STEROIDS: Use with Caution and with Confidence
Despite their potential drawbacks, steroids are essential to eye care. Aggressive initial dosing with monitored, slow tapering is the key to success.
Release Date: February 2011
Expiration Date: February 28, 2014
Corticosteroids are an integral part of topical ophthalmic therapy. When properly prescribed, topical steroids provide
tremendous benefits, such as controlling inflammation and scarring,
preventing vision loss, limiting lost productivity at work or school,
and enabling a more rapid return to comfortable contact lens wear.
However, steroids are not without risk—they can induce glaucoma,
cataracts and potentiate infection, especially in longer
treatment periods. This course reviews appropriate indications and prescribing steroids for a variety of pathologic ocular conditions.
William B. Potter, O.D.
COPE approval for 2 hours of CE credit is pending for this course. Check with your local state licensing board to see if this counts toward your CE requirement for relicensure.
This continuing education course is
joint-sponsored by the Pennsylvania College of Optometry.
Dr. Potter is on the speakers bureau for Alcon.
Steroid medications have presented a special set of challenges to the profession of
optometry as it has attained
therapeutic privileges. Opponents of
our expanded therapeutic drug prescribing have cited potential harm
to an unwary public.
In addition, optometric education
of decades past had over-emphasized the negatives of steroids, and
proposed too-narrow indication for
However, when properly prescribed, topical steroids provide
tremendous benefits, such as controlling inflammation and scarring,
preventing vision loss, limiting lost
productivity at work or school, and
enabling a more rapid return to
comfortable contact lens wear. Steroids are safe and effective as long
as the doctor understands the risks
and knows what to do in the event
of a steroid induced event.
This article encourages proper
topical steroid usage while minimizing the risk of adverse reactions.
Risks vs. Benefits
Topical ophthalmic steroids are
categorized as synthetic glucocorticoids, meaning that they are manufactured to mimic the effects of their
known as cortisol. (Cortisol suppresses the release of substances in
the body that cause inflammation. It
also increases blood sugar through
gluconeogenesis, and it aids in the
metabolism of fat, protein and
carbohydrate. The body increases
secretion of cortisol, or “the stress
hormone,” in response to physical
and psychological stress.)
Steroid medications have a wide
range of effects in suppressing
inflammatory activity, and their use
can be critical to the restoration of
a patient’s well being. However, steroids are not without risk, as doctor and patient need to be acutely
aware of steroid use as an etiology
in glaucoma, cataracts and the
potentiation of infection, especially
in longer treatment periods.1
In glaucoma, 4% to 6% of
patients will have significant IOP
increases after a month on steroid
drops.2 In fact, we have encountered
patients whose pressure increases
with only a week of therapy, so
regular tonometry is important.
Cataract is also a concern with
prolonged use of steroids. Unfortunately, this irreversible result is
due to alteration of crystalline lens
Also, because steroids are immunosuppressive, they can limit the
white blood cell response that
would normally fight off infection.
So, herpes simplex and fungal infection are especially worrisome when
steroid use is prolonged.
Thus, the key to proper steroid
use is weighing the risk vs. benefit
for each patient. Close monitoring
in follow-up care allows for risks to
be moderated with proper dosage
tapering, as well as alternate therapies if adverse effects occur.
Eye care practitioners have a wide
range of topical steroid choices.
The development of “soft steroids,” such as FML (fluorometholone
alcohol 0.1%, Allergan) and
Lotemax (loteprednol 0.5%, Bausch
+ Lomb), have changed how we
practice. Soft steroids should have a
place in any primary care optometric practice. These allow us longer
tapering schedules, which are safer,
as well as milder immunosuppression and fewer steroid side effects.3
While stronger topical agents—prednisolone, dexamethasone and
difluprednate—are indicated for
severe and acute inflammation, they
lack the safety profile for most cases
of chronic therapy. Diverse external
diseases, ranging from herpes zoster to silicone hydrogel-associated
inflammation, have an ongoing antigenicity that may require a month
or more of immunosuppression. So,
although the stronger agents may be
required initially, the softer steroids
provide a safer opportunity to taper
the anti-inflammatory effect with
less likelihood of inducing secondary glaucoma or cataract.
