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Loteprednol therapy for inflammation due to dry eye disease is considered an “off-label” use. Lipid-Based Artificial Tear Two to four times a day as needed Discontinue Lotemax SM Gel 0.38% If symptoms break through or continue, then pulse dose Lotemax SM gel drops four times a day for one week, or consider loteprednol once daily as needed. Omega-3 essential fatty acids (derived from fish and/or flaxseed oil) Can be initiated at any stage, based on clinical judgment. OUR DRY EYE MANAGEMENT ALGORITHM All therapy—dry eye included—should be individualized to the patient. That said, here is our usual approach to symptomatic dry eye management. 22 REVIEW OF OPTOMETRY JUNE 15, 2020 pathological component is conquered, there is no reason to use suboptimal, highly expensive topical medicines twice daily for years. So, for less than $70, treatment of the inflammatory aspect of dry eye disease is done—so simple, so patient-centric, so scientifically sound! However, no single approach works effectively for all patients, and sometimes deviation from our approach is needed to achieve and to maintain patient comfort. We do have several patients who require once-daily loteprednol, as that is the least anti-inflammatory effect that keeps them comfortable. We have never had a patient develop ocular hypertension at this dosing schedule. For perspective, many patients are using once-daily prednisolone acetate chronically for stromal herpetic disease, corneal transplant rejection suppression or for chronic anterior uveitis. This approach to inflammation control is time-honored. Think about this. Which is safer, loteprednol or prednisolone? Such chronic low-dose inflammatory suppression may be required for a subset of patients in a very cost-effective manner. • Cyclosporine 2.0 is upon us. Authoritative journal articles have questioned the patient benefit of Restasis.2 It is now well recognized that the vast majority of patients with dry eye disease have some degree of meibomian gland dysfunction, and patient-centric interventions include aggressive use of warm soaks (compresses), mechanical debridement of the meibomian gland orifices and mechanical expression. Note that all renditions of cyclosporine are indicated to “increase tear production.” Without a physiological lipid layer, the addition of tears is minimally effective. With Restasis (0.05% cyclosporine) now being generically available, there’s a market opportunity for a newer brand-name cyclosporine, Cequa, a 0.09% solution, available from Sun Ophthalmics, a division of Sun Pharma. It is thought that its nanomicellar formulation might be an improvement over its predecessor. The data show modest gains. The FDA trials found vehicle-increased Schirmer results of 10mm or more in 9.2% of patients, whereas the 0.09% concentration did this in 16.6% of patients.
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