Not Long for Lotemax?

In Drs. Pelino and Pizzimenti’s article, “The Body Goes to War (Part II)” (September 2009), they describe a case wherein they treated a dry eye patient with Lotemax q.i.d. for four weeks and then b.i.d. for four weeks. This case was uncomfortably similar to one I dealt with that came to a bad end.

The symptoms driving treatment were very similar to the example in the article: SPK and contact lens intolerance. I prescribed Lotemax q.i.d. with the plan to transition her into Restasis b.i.d. when she was stable. I followed her closely to track progress, which she made. But at about week six, my patient came in with reduced vision. Her IOP was in the neighborhood of 40mm Hg O.U. She had CRVO O.D. with reduced acuity that evolved into near total loss of vision in that eye. Note that she had been in just the week before and her IOP was normal. Did the IOP really cause the CRVO? Proximity in time would lead one to suspect a relationship, although coincidence can’t be ruled out.

Here is my point. Lotemax is a low risk steroid, but not a zero risk steroid. I am troubled by discussion of its use without reviewing its risk. In my mind, cases like that of the patient I treated and the patient in the article would be best served by treating them less aggressively. More ambitious application of steroids should be reserved for those patients who fail less aggressive therapy.

A great number of O.D.s read Review of Optometry, and the last thing we need is for them to start thinking Lotemax eight-week therapy is the standard of care for dry eye and contact lens intolerance. You might argue that my patient’s course was a result of a rare combination of variables creating a perfect storm of CRVO. We have to be mindful that we are modifying the variables that might be contributing to that perfect storm. No episode in my career has humbled me more than treating my patient’s contact lens intolerance and watching her go blind in one eye.

—Chris Barry, O.D.

Bellevue, Wash.

 

Drs. Pelino and Pizzimenti respond:

Thank you for reading our column. Based upon the outcome of permanent, severe loss of visual function, it appears that your patient suffered a non-perfused (ischemic) CRVO in the right eye. Long-term blinding complications in perfused (non-ischemic) CRVO are much less common than in ischemic occlusions.^1,2 Treatment with anti-VEGF agents may be beneficial in eyes with macular edema after CRVO.³

You need not blame yourself (or your prescribing of Lotemax) for causing the CRVO, as the most likely etiology is underlying systemic vascular disease. The most important potential complication now is the development of ocular neovascularization, with neovascular glaucoma as the most dreaded sequelae. Comanagement of your patient with a fellowship-trained retinologist and an internist (to address systemic factors) is the appropriate plan going forward.^1,2

According to the dysfunctional tear syndrome (DTS) severity algorithm, our patient in our column presented with level 3 ocular surface inflammatory disease.⁴ According to the DTS management algorithm, treatment with topical corticosteroids as part of the management plan is appropriate for this level of severity.⁴ Corticosteroids have been shown to improve tear production by controlling inflammation.⁵

We chose Lotemax based upon its efficacy and excellent safety profile for use over several weeks and, in some studies, months. Loteprednol etabonate 0.5% has been found to be effective and safe in double-masked, controlled studies in several indications.^6-12 In another recent study, 64 patients with keratoconjuctivitis sicca were randomized to treatment with either loteprednol 0.5% or a placebo at one drop four times daily for one month. Objective signs improved significantly only in the steroid group, and no significant changes in IOP were noted.¹³

In our patient, we continued to treat with Lotemax for several weeks, adding Restasis at week four, while slowly tapering the dosage of the steroid throughout the treatment course, eventually discontinuing the steroid. We routinely follow this general protocol, as Restasis takes three to four months to achieve a clinically significant effect.

While there are no universal, specific guidelines for the dosing of loteprednol 0.5% as adjunct therapy for DTS, our general protocol is based on the most current research evidence, in combination with our clinical practice experience.^4-13 Of course, we adjust our protocol on a case-by-case basis, depending upon various patient characteristics. Our patient was particularly uncomfortable at the time of diagnosis.

Finally, no topical corticosteroid—or any drug, for that matter—is devoid of potential side effects. Thank you for the opportunity to remind clinicians to monitor patients frequently and carefully throughout the treatment course.

Membership Lost and Found

I was delighted to read of the recent creation of the American Optometric Society (AOS). (“New Society Aims To Give Voice to O.D.s,” September 2009.) I dropped my membership to the AOA many years ago in response to their stance on advocating the first iteration of superfluous optometric board certification despite what I felt was overwhelming resistance against the concept by rank and file optometrists at large. I didn’t feel I could ethically and professionally justify membership in an organization that would be arrogant enough to claim it was acting for the benefit of all optometrists, while pursuing and advocating changes for the profession that were clearly controversial.

I have never been asked my opinion on any topic by the AOA—even when I was a member! Magazines do it. Websites do it. Manufacturers do it. Why doesn’t the AOA poll optometrists at large regarding the direction of legislation and the profession? How can they know my stand on issues if they don’t ask?