With this in mind, let’s look at
how steroids are used in the following conditions.
This condition is primarily noninfectious, and can be managed confidently at the primary care level in
the majority of cases. However, steroid fears can lead the practitioner
to under-prescribe these agents, and
actually cause a prolonged treatment period that increases the total
Pred Forte (prednisolone acetate
1%, Allergan) has been the gold
standard for anterior uveitis,
because soft steroids may lack the
needed efficacy in non-surgical
uveitis.4 The AOA Clinical Practice
Guideline on anterior uveitis recommends prednisolone acetate 1%
every one to six hours depending
on severity—the more severe the
inflammation, the more frequent the
dosage.5 (However, the guidelines,
which were last reviewed in 2004,
acknowledge that “treatment recommendations [may] change due
to continuing research and clinical
Unfortunately, sometimes patients
are started on a q.i.d. prednisolone
dosage, which is usually inadequate
in anti-inflammatory effect. While
this may be driven by the fear of
steroid-induced side effects, it actually increases the likelihood that
the drug will have to be used for
a longer period of time. Starting
the patient on hourly dosing, with
tapering over the course of a month
or more, seems to avoid prolonged
treatment periods in most cases of
Topical Ophthalmic Corticosteroids
|FDA approved dosing
Bausch + Lomb
|q.i.d. for 2 weeks, then b.i.d. for
1 week, and then gradual taper
|Up to q4h for first 24 to 48
hours; or b.i.d. to q.i.d., then
Bausch + Lomb
|Up to qh for first week; or q.i.d.
for 2 weeks, then gradual taper
|Up to >q.i.d. for first 24 to 48
hours; or b.i.d. to q.i.d., then
|Up to qh during the day, q2h
during the night as initial therapy;
or q4h, then t.i.d. to q.i.d.,
then gradual taper
In our practice, we seldom treat
anterior uveitis at an initial dosage
of less than every two hours, with
an hourly dosage being most common. Severe cases are treated with an initial dosage of one drop every
15 minutes for the first hour, and
hourly thereafter, for one week. We
reduce the prednisolone dosage by
half each week, so that the second
week’s dosing is every two hours,
and the third week is four times
daily, and so on.
If this schedule is not maintained,
we find that the patient becomes
more vulnerable to a relapse of signs
and symptoms, thus requiring a restarting of the treatment regimen.
The result is that the total steroid
use is much greater, and presents
unnecessary safety risks. Aggressive
initial dosing with monitored, slow
tapering is the key to success.
We now have a new topical
steroid option with the release of
Durezol (difluprednate 0.05%,
Alcon). This drug has demonstrated
therapeutic equivalence to topical
prednisone in treating uveitis, with
a dosing schedule that is cut in half.6
Because we know that compliance
decreases as prescribed dosage
increases, we can likely attain better results with lesser dosing.7 As
insurance formulary acceptance is
increasing, Durezol should become
a leading weapon in treating anterior uveitis at the primary care level.
However, this drug has not
eliminated concerns of cataract and
steroid-induced glaucoma (and its
IOP elevation may be comparatively
higher than with other steroids).8
Close follow-up is essential, and the
clinician must be prepared to prescribe medications to lower intraocular pressure if ongoing steroid
therapy is required. While follow-up
is geared towards the severity of the
underlying condition, we monitor
IOP weekly if steroid use approaches a month or more.
Topical steroids should be
avoided in seasonal and perennial
allergic conjunctivitis, if possible,
because they can dig the practitioner
a deep hole in terms of chronic use.
The problem with using steroids
in these cases is that the patient’s
relief may be so profound as to lead
to demands for prescription refills.
However, there are occasions when
steroid use is justified. If discomfort
persists to such a degree that it limits school or job performance, the
practitioner is obligated to provide
safe yet rapid relief.
