Is the combination of tobramycin (antibiotic) and dexamethasone (corticosteroid) eye ointment with loteprednol (corticosteroid) 0.5% eye drops an evidence-based treatment for a 1-year-old patient with eye inflammation?

From the Guidelines

The combination of tobramycin-dexamethasone eye ointment with loteprednol 0.5% eye drops is not an evidence-based treatment for a 1-year-old with eye inflammation. This approach uses two corticosteroids simultaneously (dexamethasone and loteprednol), which creates unnecessary redundancy and increases the risk of steroid-related side effects without providing additional therapeutic benefit, as noted in the study by Dieckmann et al. 1. For pediatric eye inflammation, a single corticosteroid preparation is typically sufficient, with treatment guided by the specific diagnosis (bacterial conjunctivitis, allergic conjunctivitis, etc.).

Key Considerations

• The use of topical corticosteroids, such as loteprednol 0.5% suspension or gel, has been recommended for their anti-inflammatory effects, with lower rates of increased intraocular pressure and cataract formation due to decreased intraocular penetration 1.
• Loteprednol 0.5% gel has a much lower concentration of the neurotoxic preservative benzalkonium chloride (BAK; 0.003%), as compared to other corticosteroids (0.05–0.01%) 1.
• In bacterial cases, tobramycin alone or combined with a single steroid might be appropriate, but the combination of tobramycin-dexamethasone with loteprednol 0.5% eye drops is not supported by evidence.

Treatment Approach

• For a 1-year-old patient, medication selection requires particular caution due to their developing visual system and increased susceptibility to steroid side effects, including intraocular pressure elevation and cataract formation.
• Treatment duration should be limited to the shortest effective period, usually 7-10 days, with close monitoring.
• The underlying cause of the inflammation should be determined before initiating treatment, as different etiologies require different approaches.
• Alternative anti-inflammatory therapies, such as topical calcineurin inhibitors or steroid-sparing therapies, may be considered in certain cases, as discussed by Dieckmann et al. 1.

From the Research

Assessment of Treatment

The treatment of a 1-year-old patient with eye inflammation using a combination of tobramycin and dexamethasone eye ointment along with loteprednol 0.5% eye drops can be assessed based on available evidence.

• The use of loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension has been studied in pediatric subjects, showing it to be safe in the treatment of lid inflammation or blepharoconjunctivitis 2.
• Real-world use of loteprednol etabonate 0.5%/tobramycin 0.3% ophthalmic suspension for ocular surface inflammatory conditions has demonstrated a high level of safety with no significant changes in mean intraocular pressure or visual acuity 3.
• A review of loteprednol etabonate 0.5%/tobramycin 0.3% in the treatment of blepharokeratoconjunctivitis indicates that it is effective and associated with a lower risk of clinically significant increases in intraocular pressure compared to dexamethasone 0.1%/tobramycin 0.3% 4.
• A comparison of the safety and efficacy of loteprednol 0.5%/tobramycin 0.3% with dexamethasone 0.1%/tobramycin 0.3% in the treatment of blepharokeratoconjunctivitis showed that loteprednol 0.5%/tobramycin 0.3% was non-inferior to dexamethasone 0.1%/tobramycin 0.3% in decreasing the signs and symptoms of ocular inflammation, with subjects treated with dexamethasone 0.1%/tobramycin 0.3% experiencing more of an increase in intraocular pressure 5.
• The comparison of topical tobramycin-dexamethasone with other combinations for control of inflammation after cataract surgery demonstrated that tobramycin-dexamethasone was non-inferior to dexamethasone-neomycin-polymyxin in terms of anti-inflammatory efficacy and was well-tolerated 6.

Potential Concerns and Considerations

• The combination of tobramycin and dexamethasone eye ointment with loteprednol 0.5% eye drops may increase the risk of intraocular pressure elevation, although studies suggest that loteprednol etabonate 0.5%/tobramycin 0.3% is associated with a lower risk of this compared to dexamethasone 0.1%/tobramycin 0.3% 4, 5.
• The use of corticosteroids, such as dexamethasone and loteprednol, in pediatric patients requires careful consideration due to the potential for adverse effects, including increased intraocular pressure and cataract formation 2, 4.
• Monitoring of intraocular pressure and visual acuity is recommended when using corticosteroid and antibiotic combinations in pediatric patients 3, 6.

Plan

• Close monitoring of the patient's intraocular pressure and visual acuity is necessary when using the combination of tobramycin and dexamethasone eye ointment with loteprednol 0.5% eye drops.
• Regular follow-up appointments should be scheduled to assess the efficacy and safety of the treatment regimen.
• Consideration should be given to alternative treatment options if the patient experiences adverse effects or if the treatment is not effective in reducing inflammation.