteroid has an important role in both its overall effect and its vehicle. In therapeutic mixtures, acetate and alcohol formulations will form suspensions, while phosphate preparations will remain true solutions. Furthermore, given the same corticosteroid base, acetate preparations have more anti-inflammatory activity than alcohols; phosphate preparations are yet less effective. The choice of which steroid to use is made weighing the relative cost, convenience, safety, and effectiveness of the available corticosteroids (Table 7-3) against the patient's condition and need for treatment.

Frequency of application may be as often as every hour to once a day, depending on the type, location, severity, and course of the inflammatory condition. Therapy should be started quickly and aggressively enough to suppress the inflammation. Once the inflammation is quelled, tapering should begin.

Normally, it is not necessary to taper after topical ocular therapy unless the duration of treatment exceeds 2 or 3 weeks or the inflammation was severe. In these cases, the physician may prefer to use a short tapering period: 4 times per day for 4 days, 3 times per day for 3 days, and so

Table 7-3

Effectiveness in Reduction of Corneal Inflammation of Selected Topical Corticosteroids

Drug

Prednisolone Acetate 1% Dexamethasone 0.1% Fluorometholone 0.1% Prednisolone phosphate 1% Dexamethasone phosphate 0.1%

Decrease Through Intact Epithelium

on until discontinuing the medication entirely. If used long-term or with recurrent disease, slower tapering is necessary (decreasing by only 1 drop per week or slower). Patients must always be cautioned of the dangers of discontinuing corticosteroids on their own accord.

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