Modern mast cell stabilizers
and antihistamines are extremely
effective, but may not offer symptomatic relief for the first several
days of use. Work and school performance may be limited by allergy
symptoms, to such an extent that
a steroid prescription is indicated.
Similarly, contact lens wear can be
interrupted by allergy, which can
be devastating to keratoconus and
higher refractive error patients.
Contact lens wear can be safely
restored by a conservatively short
“burst” of soft steroids, such as
FML, Lotemax or Alrex (loteprednol 0.2%, Bausch + Lomb).9 We
typically start these agents with
the instructed dosing: q.i.d. for up
to one week, then reduce to b.i.d.
dosing as contact lens wear is
The duration of allergy treatment
with steroid drops seldom needs to
exceed two weeks.9 The patient can
concurrently use mast cell stabilizer/
antihistamine drops. These drugs
will provide continued relief of
allergy signs and symptoms once the
steroids are discontinued.11
Patient management must include
discussion of the risks and benefits
of steroid treatments, with emphasis
on short-term treatment. The practitioner must gauge the patient’s
ability to comply, and err on the
side of caution if this is in doubt. It
is important to limit the patient to
only a 5mL quantity, and to maintain a “no refills without follow-up
Another reason for steroid use in
allergy patients is the consideration
of the eye’s cellular response. If antigens are persistent enough in their
presentation, eosinophil recruitment
can result. This infiltration into ocular tissue alters the inflammatory
chemistry, which limits the effectiveness of mast cell stabilizers and
antihistamines. Eosinophilia may
contribute to scarring of lid, cornea and conjunctiva, so prevention may
require steroid use. The practitioner
may use conjunctival scrapings or
other cytologic methods, but the
clinical appearance of the eye can
be the key indicator. We find that
hypertrophy and dermatitis of the
lid skin, paired with the chronicity
of the response, can indicate that
cellular elements are involved, and
that steroids are indicated.
Treatment failure with mast
cell stabilizer/antihistamine drugs
is another clinical indication that
eosinophilia has developed. This
type of lid inflammation, if left
uncontrolled, can lead to fibrosis
and scarring, which can alter cosmetic appearance and decrease lid
function. Fluorometholone and
loteprednol are ideal agents if steroid treatment is required, because
their propensity to elevate intraocular pressure is low.12
This generally non-infectious
entity is a common presentation
that benefits from steroid as well as
antibiotic therapy. In general, lens
cessation and subsequent refitting
are primary treatments. However,
antibiotic coverage is wise if there is
suspicion of an excessive bacterial
load. (See “Infectious Infiltrates vs.
Infectious Infiltrates vs.
It is important to differentiate inflammation
from true infection in contact lens-associated
infiltrative events. Pain, hyperacute redness,
anterior chamber reaction, and excavation
of the corneal epithelium in lesions
larger than 2mm should raise suspicion of
microbial keratitis. But, more commonly,
patients present with smaller infiltrates,
singly or in multiples, that have bacteria as
only a minor player.
Silbert JA. Is It an Ulcer or an Infiltrate?
Rev Optom. 2007 June;
More problematic is the ongoing
inflammatory response, which may
far outlast the infectious phase, and
make restarting or refitting of lens
wear quite difficult. Contact lens
wear itself can be an inflammatory
influence, and its resumption may
stimulate the eye’s immune response
even in the presence of an ideal fit.13
Topical ocular steroids are often
better utilized if they are not combined with antibiotic preparations.
Modern antibiotics are extremely
effective at stopping infection, but
the patient’s inflammatory response
may provide ongoing symptoms,
especially in attempts to resume
contact lens wear.
products can actually be problematic in infiltrative keratitis, as
they commonly use tobramycin as
the antibiotic agent. Tobramycin
has strong antibiotic properties,
especially against gram-negative
bacteria, but tends to be toxic to the
healing corneal epithelium.14 Clinically, this seems especially true in
treatment durations of longer than
one week. Fluoroquinolone antibiotics have less toxicity and are better tolerated.
