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Article Date: 3/1/2005

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Relieve Persistent Conditions
Learn how combination drugs can help you break the cycle of chronic blepharitis and meibomian gland dysfunction.

Many patients who complain of ocular discomfort suffer from chronic or recurring conditions, such as blepharitis. This inflammatory condition often is treated with combination steroids and anti-infectives because these agents are effective and less likely to cause adverse effects with long-term use.

Anterior blepharitis can be caused by Staphylococcus sp. entrenched in and around the base of the eyelashes.
Photograph courtesy of Ron Melton, O.D., F.A.A.O.

Combination agents also may be beneficial for patients with persistent disease. "Even if steroid or anti-infective monotherapy was successful in the past, we need to try a different approach after the third or fourth recurrence of the same disease," says Jimmy D. Bartlett, O.D., F.A.A.O. "That's when we switch to combination drugs."

Anterior blepharitis

Anterior blepharitis is one of the most common indications for combination steroid and anti-infective agents.

"I always start blepharitis patients on a regimen and see them again after 2 weeks, but the regimen varies among patients," says Marc R. Bloomenstein, O.D., F.A.A.O. "Treatment may include lid scrubs, artificial tears, and possibly, a combination eye drop at least four times a day. I may prescribe an ointment for elderly patients who aren't very active and may not mind blurry vision. I'll start tapering the dosage after the follow-up visit. Once the patient's condition is under control, I recommend a maintenance dose of one drop in the morning and one at night."

Ron Melton, O.D., F.A.A.O., follows a similar regimen. "I start blepharitis patients -- particularly those with significant inflammation -- on a combination anti-inflammatory and antibiotic agent four times a day for 1 week, then two times a day for a second week. I also instruct them to perform daily lid scrubs and apply warm compresses," he says. "When I see these patients again after 2 to 3 weeks, they usually show a good response to moderate dosing with the combination drug. I recommend they continue lid scrubs and warm compresses long-term."

Randall K. Thomas, O.D., F.A.A.O., also appreciates the efficacy of combination drugs. "Combination steroids and antibiotics are wonderful for treating anterior blepharitis because they work directly on the source of the problem," he says.

 

 

 


"Combination steroids and antibiotics are wonderful for treating anterior blepharitis because they work directly on the source of the problem."

-- Randall K. Thomas, O.D., M.P.H., F.A.A.O.

Meibomian gland dysfunction

Many doctors adopt a similar strategy for treating meibomian gland dysfunction and accompanying ocular surface disease. The steroid treats inflammation, while the antibiotic helps prevent ocular surface damage and subsequent infection.

"The eyes of patients with posterior blepharitis usually are inflamed, which disrupts the normal ocular surface flora," Dr. Melton says. "Treatment with a combination antibiotic/steroid four times a day for a week, and then twice a day for a week, helps stabilize ocular surface disease associated with meibomitis."

Dr. Bloomenstein explains the etiology of ocular surface conditions. "During the evaporative process you lose some antibiotic protection normally provided by the tear film," he says. "Combination drugs reduce meibomian gland inflammation, calm the lid surface, improve the tear film and reduce the risk of infection in my primarily elderly meibomitis patients."

Paul M. Karpecki, O.D., F.A.A.O., from Overland Park, Kan., starts with a simple regimen and adds medications as needed to reach the desired result. "I start with hot compresses and lid massage," he says. "If an eyelid has a lot of erythema and edema, I immediately add a combination drug to the regimen. My next step is to start the patient on 50 mg of doxycycline -- 20 mg if the higher dose upsets his stomach.

 


"Combination drugs reduce meibomian gland inflammation, calm the lid surface, improve the tear film and reduce the risk of infection in my primarily elderly meibomitis patients."

-- Marc R. Bloomenstein, O.D., F.A.A.O.

"I'm a big proponent of doxycycline. I prescribe it frequently. It does resolve meibomitis from the inside, but several weeks or months can pass before we see results," Dr. Karpecki says. "I find combination drops treat meibomitis and surface inflammation quicker than systemic therapy."

Dr. Thomas also uses doxycycline to treat persistent meibomitis. "Half of my meibomitis patients respond to traditional therapy," he says. "I offer doxycycline to the other half who are recalcitrant to first-line therapy."

Combination diagnosis, combination drug

"Patients rarely have posterior blepharitis without some anterior involvement. You're more likely to see mixed disease than straight posterior or anterior blepharitis," Dr. Thomas says. "Fortunately, this complex problem responds well to treatment with combination steroid and anti-infective agents." 

 

Why is Loteprednol Safer?

In December 2004, Bausch & Lomb received FDA approval to manufacture and distribute Zylet, a new ophthalmic suspension that combines loteprednol etabonate 0.5%, the first and only ester-based corticosteroid, and tobramycin 0.3%, a time-tested aminoglycoside antibiotic.

Zylet is approved for steroid-responsive inflammatory ocular conditions for which a corticosteroid is indicated and where superficial bacterial ocular infection or a risk of a bacterial ocular infection exists.

Loteprednol is designed to be active at the site of application and deactivated in a predictable single reaction after achieving its therapeutic effect, thus minimizing ocular hypertension without sacrificing powerful steroid action. Unlike other steroids (prednisolone, dexamethasone, fluorometholone, rimexolone and medrysone), the number 20 position ketone group is absent. This group has been implicated in increasing the risk of cataract formation and elevated IOP with long-term use.

In contrast, loteprednol's high lipid solubility helps active ingredients penetrate the cornea, where they exert their anti-inflammatory effect before naturally occurring esterases convert loteprednol into an inactive metabolite. When added to tobramycin, an effective antibiotic, loteprednol is a well-tolerated agent for treating a wide spectrum of chronic inflammatory ocular conditions.

 

 


Optometric Management, Issue: March 2005

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