Critical appraisal of loteprednol ointment, gel, and suspension in the treatment of postoperative inflammation and pain following ocular and corneal transplant surgery

Non-aqueous formulations in topical ocular drug delivery - a paradigm shift?

Topical eyedrop application is the preferred route for drug delivery to anterior segment tissues; however, the challenge of overcoming the eye's anatomical and physiological barriers while minimising tissue toxicity has restricted developments in this field. Aqueous vehicles have traditionally been used, which typically require several additives and preservatives to achieve physiologically compatible and sterile eyedrops, elevating their toxicity potential. Non-aqueous vehicles have been suggested as efficient alternatives for topical drug delivery as they can address many of the limitations associated with conventional aqueous eyedrops. However, despite their obvious advantages, non-aqueous eyedrops remain poorly researched and few non-aqueous formulations are currently available in the market. This review challenges the conventional hypothesis that aqueous solubility is a prerequisite to ocular drug absorption and establishes a rationale for using non-aqueous vehicles for ocular drug delivery. Recent advances in the field have been detailed and future research prospects have been explored, pointing towards a paradigm shift in eyedrop formulation in the near future.

Identification and Description of Reliable Evidence for 2016 American Academy of Ophthalmology Preferred Practice Pattern Guidelines for Cataract in the Adult Eye

Importance

Trustworthy clinical practice guidelines require reliable systematic reviews of the evidence to support recommendations. Since 2016, the American Academy of Ophthalmology (AAO) has partnered with Cochrane Eyes and Vision US Satellite to update their guidelines, the Preferred Practice Patterns (PPP).

Objective

To describe experiences and findings related to identifying reliable systematic reviews that support topics likely to be addressed in the 2016 update of the 2011 AAO PPP guidelines on cataract in the adult eye.

Design, Setting, and Participants

Cross-sectional study. Systematic reviews on the management of cataract were searched for in an established database. Each relevant systematic review was mapped to 1 or more of the 24 management categories listed under the Management section of the table of contents of the 2011 AAO PPP guidelines. Data were extracted to determine the reliability of each systematic review using prespecified criteria, and the reliable systematic reviews were examined to find whether they were referenced in the 2016 AAO PPP guidelines. For comparison, we assessed whether the reliable systematic reviews published before February 2010 the last search date of the 2011 AAO PPP guidelines were referenced in the 2011 AAO PPP guidelines. Cochrane Eyes and Vision US Satellite did not provide systematic reviews to the AAO during the development of the 2011 AAO PPP guidelines.

Main Outcomes and Measures

Systematic review reliability was defined by reporting eligibility criteria, performing a comprehensive literature search, assessing methodologic quality of included studies, using appropriate methods for meta-analysis, and basing conclusions on review findings.

Results

From 99 systematic reviews on management of cataract, 46 (46%) were classified as reliable. No evidence that a comprehensive search had been conducted was the most common reason a review was classified as unreliable. All 46 reliable systematic reviews were cited in the 2016 AAO PPP guidelines, and 8 of 15 available reliable reviews (53%) were cited in the 2011 PPP guidelines.

Conclusions and Relevance

The partnership between Cochrane Eyes and Vision US Satellite and the AAO provides the AAO access to an evidence base of relevant and reliable systematic reviews, thereby supporting robust and efficient clinical practice guidelines development to improve the quality of eye care.

Loteprednol etabonate for inflammatory conditions of the anterior segment of the eye: twenty years of clinical experience with a retrometabolically designed corticosteroid

INTRODUCTION

Topical corticosteroids are an important pharmacotherapy for the management of various inflammatory conditions affecting the anterior segment of the eye. However, medications in this class are associated with well-known risks including increased intraocular pressure (IOP) and development of cataracts. The topical corticosteroid loteprednol etabonate (LE) was developed with the specific intention of minimizing these side effects.