Although there are asymptomatic
cases of infiltrative keratitis, many
patients are troubled by discomfort,
blurred vision and redness. Typical
treatment of infiltrative keratitis is
to initiate antibiotic therapy with
a fluoroquinolone, one drop in the
affected eye, four times daily for one
week.15 We concurrently start a soft
steroid, such as fluorometholone or
loteprednol 0.5%, also four times
Follow-up examination in four or
five days provides critical information about whether to restart contact lens wear, and when to taper
the steroid drops. Significant corneal staining or persistent infiltrates
can indicate that contact lens wear
is a week or more away. Consultation with a cornea specialist is recommended if signs and symptoms
We often see infiltrative keratitis patients who have been treated
with antibiotic therapy alone. The
consequence here is that ultimate
resolution is delayed. Interestingly,
research done in the development
of Restasis (cyclosporine, Allergan) for dry eye has revealed that
inflammatory white blood cells can
have a life expectancy of 100 days
or more.16 So, a week of antibiotic
therapy does little to prevent the
inflammatory cytokines that these
cells release, once contact lens wear
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.
The cornea’s immune response to Staph. infection is a familiar cause
of inflammation. Both contact lens
wearers and non-wearers alike can
suffer from this relatively mild and
treatable condition. Patients present
with mild to moderate redness and
discomfort, with an approximately
1mm peripheral corneal infiltrate
being the significant slit lamp finding.
Antibiotic therapy is helpful,
though the infectious component
of this disorder is easy to eradicate.
The question is whether and when
steroid use is appropriate. We make
two assessments: First, what is the
risk of more serious infection, as
indicated by the appearance of the
corneal lesion? Small, non-ulcerated
lesions in the corneal periphery
generally have very low risk of progression to more serious and sightthreatening infection.
Second, what is the level of
patient discomfort, in terms of his
or her ability to function at work or
school? (Though marginal keratitis
does not usually cause extreme pain,
it may be enough to disrupt daily
routines of some patients.) Failure
to initiate steroid treatment may
expose the patient to unnecessary
discomfort and loss of productivity.
The use of steroid via antibiotic/steroid combination, such
as TobraDex (tobramycin 0.3%/
dexamethasone 0.1%, Alcon) or
Zylet (tobramycin 0.3%/loteprednol
0.5%, Bausch + Lomb), on day one
may be appropriate if the risk of
progression is low and the patient is
If there is uncertainty, prescribe
an antibiotic initially and then follow up in a day or two to assess
whether to add a separate steroid.
Posterior blepharitis, also known
as meibomian gland dysfunction, is
primarily an inflammatory disease.
While antibiotic therapy is helpful in
reducing lid flora, patients
do not attain comfort
until lid inflammation is
reduced. Steroid therapy
remains the best method
to attain rapid patient
A classic approach
has been to apply topical
combination drugs, such
as TobraDex or Zylet.18
TobraDex ST (tobramycin 0.3%/dexamethasone
0.1%, Alcon) appears
highly appropriate to treat
blepharitis because its retentionenhancing suspension vehicle (using
xanthan gum) maintains contact
with the lid and ocular surface for a
longer duration. A greater therapeutic effect is often the result, though
steroid concerns should limit treatment periods to one week.
Because posterior blepharitis
tends to be a recurrent and chronic
condition, exercise great caution in
limiting steroid use, especially for
dexamethasone or prednisolone.
The advent of topical ophthalmic
azithromycin, AzaSite (azithromycin
1%, Inspire) has provided another
option, as its antibiosis is supplemented by effective anti-inflammatory activity.19
Note that the prescribing of AzaSite in posterior blepharitis remains
an off-label use, as its present indication is for bacterial conjunctivitis. Azithromycin down-regulates
inflammatory mediators NF-KB,
cytokines and matrix metalloproteinase.20-23
Our choice for chronic blepharitis
patients is to initiate AzaSite once
daily for one month.24 In addition,
we use a soft steroid four times
daily for the first week, and one to
two times daily for the second week
if needed. This method provides
great relief of symptoms by way of
the soft steroid, and allows time for
the AzaSite to begin to have its antiinflammatory and antibiotic effect.
