Immediate Discontinuation of Steroid-Containing Drops and Urgent Ophthalmology Evaluation Required
This patient must stop the neomycin-polymyxin B-dexamethasone drops immediately and be evaluated urgently by an ophthalmologist within 24 hours to rule out bacterial keratitis, fungal infection, or steroid-induced complications. The development of eye pain and pressure after starting corticosteroid-containing drops for presumed simple conjunctivitis represents a potentially sight-threatening complication that requires immediate action.
Critical Diagnostic Considerations
Why This Is an Emergency
Corticosteroids can mask and worsen serious infections: The FDA label explicitly warns that "use of ocular steroids may prolong the course and may exacerbate the severity of many viral infections of the eye (including herpes simplex)" and that "acute purulent or parasitic infections of the eye may be masked or activity enhanced by the presence of corticosteroid medication" 1.
Fungal keratitis risk: The American Academy of Ophthalmology emphasizes that "fungal infections of the cornea are particularly prone to develop coincidentally with long-term corticosteroid applications" and that "fungal invasion should be suspected in any persistent corneal ulceration where a corticosteroid has been used or is in use" 2.
Steroid-induced glaucoma: The FDA warns that "prolonged use of corticosteroids may result in glaucoma with damage to the optic nerve" and that increased intraocular pressure can occur even after short-term use 1.
What the Pain and Pressure Indicate
The development of pain and pressure after only one day suggests:
Bacterial keratitis progression: The American Academy of Ophthalmology states that patients on corticosteroids at presentation of suspected bacterial keratitis "should have their corticosteroid regimen reduced or eliminated until the infection has been controlled" 2.
Acute angle-closure glaucoma or steroid response: Eye pressure elevation can occur rapidly in steroid responders 1.
Corneal epithelial defect or ulceration: The FDA label states "if signs and symptoms fail to improve after two days, the patient should be reevaluated" 1.
Immediate Management Algorithm
Step 1: Stop All Medications Immediately
Discontinue the neomycin-polymyxin B-dexamethasone drops: The corticosteroid component is contraindicated until infection is ruled out 2, 1.
Do not substitute with other steroid-containing preparations 1.
Step 2: Arrange Urgent Ophthalmology Evaluation (Within 24 Hours)
The ophthalmologist must perform:
Slit-lamp biomicroscopy with fluorescein staining: The FDA label mandates that "the initial prescription and renewal of the medication order should be made by a physician only after examination of the patient with the aid of magnification, such as slit lamp biomicroscopy, and where appropriate, fluorescein staining" 1.
Intraocular pressure measurement: To assess for steroid-induced pressure elevation or acute glaucoma 1.
Corneal culture if ulceration present: The American Academy of Ophthalmology recommends cultures when bacterial keratitis is suspected, especially given the increasing frequency of MRSA 2.
Step 3: Differential Diagnosis to Rule Out
The ophthalmologist must exclude:
Bacterial keratitis: The American Academy of Ophthalmology states that "patients being treated with ocular topical corticosteroids at the time of presentation of suspected bacterial keratitis should have their corticosteroid regimen reduced or eliminated until the infection has been controlled" 2.
Herpes simplex keratitis: Corticosteroids are contraindicated and can cause severe complications in herpetic disease 1.
Fungal keratitis: Fungal cultures should be taken when appropriate, as outcomes with corticosteroids are poor 2.
Corneal perforation risk: The FDA warns that "use of topical corticosteroids in the presence of thin corneal or scleral tissue may lead to perforation" 1. A case report documented corneal perforation in a patient using dexamethasone-polymyxin B-neomycin drops post-cataract surgery 3.
Why Steroids Were Inappropriate for Initial Conjunctivitis Treatment
Simple Conjunctivitis Does Not Require Steroids
Topical antibiotics alone are first-line: The American Academy of Ophthalmology recommends topical antibiotics without steroids for bacterial conjunctivitis 2.
Steroids add risk without benefit in uncomplicated cases: A 1976 study found that while corticosteroids suppress inflammation, they were not necessary for resolution of simple conjunctivitis 4.
When Steroids Might Be Considered (But Not Initially)
The American Academy of Ophthalmology states that in bacterial keratitis, "topical corticosteroid therapy may be added to the regimen following at least 2 to 3 days of progressive improvement with topical antibiotic treatment, typically after identification of the pathogen (and after fungal infection has been ruled out)" 2.
Common Pitfalls and How to Avoid Them
Pitfall 1: Assuming Worsening Symptoms Mean Treatment Failure
The American Academy of Ophthalmology warns that "inflammation and symptoms may temporarily increase as corticosteroids are reduced because of the lack of local immune suppression. The increase in inflammation may not be due to worsening of the infection" 2.
However, new pain and pressure after starting steroids is different and suggests a serious complication, not withdrawal inflammation 1.
Pitfall 2: Continuing Steroids While Adding More Antibiotics
- This is dangerous: The infection must be controlled before any steroid use is considered 2.
Pitfall 3: Neomycin Hypersensitivity
The FDA warns that "products containing neomycin sulfate may cause cutaneous sensitization" with a 13-30% prevalence in chronic otitis externa patients 2, 1.
Symptoms include "erythema, itching, urticaria, skin rash" and can progress to severe reactions 1.
However, pain and pressure after one day more likely represent infection or steroid complications rather than allergy 1.
What Should Have Been Done Initially
For presumed simple bacterial conjunctivitis:
Antibiotic-only drops: Such as polymyxin B-trimethoprim, fluoroquinolones, or aminoglycosides without steroids 2.
Observation: Many cases of viral conjunctivitis resolve without treatment 2.
Reserve steroid combinations: Only for confirmed inflammatory conditions after infection is ruled out 2.
Follow-Up After Ophthalmology Evaluation
If bacterial keratitis is confirmed:
Intensive fortified antibiotics: The American Academy of Ophthalmology recommends frequent dosing (every 30-60 minutes initially) for bacterial keratitis 2.
No steroids until improvement: Only after "at least 2 to 3 days of progressive improvement with topical antibiotic treatment" 2.
Close monitoring: Patients should be examined within 1-2 days after any treatment change 2.
If simple allergic or toxic reaction: