lotemax long-term?

[littlemermaid]

http://www.osnsupersite.com/view.aspx?rid=63670 OCULAR SURGERY NEWS U.S. EDITION May 10, 2010 Steroids enable aggressive treatment of ocular inflammatory disease - here's some of what they're currently thinking on short-term/long-term risks/benefits, ie inflammation damage is worse but make sure the prescription is tailored to your needs.

Read somewhere it's the length of time you use steroid eyedrops that affects the possibility of cataracts rather than number of drops per day, therefore US ophths prescribe initially in high dose pulse therapy to reduce inflammation fast (UK ophths 'pulse therapy' for eg prednisolone reflects standard NHS follow up time more than clinical need IMHO but they think FML is OK for long term, ie months, years because it is not readily absorbed by eye surface... hmm). Dr Latkany thread also has some noble thoughts on how he ideally uses steroid (minimally) to control inflammation fast, then off it to concentrate on causes.

No one knows how often to get intraocular pressure checked (some drug info says within first 3 or 7 days in case of immediate response, then periodically as you assess risk; UK ophth risk it between 4 wk appointments and look relieved when you're OK - 6 point variation through the day is normal says our optom). I read they think is related to your eyes' individual response to absorption so raised IOP could be within days of starting or years.

Also patient leaflets say to prevent absorption in system, press tear drain (hole at nose side of lower lid) for a minute or two (should not get taste at back of throat). Place drop carefully under lower lid rather than habitually dropping onto eye surface from a height, clean eye surround in case of splashes (skin thinning).

You mustn't just stop a steroid - you have to taper the dose according to doc's monitoring, even within a week. We have had steroid rebound inflammation. Also inflammation untreated by steroid dose too low, severe neovascularisation, epithelial damage. (Now we are successfully tapered, inflammation under control, 1 x FML weekly, surface looking good.) Love/hate steroids. I think, satisfy yourself whether prescription is tailored to your needs, ask for IOP checks according to your fears (check out different tonometry techniques, don't want eye surface desensitised too often).

[Bored]

Hi guys. I skimmed through the thread, but I have one question which hasn't seem to be answered anywhere.

What constitutes as "long-term" use? I keep reading that long-term use of the steroids can cause problems; but what is long term? To try to understand my issue; my original thread on this site might help: http://www.dryeyezone.com/talk/showt...2695#post52695

Below is what I wrote on that thread:

So now he has me on some drops called Bion and has also told me to use Alrex for 2 weeks.

3 times a day for 1 week, and 2 times a day for 1 week. I have only used Alrex (0.2%) 5 times so far [almost 2 days now], but I have a very bad feeling about it. He told me to come back in 2 weeks, but after reading up a bit on it online, it seems that it can increase eye pressure and make things even more worse. I am going to call the hospital on Monday and see if I can get a follow-up appointment ASAP to get my eye pressure monitored. The last thing I want is to get Glaucoma or something!

With my 5th time putting in the drops, I think I have feeling some of the side effects of it [a very slight headache] and eyes feel a bit weird and I definitely get that weird taste in the back of my throat. My eyes right now are white in general, but as I said I have some very permanent veins caused by rebound hyperemia which are still there.

I am wondering if anyone has any experience with Alrex? Is 14 days too much of a time to use it without getting your eyes checked in the middle? Most online sites say that if you are using it for more than 10 days make sure to get them checked. Some even say 3 days. I am kind of worried - should I continue to use it or just stop? If I stop, there won't be too much point of the next follow up, because the doc will say I have nothing to assess.

[sighthound]

Hi ringo,
I will give it a try putting the lotemax in after the restasis. I can't use other eyedrops because my eyes hate everything. I think I will look into the compounded cyclo.
Stella: I first used tobradex 4 years ago. It was a mircacle drug. My eyes were gushing 2 days after I started! Even a co-worker commented on my eyes looking 'bigger'. I wasn't wincing them as usual. I used it for a month. The first day I didn't use it, I felt a little drier, then slowly went back to being really dry again. What a downer. I used it 3 months later and only got 50% the same result. Go figure. You don't need to use very much. About a 1/4 " bead. Just don't stay on it very long.

[stella]

Thank you for that info Ringo

Just a quick note to Stella regarding Tobradex-- I was prescribed this ointent for a month when I had ulcers/corneal erosions. It did help me a lot, I was putting it at night.

One word of caution: it has a much greater potential to raise IOP than Lotemax or FML. Dexamethasone is a strong steroid. I do not think it can be used for longer periods, like Lotemax for example, even in non steroid responders.

Thanks Stella and Kitty for your remarks,

I just feel like a patient should try all options regarding the cyclosporine preparatons before they totally give up on it, as it is the only thing thatFDA has acknowledged to treat certain aspcts of dry eye and it did help so much in my case (others have benefited here on the forum and in the clinical trials).

[stella]

Hi sighthound
How did you find tobradex? Did it work for you?
I persauded my GP to prescribe it as an ointment (there are drops )
I have had a recent flare-up after doing soo well for 2 years
I'm back on Doxy again and just today opened the tobradex and put a tiny bit on the outer lid and lid margin of one eye only If it works i may use it on both eyes once a day for a while

Tobradex = dexamethasone 0.1% + neomycin sulphate and polymixin B sulphate

My thinking is that it could help my lids, which is my main problem - prickling and itching ,so if used on the outer lids + margins only - the eyes would not get as much of the steroid as doing drops in the eye would -although i know some is bound to migrate into the eye and be absorbed through the lid into the eye also

Any one know how much ointments on the lids + mrgins do migrate to the eye itself ?