The month of AzaSite treatment
is followed by a month off in most
cases, because the half-life of the
drug is longer than one week. Treatment may be restarted if symptoms
reappear, hopefully without the
steroid accompaniment. AzaSite
contains BAK as a preservative (at
0.003%), and we should always be
aware of potential BAK allergy and
toxicity with long-term use. However, the steroid dosage is reduced so
quickly in this regimen that we have
never found preservative reactions
to be problematic.
AzaSite’s benefits include the
possibility of limiting total steroid
use in our blepharitis patients. A
recent study demonstrated improved
patient comfort and tear breakup time in blepharitis patients
who used AzaSite once daily for a
month.24 No other drug has been
shown to do this to date. In addition, we use soft steroid drops for
about one week in order to attain
Ocular Herpetic Disease
Perhaps the primary care optometrist’s most difficult decision regarding steroids involves the patient with
ocular herpes. Occasional cases blur
the line between simplex and zoster.
Here are some guidelines for steroid use for herpetic involvement.
• Herpes simplex. Steroids are
not indicated for herpes simplex
cases with epithelial involvement.
Yet when epithelial episodes have
residual subepithelial haze, or
possible evolution to a disciform
involvement, then steroid use is
mandatory.25 Disciform and interstitial keratitis are the immunologic
results of herpetic infection, whose
comanagement with a corneal specialist may be indicated.
In the case of herpes simplex
keratitis, subepithelial haze can be a
sight-threatening result of epithelial
disease, even in the absence of true
disciform inflammation. Depending
on severity, we start steroid therapy
once there is epithelial closure, i.e.,
upon resolution of the ulcer itself.25
Specifically, start fluorometholone
or loteprednol 0.5% at q.i.d. dosing for the first week, then taper
the dosage by half for two to four
weeks. More severe cases indicate
prednisolone or difluprednate
treatment at similar dosages, and
specialty corneal consultation is
encouraged. Steroid initiation prior
to epithelial closure could potentiate
Meanwhile, maintain oral antiviral coverage, such as Valtrex
500mg t.i.d. (valacyclovir, GlaxoSmithKline), at least through the first
week of topical steroid therapy.
• Herpes zoster. Herpes zoster
ophthalmicus has a clear indication
for topical steroids if there is ocular
involvement, such as staining and
mucoid plaques. Patients with these
findings are at greater risk for uveitis, which can be severe.26
Start a soft steroid on a q.i.d.
basis, with careful slit lamp monitoring on a minimum of alternate
days. Tapering may take several
weeks. Be prepared to increase
steroid potency to Pred Forte or
Durezol if corneal findings worsen
or if uveitis develops.
Along with other treatments, consider steroid therapy in the disease
spectrum of dry eye syndrome. As
inflammatory theories have been
elaborated, and optometrists gain
clinical experience, steroid treatment
has become standard to offer short
term relief of symptoms. Restasis,
AzaSite, punctal plugs and advanced
lubricants are all excellent chronic
treatments for dry eye. However,
for acute symptoms, none of these
treatments offer the rapid relief of
steroid medications. If a practitioner
simply increases lubricants as acute
therapy, the patient will suffer a
much longer course of unresolved
symptoms and signs.
The soft steroids fluorometholone
and loteprednol 0.5% are ideal for
treatment of an acute inflammatory
episode in dry eye. They should be
considered mainstream therapy,
even in the presence of moderate
signs and symptoms.27,28 These drugs can get a patient in pain “over
the hump” while the more chronic
agents are given a chance to work.
Steroids rapidly calm the inflammation caused by cell death in the
cornea and conjunctiva, as well as
calm the inflammation in the tear
glands that may have contributed to
the dry eye in the first place.
Dosing q.i.d. for the first week of
treatment, followed by a tapering
period of one to three weeks, works
well and poses little risk for the
acutely inflamed dry eye patient.
