What is the recommended treatment approach for a patient with dry eyes and an inflammatory component, considering potential steroid eye drop use, particularly in those with a history of glaucoma or ocular hypertension?

Steroid Eye Drops for Dry Eyes

Direct Recommendation

For dry eyes with inflammatory component, use short-term topical corticosteroids (2-4 weeks maximum) as second-line therapy after artificial tears prove insufficient, but avoid in patients with glaucoma or ocular hypertension due to risk of IOP elevation. 1

Treatment Algorithm by Disease Severity

Mild Dry Eye (First-Line)

• Start with preservative-free artificial tears containing methylcellulose or hyaluronate at least twice daily, increasing frequency up to hourly based on symptoms 1, 2
• Use preservative-free formulations when applying more than 4 times daily to avoid ocular surface toxicity 1, 2
• Apply ophthalmic ointments before bedtime for overnight symptom control, followed by morning lid hygiene to prevent blepharitis 1

Moderate Dry Eye with Inflammation (Second-Line)

• Add topical corticosteroids for maximum 2-4 weeks when artificial tears fail to control symptoms 1
• Loteprednol etabonate 0.5% is preferred due to lower IOP elevation risk (1% vs 6% with prednisolone) - apply 1-2 drops four times daily 3, 4
• Alternative: Low-dose hydrocortisone 0.335% for 12-14 days significantly reduces conjunctival hyperemia and OSDI scores without IOP changes 5
• Fluorometholone 0.1% rapidly relieves symptoms within 1 week in moderate-to-severe cases 6

Severe/Refractory Dry Eye (Third-Line)

• Transition to cyclosporine 0.05% twice daily for long-term anti-inflammatory control after steroid taper, with success rates of 67-74% 1, 2
• Consider lifitegrast 5% as alternative immunomodulator blocking LFA-1/ICAM-1 interaction 1
• Autologous serum eye drops improve corneal staining in severe cases, particularly Sjögren's syndrome 1, 2

Critical Contraindications and Monitoring

Glaucoma/Ocular Hypertension Patients

• Avoid topical corticosteroids entirely in patients with history of glaucoma or ocular hypertension 1
• Steroid-induced IOP elevation occurs through trabecular structural changes and aqueous outflow obstruction 7
• If steroids absolutely necessary, use loteprednol etabonate with lowest IOP risk profile and monitor IOP closely 3, 4

Mandatory Monitoring During Steroid Use

• Check IOP at baseline and every 1-2 weeks during treatment 1
• Monitor for cataract formation with extended use 1
• Screen for secondary infections (bacterial, fungal, viral) 1
• Re-evaluate after 2 days if no improvement 3

Common Pitfalls to Avoid

• Never extend topical corticosteroid use beyond 4 weeks - risks include infections, increased IOP, and cataract development 1
• Do not discontinue steroids abruptly; taper dosing frequency over final days of treatment 3, 5
• Failing to treat underlying blepharitis or meibomian gland dysfunction will cause treatment failure 1, 2
• Using preserved artificial tears more than 4 times daily causes ocular surface toxicity 1, 2

Optimal Steroid Bridging Strategy

• Pre-treat with topical corticosteroids for 2 weeks before initiating cyclosporine to reduce initial stinging and provide faster symptom relief 1, 4
• This approach reduces corneal fluorescein staining and ocular irritation more rapidly than cyclosporine plus artificial tears alone 1
• Taper steroids as cyclosporine reaches therapeutic effect (typically 4-6 weeks) 4

When to Refer to Ophthalmology

• Lack of response after 2-4 weeks of optimized treatment 2, 8
• Any vision loss, corneal infiltration, or ulceration 8
• Patients requiring steroids beyond 4 weeks need specialist management 1
• Refractory cases with ocular staining score requiring advanced therapies like punctal occlusion or serum drops 1