Cataract Surgery Focus on Advanced Therapeutics

APRIL 2010 CATARACT & REFRACTIVE SURGERY TODAY 33 F or more than 6 decades, topical corticosteroids have been the cornerstone of therapy for the treatment of various forms of ocular inflammation, both surgical and autoimmune in nature.1 By inhibiting the release of phospholipase A2 early in the inflammatory cascade, steroids provide a broad range of anti-inflammatory activity, because they attenuate the effects of inflammatory mediators and prevent their release. Despite steroids’ ubiquity in the treatment of inflammation, little innovation in this class of drug has occurred in terms of therapy for moderate-to-severe inflammation. In late 2008, however, Durezol (difluprednate ophthalmic emulsion 0.5%; Sirion Therapeutics) was approved for the treatment of inflammation and pain associated with ocular surgery. Although we were initially skeptical that Durezol was any different from prednisolone acetate, we soon realized that the former performs in ways that the latter cannot. One of our initial experiences with Durezol involved a 30-year-old woman who had received bilateral corneal transplants for pellucid marginal degeneration. After doing well for 9 months with excellent visual acuity, she developed chronic, bilateral endothelial and stromal rejection. Despite several courses of oral prednisone combined with subconjunctival and intracameral corticosteroids and frequent dosing with a topical steroid, the patient’s inflammation and visual loss continued to progress. Her condition finally stabilized with oral mycophenolate (CellCept; Genentech, Inc.) and topical prednisolone acetate dosed every 2 hours. She continued, however, to have a low-grade anterior chamber reaction and progressive stromal neovascularization. When Durezol was approved by the FDA, this patient was the first to whom we prescribed it. She administered the drug every 2 hours and discontinued the prednisolone acetate. Over the next few weeks, her stromal neovascularization regressed, and her anterior chamber reaction cleared. During the next 2 months, her CellCept was tapered and then discontinued. By the fourth month, the patient’s use of Durezol was tapered to four times a day. By 6 months, she used the drug twice a day and was free of inflammation. This article provides an overview on this next-generation steroid.