Many practitioners take on a
philosophy of accepting no risk in
terms of steroid use. Our argument
is that we need to weigh risk versus
benefit of symptomatic relief in a
variety of inflammatory conditions.
Intraocular pressure measurement
is a key component at return visits,
as steroid responses are fairly common.29
While we cannot practice in a
risk-free environment, we can control steroid risks with close followup including tonometry, and a
“no-refill without visit” policy. The
rewards of patient retention and satisfaction are exponentially greater
when steroid medications are used
in their best indications.
Dr. Potter is chief of optometry
and contact lens services at Millennium Eye Care, in Freehold, N.J. He
is on the speakers bureau for Alcon.
- Jaanus SD, Cheetham JK, Lesher GA. Anti-inflammatory drugs. In:
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- Armaly MF, Becker B. Intraocular pressure response to topical corticosteroids. Fed Proc. 1965 Nov-Dec;24(6):1274-8.
- Abelson M, Sleeper A. Insights on anti-inflammatories. Rev Ophthalmol. 2005 June; 12(6):80-4.
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- Optometric Clinical Practice Guideline Care of the Patient with
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- Foster CS, Davanzo R, Flynn TE, et al. Durezol (Difluprednate Ophthalmic Emulsion 0.05%) compared with Pred Forte 1% ophthalmic
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- Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001 Aug;23(8):1296-310.
- Meehan K, Vollmer L, Sowka J. Intraocular pressure
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- Bielory L, Katelaris CH, Lightman S, Naclerio RM. Treating
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- Lotemax package insert. Bausch + Lomb. 2006 April.
Available at: www.bausch.com/en_US/downloads/ecp/
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- Khurana S, Sharma N, Agarwal T, et al. Comparison
of olopatadine and fluorometholone in contact lensinduced papillary conjunctivitis. Eye Contact Lens. 2010
- Multack RF, Genge MR, Skorin L. Immune Disease. In:
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Lippincott Williams & Wilkins; 2005:246.
- Zhivov A, Stave J, Vollmar B, Guthoff R. In vivo confocal
microscopic evaluation of langerhans cell density and distribution in the corneal epithelium of healthy volunteers and
contact lens wearers. Cornea. 2007 Jan;26(1):47-54.
- Matsumoto S, Stern ME. Effect of anti-infective ophthalmic solutions on corneal cells in vitro. Adv Ther. 2000
- Donshik PC, Suchecki JK, Ehlers WH. Peripheral corneal
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- Jackson WB. Management of dysfunctional tear syndrome: a Canadian consensus. Can J Ophthalmol. 2009
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- Jackson WB. Blepharitis: current strategies for diagnosis
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- Opitz DL, Tyler KF. Efficacy of azithromycin 1% ophthalmic solution for treatment of ocular surface disease from
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- D’Acquisto F, May MJ, Ghosh S. Inhibition of nuclear
factor kappa B (NF- B): an emerging theme in anti-inflammatory therapies. Mol Interv. 2002;2(1):22-35.
- McDermott AM, Perez V, Huang AJW, et al. Pathways of
corneal and ocular surface inflammation: a perspective from
the Cullen Symposium. Ocul Surf. 2005;3(4):S131-8.
- De-Quan L, Pflugfelder SC. Matrix metalloproteinases in
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- Leonardi A, Brun P, Abatangelo G, et al. Tear levels and
activity of matrix metalloproteinase (MMP)-1 and MMP-9
in vernal keratoconjunctivitis. Invest Ophthalmol Vis Sci.
- Foulks GN, Borchman D, Yappert M, et al. Topical
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- Wilhelmus KR, Gee L, Hauck WW, et al. Herpetic Eye
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- Foster CS. Uveitis. Lecture presented at annual meeting of American Academy of Ophthalmology, 2002; New
- Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear
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- Pflugfelder SC, Maskin SL, Anderson B, et al. A randomized, double-masked, placebo-controlled, multicenter
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