Close monitoring recommended during difluprednate treatment for pediatric uveitis

This retrospective case series evaluates the use of topical difluprednate 0.05% (Durezol) for noninfectious refractory uveitis in phakic children. The results, reported in the American Journal of Ophthalmology, indicate that difluprednate is an effective agent for both control of anterior segment inflammation and reduction of cystoid macular edema (CME) when used as an adjuvant to systemic immunomodulatory therapy. However, there was a high rate of steroid-induced IOP elevation and cataract formation. The authors therefore conclude that young patients require frequent monitoring while using topical difluprednate.

They reviewed the cases of 14 patients (26 eyes) younger than 18 years with noninfectious uveitis treated with topical difluprednate at a referral uveitis clinic or referral pediatric ophthalmology clinic during a year-long period. They were followed for at least six months.

Upon initiation of treatment, the medication was administered between four times a day and every two hours and tapered based on clinical response.

The median duration of treatment was 27 weeks, and ranged between four and 63 weeks. Ten patients received additional systemic immunosuppression. Three patients also used topical nepafenac.

After six months of treatment visual acuity improved, with a mean logMAR decrease of 0.08. Inflammation either decreased by two lines or resolved in 88 percent of eyes. CME, which had been initially diagnosed in nine eyes, was improved in seven eyes (78 percent) at the first follow-up visit. One patient who had initially shown improvement in CME while using difluprednate experienced an increase in CME after the medication was stopped due to elevated IOP.

Mean IOP increased by 11.2 ± 11.9 mm Hg during treatment. Half of the patients experienced a significant IOP elevation (10 mm Hg or greater from baseline and IOP greater than 24 mm Hg). Three patients (six eyes) were managed medically. Two patients (three eyes) required glaucoma surgery.

Cataract formation occurred in 39 percent of eyes. Three patients underwent cataract surgery.

This study shows that difluprednate produces a favorable anti-inflammatory response in children, much like it does in adults. However, this potent corticosteroid is associated with more severe side effects than conventional prednisolone acetate. The authors say that difluprednate penetrates the eye in concentrations high enough to treat CME, but as with all corticosteroids, patients may develop elevated IOP and cataract, which may be more pronounced in children.