AREAS COVERED

The focus of this review is to examine published efficacy and safety data for LE, a drug engineered to undergo rapid metabolism to inactive metabolites with the goal of improved safety. Two decades of clinical research focused on LE formulations are reviewed, including the use of LE in combination with tobramycin. The cumulative body of experience affirms the concept that the molecular design of LE confers certain safety benefits without compromising the desired anti-inflammatory efficacy of a topical corticosteroid.

EXPERT OPINION

Loteprednol etabonate is a mainstay for topical therapy of a wide variety of commonplace and niche conditions of the ocular surface and the anterior segment, including in the healing post-operative patient. Its versatility and safety allow eye care providers to recommend both acute induction as well as chronic maintenance therapy with appropriate follow-up.

Comparison of Efficacy and Safety of Loteprednol Etabonate 0.5% and Topical Dexamethasone 1% in Post-Vitrectomy Inflammation

PURPOSE

To compare the efficacy and safety of postoperative topical loteprednol etabonate (LE) 0.5% with dexamethasone (DEX) 0.1% for the treatment of inflammation following pars plana vitrectomy (PPV).

METHODS

A total of 150 eyes of 150 patients who underwent transconjunctival PPV for various diagnoses were included in this prospective, randomized study. The patients were assigned into two groups as Group LE (n = 75) and Group DEX (n = 75). Intraocular inflammation, intraocular pressure (IOP), and the intensity of postoperative pain were compared between the groups.

RESULTS

The mean IOP was higher in the patients treated with DEX (p > 0.05). The need for anti-glaucoma medications was significantly lower in Group LE (5.3%) than in Group DEX (17.3%) (p = 0.020). Tyndall scores were less in Group DEX at postoperative Days 1 (p = 0.01) and 3 (p = 0.017). On Day 1, it was more likely for patients to have mild or moderate pain in Group LE (p < 0.001). On Day 3, the number of the patients with no pain was higher in Group DEX (p = 0.005).

CONCLUSIONS

Although DEX is more effective in the early postoperative days, LE appears to be as effective in controlling inflammatory response following PPV in the long-term. Topical LE is associated with less increase in the IOP and a lower need for anti-glaucoma medications.

Loteprednol Etabonate 0.5% Gel Vs. Prednisolone Acetate 1% Solution After Descemet Membrane Endothelial Keratoplasty: Prospective Randomized Trial

PURPOSE

To compare intraocular pressure (IOP) elevation and graft rejection with loteprednol etabonate 0.5% gel and prednisolone acetate 1% solution after Descemet membrane endothelial keratoplasty (DMEK).

METHODS

In this prospective, evaluator-masked trial, 167 patients were randomized to loteprednol or prednisolone in a 1:1 ratio 1 month after DMEK; 66 fellow eyes were enrolled and assigned to the opposite treatment. Dosing was 4 times daily for 2 months, thrice daily for 1 month, twice daily for 1 month, and once daily for 7 months. The main outcomes were IOP elevation (defined as IOP ≥ 24 mm Hg or an increase of ≥10 mm Hg over the baseline preoperative level) and immunologic rejection episodes, assessed by Kaplan-Meier survival analysis and proportional hazards modeling.

RESULTS

A total of 233 eyes were assigned to treatment. Loteprednol etabonate 0.5% gel and prednisolone acetate 1% solution were equally effective in preventing immunologic rejection episodes; none (0%) occurred with either treatment (P = 1). IOP elevation was twice as likely in the prednisolone-treated eyes (relative risk = 2.3, 95% confidence interval: 1.2-4.5, P = 0.016). The proportion with IOP elevation was 25% in prednisolone-treated eyes versus 11% in loteprednol-treated eyes (P = 0.013). In 66 subjects with fellow eyes assigned to opposite treatments, an IOP increase of ≥10 mm Hg was significantly more likely in the prednisolone-treated eye (P = 0.031).

CONCLUSIONS

Loteprednol etabonate 0.5% gel was as effective as prednisolone acetate 1% solution in preventing immunologic graft rejection episodes after DMEK and was significantly less likely to cause IOP elevation.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01853696.