Vol. 2, #25   •   Thursday, October 28, 2021


Review's Chief Clinical Editor
Paul M. Karpecki, OD, FAAO

Provides you with cutting-edge clinical strategies for optimal management of ocular surface disease and beyond.


Staining Means Steroids


It’s important to know when to use topical corticosteroids to treat DED and what cases require other therapies.

One of the more common questions I get is when to use topical corticosteroids to treat a patient with dry eye disease (DED). This has come up even more frequently since the FDA approved EYSUVIS (loteprednol 0.25%) for the short-term treatment of dry eye signs and symptoms.

Induction Therapy
For years, it was commonplace to start a DED patient with topical corticosteroids prior to initiating cyclosporine. With the approval of lifitegrast/Xiidra in 2016, many doctors moved to using corticosteroids if Xiidra caused burning or other side effects. Today a mix of the above approaches is used in DED management.

To make things simpler, if I see ocular surface staining, I promptly begin with topical corticosteroids. In the clinical trials for EYSUVIS, patients noticed statistically significant improvement as soon as two days. I have found corticosteroids also seem to affect corneal and conjunctival staining more quickly than other prescription agents. As a result, I often use topical steroids for the first two to six weeks, with monitoring of IOP around three to four weeks after initiation.

Dry Eye Flares
Immune-mediated diseases like asthma, rheumatoid arthritis, and DED are all characterized by periodic flareups. In most diseases, these are managed with short-term corticosteroids. In DED, it’s not uncommon to see four to six flareups per year even while patients are on other therapies. In these cases, the use of topical corticosteroids is a four to 14-day duration.

Preparing the Ocular Surface
When I receive DED patients who are planning to undergo cataract surgery, I know they and the surgeon don’t want to wait months to resolve dry eye signs. Corticosteroids are a faster-acting option to achieve resolution.

When Not to Use Steroids
While I have found steroids to be the most effective agents for inflammation, they are not ideal for long-term treatment, given the risk of IOP elevation and potential for secondary infections. I also avoid corticosteroids for corneal abrasions, with contact lenses (including bandage lenses), and in patients with any signs of potential microbial keratitis. In addition, I tend to avoid them in glaucoma patients.

KEY TAKEAWAY: When ocular surface staining is present in DED, consider treating with steroids to quickly resolve DED signs and symptoms, control flareups, and rapidly prepare the ocular surface. But also know when to avoid them and seek alternative therapies.



Supported by an independent medical grant from Kala Pharmaceuticals

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