Inflammation concerns all surgeons and virtually every medical discipline. Wound healing is essentially a controlled extension of the inflammatory process, and infectious threats must be eliminated by controlled adaptive immune inflammatory responses.¹

Nevertheless, chronic immunologic conditions, such as rheumatoid arthritis, dysthyroid ophthalmopathy, scleritis and uveitis, result from excessive inflammation unfettered by expected autoregulatory controls.² In fact, infections clearly trigger the emergence of some neoplastic and chronic autoimmune disorders.³ Cataracts, glaucoma, dry eye, pterygium and macular degeneration are attributed in significant proportion to inflammatory etiology,⁴ while aging itself is a condition of inflammatory senescence.⁵

Exercise⁶ and dietary discipline⁷ mitigate the aging threat, at least to some extent. Similarly, nutritional supplementation may actually stabilize otherwise worsening ocular surface inflammatory markers.⁸

IN THIS ISSUE

Steroids remain the most effective and most rapid-acting tool, yet steroid-sparing strategies dominate our strategic approach to virtually every cornea, uveitis, trauma and surgical patient due to legendary glucocorticoid toxicity. Our practical August issue features thoughtful, resourceful clinicians who continue to learn more about the ocular inflammatory response from their patients and their peers.

We venture into traditional topical antagonists, preventive strategies and natural therapies as well as game-changing systemic biologics. This issue’s contributors examine the best features and biggest safety concerns of key medication groups. They reveal insights into specific ocular conditions, both rare and commonplace, to guide both novice and seasoned practitioner. Finally, our expert surgeons delineate their personal approach to perioperative anti-inflammatory therapy for their own “bread and butter” operative procedures.

AN EVOLVING APPROACH

Genomic analysis and personalized medicine will soon identify far more specific targets for inflammatory diseases. Intelligent drug transport provides more potent, safer solutions: novel ocular surface vehicles, sub-conjunctival, sub-Tenon, intracameral and suprachoridal drug delivery offer magnificent therapeutic index advantages to inventor and industry alike.

Understanding and controlling inflammation proactively may be the most important discipline of the 21st century,⁹ while patients with blinding ocular disease may be the most blessed beneficiaries. OM

REFERENCES

1. Barton GM. A calculated response: control of inflammation by the innate immune system. J Clin Invest. 2008 Feb 1;118:413-420.
2. Hunter, P. The inflammation theory of disease. EMBO Rep 2012 Nov;13:968-970.
3. O’Connor SM, Taylor CE, Hughes JM. Emerging infectious determinants of chronic diseases. Emerg Infect Dis. 2006 Jul;12:1051-1057.
4. Chen M, Xu H. Parainflammation, chronic inflammation, and age-related macular degeneration. J Leukoc Biol. 2015 Nov;98:713-25.
5. Bektas A, Schurman SH, Sen R, Ferrucci L. Aging, inflammation and the environment. Experimental Gerontology. May 2018;105:10-18.
6. Woods JA, Wilund KR, Martin SA, Kistler BM. Exercise, Inflammation and Aging, Aging Dis. 2012 Feb; 3:130-140.
7. Tan A, Sullenbarger B, Prakash R, McDaniel JC. Supplementation with eicosapentaenoic acid and docosahexaenoic acid reduces high levels of circulating proinflammatory cytokines in aging adults: A randomized, controlled study. Prostaglandins Leukot Essent Fatty Acids. 2018 May;132:23-29.
8. Sheppard JD, Singh R, McClellan AJ, Weikert MP, Scoper SV, Joly TJ, Whitely WO, Kakkar E, Plugfelder SC. Long-term supplementation with n-6 and n-3 PUFAs improves moderate-to-severe keratoconjunctivitis sicca: A randomized double-blind clinical trial. J Ocul Pharmacol Ther. 2011 Feb;27:23-27.
9. Serhan CN. Treating inflammation and infection in the 21st century: new hints from decoding resolution mediators and mechanisms. FASEB J. 2017 Apr;31:1273-1288.

Dr. Sheppard is president of Virginia Eye Consultants in Norfolk, Va. He is a professor, research director for the ophthalmology residency program, and clinical director of the Thomas R. Lee Center for Ocular Pharmacology at Eastern Virginia Medical School. He also serves as medical director with the Lions Medical Eye Bank and Research Center of Eastern Virginia.