I have a tendency to treat myself - I have not much option, with our long waiting lists in GB My GP believes i know what i am doing - so co-operates with my requests ( I dont know how wise that is but it suits me )

I have made an appointment with my optometrist to have my IOP done next week and note with interest that Ringo has hers done once a month while doing steroids - Thanks for that Ringo

thank you for your reply Kitty.

I had horrible reactions with restasis in the first couple of months, and the doctors I was seeing at the time were saying that many patients feel actual deterioration of symptoms, rather than improvement when initially treated with cyclosporine. That is why many doctors are prescribing it in combination with other medications, and like you mentioned lubricating drops as well.

In some people the irritation from cyclosporine and castor oil is proportionate to the underlying inflammation in the eye. (I had a time when even artificial tears were burning my eys like acid so I know about inflammation reducing the tolerance of the eyes to many things).

However, everyone is individual, and like I said before, some are sensitive to the drop or some ingredients, others may even be allergic to the drops;

in some sensitivity is manageble by mild steroids/ NSAIDS, or even only lubricating drops, in others it is not.

And still others benefit from different formulations with the same active substance.

Others benefit from first using medications that resolve inflammation more rapidly, like they are given a course of mild steroids first, and then started on restasis, or whatever cyclosporine preparation their doctors prescribe.

Everyone is individual, I know this is the point you are emphasizing. I was only trying to suggest options to sighthound, without insisting or anything.

you had such a horrible intolerance to restasis, how did you resolve it?

[kitty]

hi ringo,
I started restasis without the lotemax. But I have been on both of them at the same time. The trick of putting in the lotemax 10 mins before the restasis didn't work to stop the stinging. I can only handle taking restasis once per day, just before bed. It is O.K. if I don't open my eyes after I put it in. But I really am not sure if it is actually helping. Just scared to stop it since it takes so long to start working.

Hi Ringo. I am one of those who cannot tolerate Restasis no matter what I try. My doctor has determined that I have a hypersensitivity to the medication. I had not only stinging, but intense itching and major flare of all of my DES symptoms after I put in the Restasis. One thing I don't recall you mentioning that you might try, is to put in a really good lubricating drop 10 minutes before and again 10 minutes after instilling the Restasis. This can provide a "cushion" that might help you to tolerate the Restasis easier. This is advise my doctor gave me.

I know that sounds so silly...but have you tried putting the Lotemax after the restasis?
Have you ever considered asking your doctor about a different formulation containing cyclosporine? (compounded)
some people on this forum, including myself, have tolerated the cyclosporine much better even at higher concentrations when dissolved in corn oil (like the Moorfield hospital cyclosporine drops). If you are willing to continue this cyclosporine therapy it might be worth it asking your doctor about different formulations.

Regards,
Dani

[sighthound]

hi ringo,
I started restasis without the lotemax. But I have been on both of them at the same time. The trick of putting in the lotemax 10 mins before the restasis didn't work to stop the stinging. I can only handle taking restasis once per day, just before bed. It is O.K. if I don't open my eyes after I put it in. But I really am not sure if it is actually helping. Just scared to stop it since it takes so long to start working.

Hi sighthound,

were you on lotemax together with the restasis?

Thanks.

[sighthound]

Thanks everyone for your advice! I have been on tobradex and lotemax before, so I know to get the pressure checked. I was on lotemax for 6 weeks last fall, and I did feel quite a bit better. But about 1 month after coming off it, I was back to square one. That is the hard part: feeling good and actually being able to forget about my eyes, then feeling crappy when off the steriods. So, yes, I feel tempted to go on lotemax again. I have addressed allergies, nutrition, used restasis for the past 1.5 years (my eyes hate it, so I could not handle a higher concentration of cyclo.), warm compresses, cold compresses, doxy, azasite, blephagel, blah blah blah - everything. So I feel that if there is a treatment in the future, I have to at least keep the m. glands working until something safer than steroids becomes available. I called Leighter's pharmacy and asked if they compound lotemax preservative-free, but they said that they just dilute it. I see my local dr again in a month. I will give him a decision at that point. I will let you guys know.

Thanks for replying Kitty,

I understand there are more factors your doctor is taking into consideration; and surely observation of the optic nerve will provide a clearer picture of what goes on with you.

hope you have good news from the upcoming tests,

Dani

[kitty]

Ringo, I have no idea how long my IOP has been elevated. In the past when I used Lotemax for short durations (3 weeks or less) my IOP never went up. The fact that my IOP has not dropped with a reduction in dose of Lotemax makes my doctor suspicious for glaucoma. Also of concern is a 5 point or more increase in my baseline IOP in the last year. I will know more after I have the GDX test. I also have some unexplained blurred vision in one eye. I have thinner than average cornea thickness which increases my risk for glaucoma 3-fold. I am nearly 50 years of age and have inflammatory eye disease, both risk factors for glaucoma. I trust my doctor's judgment.