Loteprednol prevents graft rejection with less IOP risk

As Decemet membrane endothelial keratoplasty (DMEK) surgery slowly becomes more popular as a treatment for endothelial dysfunction, it is important to assess if it is possible to safely reduce the use of corticosteroids after surgery.

To see if loteprednol etabonate is as effective as a traditional corticosteroid, the authors of this study conducted a randomized trial, comparing prednisolone acetate 1% solution to loteprednol etabonate 0.5% gel after DMEK. Subjects included 167 patients (233 eyes) from a single center in Indianapolis who used prednisolone acetate 4 times daily for the first month after surgery. Patients were then randomized to receive either prednisolone acetate 1% or loteprednol etabonate 0.5% for the next 2 to 12 months.

At 12 months postop, no patient in either group experienced rejection. But prednisolone-treated eyes had a higher rate (25% vs. 11%, P=0.013) and a higher risk (relative risk 2.3, P=0.016) of IOP elevation compared to eyes treated with loteprednol.

Additionally, intrapersonal differences in the response to both corticosteroids were assessed in 66 patients who had fellow eyes assigned to the opposite treatment arms. The proportion of prednisolone-treated eyes with an IOP increase of at least 10 mm Hg over the preoperative baseline level was significantly higher than the proportion of loteprednol-treated fellow eyes (16% vs. 3.2%, respectively, P=0.031).

No serious side effects were noted in either study group.

The authors suggest that loteprednol etabonate 0.5% gel is a good alternative to prednisolone acetate 1% in the postoperative period. They also advise that patients on long-term topical corticosteroids receive regular pressure checks to minimize risk of IOP-related complications such as glaucomatous nerve damage. Follow-up continues with these patients, as the authors assess the difference between  continuing or discontinuing corticosteroids after the first postop year.