What should be done for a patient on day two of steroid eye drops with persistent inflammation, swelling, and redness of the upper white part of the eye, despite some improvement in swelling under the eye?

Management of Persistent Ocular Inflammation on Day Two of Steroid Eye Drops

This patient requires urgent ophthalmologic evaluation within 1-2 days to determine the underlying cause of inflammation, assess treatment response, and rule out infectious etiologies before continuing or escalating steroid therapy. 1

Immediate Assessment Priorities

The presence of persistent redness, inflammation, and periorbital swelling after two days of topical steroids raises critical diagnostic concerns that must be addressed before proceeding:

• Rule out infectious keratitis immediately - bacterial, fungal, or viral infections can be worsened or masked by corticosteroid therapy, particularly Nocardia and fungal infections which have poor outcomes with steroid use 1
• Confirm the specific diagnosis through comprehensive slit-lamp examination and corneal evaluation, as treatment depends entirely on the underlying etiology 2
• Assess for masquerade syndromes including malignancy or atypical infections that may mimic inflammatory conditions 3

Critical Decision Point: Is This Infection or Inflammation?

If Infectious Keratitis is Suspected or Confirmed:

• Reduce or discontinue topical corticosteroids immediately until the infection is controlled with appropriate antimicrobial therapy 1
• Initiate or optimize topical antibiotic therapy as the primary treatment 2
• Only consider adding corticosteroids after 2-3 days of progressive improvement on antibiotics, once the pathogen is identified and fungal infection is ruled out 1, 2
• Warn the patient that inflammation may temporarily worsen when steroids are reduced due to loss of immune suppression - this does not necessarily indicate worsening infection 1

If Non-Infectious Inflammation is Confirmed:

• Continue topical prednisolone acetate 1% as the preferred corticosteroid formulation due to superior corneal penetration 1
• Monitor intraocular pressure (IOP) within 1-2 days of steroid initiation, as IOP elevation risk increases significantly with ≥2 drops daily 1
• Expect clinical improvement within 48 hours - lack of improvement suggests either incorrect diagnosis, inadequate therapy, or need for systemic treatment 1

Signs of Positive Treatment Response to Monitor

The following features indicate appropriate response to therapy and should be assessed at follow-up 1:

• Reduced pain and photophobia
• Decreased discharge
• Lessened eyelid edema and conjunctival injection
• Sharper demarcation and consolidation of any infiltrate

When to Escalate Beyond Topical Steroids

If the patient continues requiring prednisolone acetate 1% at 1-2 drops daily (or equivalent) after 3 months, systemic immunosuppression should be added to allow tapering of topical therapy 1

For severe or refractory cases, consider 1, 3:

• Topical cyclosporine 0.05% to 2% for steroid-refractory inflammation
• Topical tacrolimus 0.03% or 0.1% as an alternative immunomodulator
• Systemic immunosuppressants (methotrexate, mycophenolate mofetil, or azathioprine) under specialist guidance for cases unresponsive to topical therapy

Critical Monitoring Requirements

• Measure IOP regularly - risk of steroid-induced glaucoma increases with frequency and duration of use 1, 4, 5
• Examine for cataract formation with prolonged steroid exposure 1, 5
• Watch for infectious crystalline keratopathy with chronic topical immunotherapy, which appears as snowflake-like crystals in the cornea 1
• Monitor for systemic absorption effects in children and with prolonged use, including cushingoid features and adrenal suppression 6

Common Pitfalls to Avoid

• Never continue steroids empirically without confirming the diagnosis - this can lead to devastating outcomes in fungal or Nocardia infections 1, 2
• Do not use prolonged topical steroids without monitoring IOP - steroid-induced glaucoma can develop insidiously 1, 4
• Avoid abrupt cessation of long-term corticosteroid therapy as this can precipitate adrenal crisis if systemic absorption has occurred 6
• Do not overlook associated conditions such as blepharitis or dry eye that may perpetuate inflammation 2