Ophthalmic Uses of Prednisone (Prednisolone)
Prednisone, typically administered as prednisolone acetate eye drops, is the first-line treatment for steroid-responsive inflammatory conditions of the eye, including anterior uveitis, allergic conjunctivitis, keratitis, iritis, cyclitis, and corneal injury from chemical, thermal, or radiation burns. 1
Primary Indications
Prednisolone acetate is FDA-approved for treating inflammatory conditions affecting: 1
- Palpebral and bulbar conjunctiva (allergic conjunctivitis, selected infective conjunctivitides)
- Cornea (superficial punctate keratitis, herpes zoster keratitis, corneal injury from burns or foreign body penetration)
- Anterior segment (iritis, cyclitis, acne rosacea)
Clinical Application by Uveitis Type
For anterior uveitis, topical prednisolone acetate 1% is the first-choice therapy because it penetrates the cornea effectively due to its lipophilic properties. 2 Topical corticosteroids are typically indicated specifically for anterior uveitis, while posterior or intermediate uveitis requires periocular or intravitreal administration. 3
For immune checkpoint inhibitor-related ocular toxicity: 4
- Grade 2 anterior uveitis: Hold immunotherapy, coordinate with ophthalmology for topical corticosteroids plus cycloplegic agents
- Grade 3-4 posterior/pan-uveitis: Consider systemic corticosteroids in addition to intravitreal/periocular/topical treatment as recommended by uveitis specialist
Critical Duration and Safety Limits
Topical prednisolone should be limited to ≤3 months of therapy due to significant risk of elevated intraocular pressure and cataract formation. 5 Key safety parameters include:
- Using ≥2 drops/day is a strong risk factor for IOP elevation 5
- Using ≥4 drops/day significantly increases cataract risk compared to ≤3 drops daily 5, 6
- Beyond 3 months, systemic immunosuppressive therapy should be considered to allow tapering of topical steroids 5
Absolute Contraindications
Never use prednisolone eye drops in: 1
- Viral corneal diseases (epithelial herpes simplex keratitis/dendritic keratitis, vaccinia, varicella)
- Mycobacterial eye infections
- Fungal diseases of ocular structures
Critical pitfall: Starting steroids before ophthalmologic examination may worsen infectious conditions like herpetic keratitis or mask accurate diagnosis. 4
Role in Comprehensive Uveitis Management
While corticosteroids control inflammation quickly and effectively, they are not appropriate for long-term therapy in most uveitis cases due to serious side effects. 7 For noninfectious uveitis requiring control beyond 3 months, noncorticosteroid immunomodulatory therapy should be initiated as steroid-sparing agents. 4, 8 This prevents both local complications (glaucoma, cataracts) and systemic toxicity while maintaining disease control. 4
Monitoring Requirements
Regular monitoring for elevated IOP and cataract formation is essential, especially when treatment extends beyond a few weeks. 5 Close ophthalmologic follow-up is necessary even for patients on low-dose prednisolone (1-2 drops/day) for extended periods. 5