Prednisolone Ophthalmic Dosing
For acute anterior uveitis, initiate prednisolone acetate 1% at 1 drop every 1-2 hours while awake during the first week, then taper based on clinical response, with the goal of discontinuing within 3 months to minimize risk of glaucoma and cataracts. 1, 2
Initial Dosing for Acute Anterior Uveitis
- Start with intensive dosing: Most uveitis specialists initiate prednisolone acetate 1% at 6 times daily while awake (most common practice pattern), though hourly dosing may be used for severe inflammation 3
- Prednisolone acetate 1% is the preferred topical corticosteroid due to superior corneal penetration compared to other formulations 1, 4
- Schedule follow-up within one week to assess treatment response 3
Tapering Schedule
- Week 1: Every 1-2 hours while awake 5
- Week 2: Every 2 hours while awake 5
- Week 3: Four times daily 5
- Week 4: Once daily for final 3 days before discontinuation 5
- Taper as soon as anterior chamber cellular reaction comes under control to minimize complications 1
Duration Limits and Systemic Therapy Thresholds
- Maximum duration should not exceed 3 months as short-term therapy to avoid ocular complications 1, 2
- If requiring 1-2 drops/day for >3 months: Add systemic immunomodulatory therapy (methotrexate, adalimumab, or other DMARDs) to allow discontinuation of topical steroids 1
- If no response within 2-3 weeks: Consider switching to difluprednate or adding oral prednisone as bridging therapy 3
Critical Monitoring Requirements
Intraocular Pressure (IOP) Monitoring:
- Check IOP at baseline before initiating therapy 6
- Monitor IOP at each follow-up visit, especially when treatment extends beyond a few weeks 2, 6
- Risk increases significantly with ≥2 drops/day and longer duration of therapy 1, 2
Monitoring Schedule Based on Clinical Status:
- Active uveitis on treatment: Ophthalmologic exam within 1 week initially 3
- Tapering topical steroids: Ophthalmologic exam within 1 month 1
- Stable on low-dose therapy: Ophthalmologic exam at least every 3 months 1
Dose-Related Risk Thresholds
- ≥2 drops/day: Strong risk factor for IOP elevation, with risk increasing proportionally with higher frequency 1, 2
- ≥4 drops/day: Significantly increases cataract risk compared to ≤3 drops/day 1, 2
- 1-2 drops/day for >3 months: Threshold for adding systemic therapy to allow topical steroid discontinuation 1
Management of IOP Elevation
Mild elevation (21-25 mmHg):
- Continue close monitoring and reduce steroid frequency if clinically feasible 6
Moderate elevation (26-35 mmHg):
- Initiate topical IOP-lowering medication 6
- Switch to lower-potency steroid (loteprednol or fluorometholone) if inflammation allows 6, 4
- Re-evaluate within 1-2 weeks 6
Severe elevation (>35 mmHg):
- Discontinue steroid if clinically feasible 6
- Initiate multiple topical IOP-lowering medications 6
- Consider oral carbonic anhydrase inhibitors 6
- Urgent referral to glaucoma specialist 6
Alternative Formulations
Difluprednate 0.05%:
- More potent, allowing less frequent dosing (better compliance) 1, 7
- Higher risk of steroid-induced IOP elevation and cataracts compared to prednisolone acetate 1% 1
- Reserve for cases not responding to prednisolone acetate 1, 3
Lower-potency alternatives (loteprednol, fluorometholone):
- Less effective than prednisolone acetate for acute inflammation 4, 8
- Lower risk of IOP elevation 6, 4, 8
- Consider for patients with steroid-response or mild inflammation 4
Common Pitfalls to Avoid
- Never continue topical steroids beyond 3 months without adding systemic therapy or having a specific plan for discontinuation 1, 2
- Never use ≥4 drops daily long-term due to dramatically increased cataract risk 1, 2
- Never fail to monitor IOP regularly during treatment, as steroid-induced glaucoma can develop insidiously 2, 6
- Never maintain patients on 1-2 drops/day indefinitely without considering systemic immunomodulatory therapy 1