Choosing the Appropriate
Anti-inflammatory

BY WILLIAM TOWNSEND, O.D.
NOV. 1996

The term 'ophthalmic anti-inflammatory drops' used to be synonymous with corticosteroids. Fortunately, we now have a broad spectrum of agents that can be considered anti-inflammatory -- non-steroidal anti-inflammatories (NSAIDs), vasoconstrictors, antihistamines and mast cell stabilizers, as well as topical steroids. How do you know which one to use in a given situation? Although this is a complex issue, here are some guidelines for treating the more common causes of ocular inflammation.

MANAGING ALLERGIC OCULAR INFLAMMATION

When obtaining the ocular allergy history, it's important to learn what is actually bothering the patient. We often assume that the biggest problem is itching or watering, but it's not unusual to see a patient with ocular allergy whose only complaint is redness. Combination antihistamine/decongestants are an excellent choice for these patients.

Consider the duration and severity of the symptoms. Patients with intense itching that is short-lived, seasonal or intermittent do well on a potent H-1 blocker such as Livostin (levocabastine). Patients with chronic allergic eye disease may have better long-term relief with a mast cell stabilizer such as Alomide (lodoxamide) or Crolom (cromolyn sodium).

We must also be aware of the limitations imposed by managed care formularies. An HMO in our area includes the combination antihistamine/decongestants on its formulary, but not Livostin, a more expensive product. It's no surprise then that panel doctors here don't prescribe much Livostin, since to do so, they must first submit a special request form.

Topical NSAIDs are valuable resources for managing chronic ocular allergy. Although used primarily as analgesics, Voltaren (diclofenac), Acular (ketorolac), Ocufen (flurbiprofen) and Profenal (suprofen) help reduce chronic symptoms. They are best used in conjunction with an antihistamine or a mast cell stabilizer.

MANAGING THE PAIN OF INFLAMMATION

Pain, a major aspect of inflammation, is mediated by several substances, but the most common are the prostaglandins, which reduce the body's threshold for pain. Unlike histamine and serotonin, prostaglandins must be synthesized. Corticosteroids or NSAIDs can block this process. Where there's an accompanying cellular response, such as in uveitis, steroids have the obvious edge. In adenoviral disease, many doctors routinely prescribe steroids, but there is a growing number of practitioners who feel NSAIDs are best for all but the most serious forms of epidemic keratoconjunctivitis. NSAIDs are less likely to cause dependence or elevation of IOP than steroids. Topical NSAIDs are also useful to treat patients prior to corneal foreign body removal, and they also reduce postoperative pain and discomfort.

Oral NSAIDs are also useful for managing ocular pain and irritation. They exert their influence both peripherally and in the central nervous system. Oral acetaminophen exerts an analgesic effect within the CNS, but does not have a peripheral effect. These are important considerations when prescribing an oral analgesic in addition to topical medications.

PREVENTING DAMAGE FROM INFLAMMATION

Inflammation is generally a good thing. It gets cells to the site of damage or infection, increases temperature to inhibit bacterial and viral growth, and prepares tissue for repair. But in some cases, inflammation may cause damage.

In the eye, most damage results from leukocyte activity or from the release of protein and the activity of fibroblasts. Steroids are still the best means of preventing inflammation-induced cellular damage, but beware of side effects such as intraocular pressure elevation, cataract and reduced resistance to pathogens.

REMEMBER THESE IMPORTANT CAVEATS

• Determine what's really bothering the patient.
• Use the drug that has the best efficacy with minimal side effects.
• Prevent inflammatory damage to affected tissue.

Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center.