When do you prescribe steroid eye drops, such as prednisolone acetate (corticosteroid) or loteprednol etabonate (corticosteroid), for ocular inflammation?

When to Prescribe Steroid Eye Drops

Steroid eye drops should be prescribed for ocular inflammatory conditions including uveitis, post-surgical inflammation, allergic conjunctivitis, and other inflammatory eye conditions, with prednisolone acetate 1% being the preferred topical steroid for most conditions, particularly anterior uveitis. 1, 2, 3

Specific Indications for Steroid Eye Drops

Anterior Uveitis

• First-line treatment: Prednisolone acetate 1% is preferred over difluprednate due to better corneal penetration 1
• Initial dosing: Frequent administration (every 1-2 hours) with gradual tapering as inflammation resolves 2, 3
• Duration: Short-term use is preferred; prolonged use beyond 3 months increases risk of complications 2

Post-Surgical Inflammation

• Indicated for inflammation following ocular surgery 3, 4
• Typically started immediately post-operatively and continued for 2-4 weeks
• Dosing: 1-2 drops 2-4 times daily with tapering schedule 3

Allergic Conjunctivitis

• Moderate to severe seasonal allergic conjunctivitis 5, 6
• Loteprednol etabonate 0.2% may be preferred (4 times daily for 2 weeks) 5

Other Inflammatory Conditions

• Giant papillary conjunctivitis 5, 6
• Episcleritis/scleritis (with comprehensive autoimmune workup) 2
• Ocular surface inflammation associated with dry eye 6

Choice of Steroid Eye Drop

Prednisolone Acetate 1%

• Preferred for: Anterior uveitis and conditions requiring strong anti-inflammatory effect 1, 2
• Advantages: Better corneal penetration, more potent anti-inflammatory effect 1
• Dosing: 1-2 drops 2-4 times daily, may increase frequency during initial 24-48 hours 3

Loteprednol Etabonate

• Preferred for: Conditions requiring longer-term treatment or in steroid responders 5, 6
• Advantages: Lower risk of IOP elevation, rapid conversion to inactive metabolites 5, 7
• Best for: Seasonal allergic conjunctivitis, giant papillary conjunctivitis, and post-operative inflammation in patients at risk for steroid-induced IOP elevation 5, 4

Monitoring and Safety Considerations

IOP Monitoring

• Monitor IOP regularly, especially with prolonged use
• Risk of IOP elevation increases with:
  • Dosing frequency ≥2 drops/day 1
  • Duration of therapy >3 months 1, 2
  • Children have higher risk of steroid-induced IOP elevation 2

Cataract Formation

• Risk increases with:
  • Dosing of ≥4 drops daily 1
  • Prolonged use beyond 3 months 2

Follow-up Schedule

• For active inflammation: Every 2-6 weeks based on severity 1
• For controlled inflammation on stable therapy: Every 3 months 2
• After changes in therapy: Within 1 month of topical therapy change 2

When to Add Systemic Therapy

• When topical steroids are required for ≥3 months 1, 2
• When patient requires 1-2 drops/day of prednisolone acetate 1% for ≥3 months despite systemic therapy 1
• In presence of poor prognostic factors (male gender, posterior synechiae, band keratopathy, glaucoma, cataract, poor initial vision) 2
• For severe uveitis with sight-threatening complications 1

Treatment Algorithm

1. Initial Assessment:

   • Determine severity and type of ocular inflammation
   • Check for contraindications (active viral/fungal infection, glaucoma history)

2. Acute Inflammation:

   • Start with prednisolone acetate 1% for most inflammatory conditions
   • Initial dosing: Every 1-2 hours for severe inflammation, then taper
   • For mild-moderate inflammation: 4 times daily

3. Monitoring:

   • Reassess within 2-7 days for response
   • If no improvement after 2 days, reevaluate diagnosis 3
   • Monitor IOP at each follow-up visit

4. Tapering:

   • Begin tapering once inflammation is controlled
   • Typical taper: Reduce by one drop per day each week
   • Do not discontinue abruptly

5. Consider Systemic Therapy When:

   • Topical steroids required beyond 3 months
   • Unable to taper below 1-2 drops/day
   • Sight-threatening complications present

Common Pitfalls to Avoid

1. Overuse of topical steroids:

   • Limit continuous use to <3 months when possible
   • Consider systemic immunomodulatory therapy for chronic conditions 2

2. Inadequate monitoring:

   • Failure to check IOP regularly
   • Not monitoring for cataract formation with long-term use

3. Inappropriate discontinuation:

   • Abrupt discontinuation can lead to rebound inflammation
   • Always taper gradually

4. Delayed systemic therapy:

   • Continuing topical steroids beyond 3 months without adding systemic therapy 1, 2

5. Inadequate initial treatment:

   • Insufficient dosing frequency for severe inflammation
   • Failure to use prednisolone acetate 1% for conditions requiring deep penetration