Dissenters within the AOA and the many non-AOA members seem to have often been ignored, and this has created much alienation within the profession nationwide. I was proud to be able to tender my charter membership in the AOS. My hope is that the AOS will legitimately be able to speak for all optometrists by enabling every optometrist to have a voice and a vote.

—Dana C. Rohleder, O.D.

Port Kent, N.Y.

‘Top Optometrist’ Comes Clean

I recently received a letter notifying me that I had been selected as one of “America’s Top Optometrists” by Consumers’ Research Council of America. I was skeptical that I deserved to be considered a top optometrist. I have not done a residency, I have not published a single paper, I am not a Fellow of the American Academy of Optometry and I have less than 10 years of experience. By these standards, I’m not even a top optometrist at my own clinic. 

I found a very informative article on the Forbes website. One of many interesting revelations was that Consumers’ Research Council of America has just five employees and the listed address is a rented mailbox in a UPS store. Furthermore, the guide is an e-book only and not available in a hard copy format. The top professionals are merely names in a difficult-to-navigate online database.

I would expect that anyone receiving a similar letter would realize that it is just junk mail. But, I was surprised and disappointed that a Google search of “top optometrists” revealed that many optometrists display this award on their business websites and CVs. To be fair, many other specialists, including ophthalmologists, dentists, surgeons and oncologists, also flaunt this award.

With all due respect to my “top” optometric brethren, this award has no merit whatsoever. Dignifying this “accomplishment” legitimizes this ridiculous organization and misleads unsuspecting patients.

—Max P. Hergott, O.D.

Minneapolis, Minn.

 

1. Hayreh SS. Management of central retinal vein occlusion. Ophthalmologica. 2003 May-Jun;217(3):167-88.

2. The Central Vein Occlusion Study Group. Natural history and clinical management of central retinal vein occlusion. Arch Ophthalmol. 1997 Apr;115(4):486-91.

3. Iturralde D, Spaide RF, Meyerle CB, et al. Intravitreal bevacizumab (Avastin) treatment of macular edema in central retinal vein occlusion: a short-term study. Retina. 2006 Mar;26(3):279-84.

4. Behrens A, Doyle JJ, Stern L, et al.; Dysfunctional Tear Syndrome Study Group. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006 Sep;25(8):900-7.

5. Pflugfelder SC. Antiinflammatory therapy for dry eye. Am J Ophthalmol. 2004 Feb;137(2):337-42.

6. Dell SJ, Shulman DG, Lowry GM, Howes J. A controlled evaluation of the efficacy and safety of loteprednol etabonate in the prophylactic treatment of seasonal allergic conjunctivitis. Loteprednol Allergic Conjunctivitis Study Group. Am J Ophthalmol. 1997 Jun;123(6):791-7.

7. Friedlaender MH, Howes J. A double-masked, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. The Loteprednol Etabonate Giant Papillary Conjunctivitis Study Group I. Am J Ophthalmol. 1997 Apr;123(4):455-64.

8. Asbell P, Howes J. A double-masked, placebo-controlled evaluation of the efficacy and safety of loteprednol etabonate in the treatment of giant papillary conjunctivitis. CLAO J. 1997 Jan;23(1):31-6.

9. Neumann R, Howes J. Loteprednol etabonate: a novel ocular steroid with improved safety profile. In: Nussenblatt RB, Whitcup SM, Caspi RM, Gery I, eds. Advances in Ocular Immunology: Proceedings of the 6th International Symposium on the Immunology and Immunopathology of the Eye, Bethesda, USA. New York: Elsevier; 1994:245-8.1

10. The Loteprednol Etabonate Postoperative Inflammation Study Group 2. A double-masked, placebo-controlled evaluation of 0.5% loteprednol etabonate in the treatment of postoperative inflammation. Ophthalmology. 1998 Sep;105(9):1780-6.

11. Stewart R, Horwitz B, Howes J, et al. Double-masked, placebo-controlled evaluation of loteprednol etabonate 0.5% for postoperative inflammation. Loteprednol Etabonate Post-operative Inflammation Study Group 1. J Cataract Refract Surg. 1998 Nov;24(11):1480-9.

12. Novack GD, Howes J, Crockett RS, Sherwood MB. Change in intraocular pressure during long-term use of loteprednol etabonate. J Glaucoma. 1998 Aug;7(4):266-9.

13. Pflugfelder SC, Maskin SL, Anderson B, et al. A randomized, double masked, placebo-controlled, multicenter comparison of loteprednol etabonate ophthalmic suspension, 0.5%, and placebo for treatment of keratoconjunctivitis sicca in patients with delayed tear clearance. Am J Ophthalmol. 2004 Sep;138(3):444-57.