Topical nonpreserved methylprednisolone therapy for keratoconjunctivitis sicca in Sjogren syndrome

Objective: To review the efficacy and side effects of topical nonpreserved corticosteroid therapy for treatment of severe keratoconjunctivitis associa ted with Sjogren syndrome. Design: Retrospective, noncomparative case series. Participants: Twenty-one patients with Sjogren syndrome-associated keratoco njunctivitis sicca and annoying ocular irritation. Intervention: Treatment with topical nonpreserved methylprednisolone sodium succinate, Main Outcome Measures: Symptom severity, frequency of instillation of artif icial tears, corneal fluorescein staining scores, resolution of filamentary keratitis, steroid-related side effects. Results: Before starting methylprednisolone therapy, all patients were expe riencing moderate-to-severe eye irritation despite prior punctal occlusion in most cases and frequent use of nonpreserved artificial tears by all. Aft er 2 weeks of topical application, three to four times per day, moderate (4 3%) or complete (57%) relief of irritation symptoms was experienced by all patients and no complications were observed. An average decrease in corneal fluorescein scores of 2.6 +/- 0.5 points (on a 12-point scale) was observe d, and filamentary keratitis resolved in all ten eyes with this condition. Therapy was stopped after 2 weeks in eight patients, and six of these patie nts reported that their symptoms remained at a tolerable level for weeks to months. Lower dose steroid therapy was continued in the remaining patients , whose symptoms worsened after attempted weaning. Complications of cortico steroid therapy in patients receiving prolonged therapy included increased intraocular pressure in one patient at 3 months, worsening of pre-existing posterior subcapsular cataracts in one patient at 6 months, and formation o f posterior subcapsular cataracts in another patient at 6 months. Conclusions: These findings indicate that topical nonpreserved methylpredni solone is an effective treatment option for patients suffering from severe keratoconjunctivitis sicca who continue to experience bothersome eye irrita tion despite maximum aqueous enhancement therapies. They also suggest that inflammation is a key pathogenic factor in this condition. Careful monitori ng is essential in dry eye patients treated with corticosteroids for more t han 2 weeks because steroid-related complications (increased intraocular pr essure and cataract formation) were observed after several months of therap y in this series. Because of the chronic nature of this disease and the lik elihood of patients developing steroid-related complications with their lon g-term use, topical nonpreserved methylprednisolone therapy appears to be m ost appropriate for short-term "pulse" treatment of exacerbations of kerato conjunctivitis sicca.