Ophthalmic steroids

Definition and Clinical Purpose
Ophthalmic steroids are a class of corticosteroids specifically formulated for topical ocular use. They are employed in managing inflammatory eye diseases, postoperative complications, allergic responses, and immune-mediated ocular disorders. These agents help suppress the inflammatory cascade and provide relief from symptoms such as redness, pain, swelling, and photophobia that accompany a wide range of anterior and posterior segment eye disorders.

Their administration route is local (topical), targeting affected ocular tissues while minimizing systemic absorption. Despite their localized use, prolonged or inappropriate application may lead to ocular complications, necessitating careful monitoring.

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1. Mechanism of Action

Ophthalmic corticosteroids function by:

• Inhibiting phospholipase A2, thereby preventing the release of arachidonic acid.

• Reducing production of inflammatory mediators including:

  • Prostaglandins

  • Leukotrienes

  • Cytokines

• Decreasing:

  • Capillary dilation

  • Fibroblast proliferation

  • Leukocyte migration

  • Scar tissue formation

This action leads to reduced inflammation, decreased vascular permeability, and dampened immune response, helping to preserve ocular structure and function.

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2. Therapeutic Indications

Ophthalmic steroids are prescribed in various clinical contexts, including:

• Postoperative inflammation (cataract, glaucoma, LASIK)

• Uveitis (anterior, intermediate, posterior)

• Keratitis and scleritis (non-infectious types)

• Allergic conjunctivitis

• Iritis and episcleritis

• Chemical burns and trauma

• Dry eye-related inflammation

• Ocular pemphigoid or Stevens-Johnson syndrome

• Prevention of graft rejection after corneal transplant

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3. Commonly Used Ophthalmic Steroids

Generic Name	Potency	Brand Examples	Formulation Types
Prednisolone acetate	High	Pred Forte, Omnipred	Suspension
Dexamethasone	High	Maxidex, Ozurdex	Suspension, intracameral implant
Fluorometholone	Moderate	FML, Flarex	Suspension, ointment
Loteprednol etabonate	Moderate	Lotemax, Alrex	Suspension, gel, ointment
Rimexolone	Moderate	Vexol	Suspension
Hydrocortisone	Low	Cortef, HydroDrops	Suspension
Difluprednate	Very High	Durezol	Emulsion
Triamcinolone acetonide	High	Kenalog, Triesence	Injectable (intravitreal, subconjunctival)
Betamethasone	High	Betnesol Eye Drops	Solution

4. Pharmacokinetics and Administration

Parameter	Details
Route	Topical (drops, ointments), subconjunctival, intravitreal
Absorption	Primarily local; systemic absorption possible through nasolacrimal drainage
Onset of Action	Usually within 1–2 hours for topical agents
Duration	Depends on formulation; ointments last longer
Frequency	Often q.i.d. initially; taper based on clinical response

5. Formulation Types

• Suspensions: Require shaking; commonly used for anterior segment inflammation

• Ointments: Provide prolonged contact time; useful for nighttime use

• Emulsions: Enhanced stability and bioavailability; e.g., difluprednate (Durezol)

• Gels: Longer retention, less blurring

• Implants: Long-acting, biodegradable intravitreal (e.g., Ozurdex) for posterior segment diseases

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6. Comparative Potency and Use Cases

Agent	Potency	Best Use Case
Difluprednate	Very High	Postoperative inflammation, uveitis (intense cases)
Prednisolone acetate	High	Anterior uveitis, severe ocular inflammation
Dexamethasone	High	Short-term post-op use, allergic inflammation
Fluorometholone	Moderate	Surface inflammation, lower IOP risk
Loteprednol	Moderate	Long-term use, steroid responders (soft steroid)
Hydrocortisone	Low	Mild allergic conjunctivitis, chronic low-grade inflammation

7. Adverse Effects

Ocular:

• Elevated intraocular pressure (IOP) → steroid-induced glaucoma

• Posterior subcapsular cataracts

• Corneal thinning and perforation

• Delayed epithelial healing

• Secondary infections (fungal, viral like herpes simplex)

• Mydriasis, ptosis (rare)

Systemic (minimal but possible):

• Hypothalamic-pituitary-adrenal (HPA) axis suppression (rare)

• Cushingoid features with chronic high-dose use

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8. Contraindications

• Herpes simplex keratitis (dendritic ulcers)

• Fungal eye infections

• Tuberculosis of the eye

• Acute purulent infections without anti-infective coverage

• Untreated glaucoma

• Known hypersensitivity to corticosteroids or preservatives (e.g., benzalkonium chloride)

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9. Precautions and Monitoring

• Monitor intraocular pressure during and after use

• Avoid prolonged use without ophthalmologist supervision

• Use in pregnancy: category C (risk cannot be ruled out)

• Avoid contact lenses during active treatment with steroids

• Consider tapering instead of abrupt discontinuation to prevent rebound inflammation

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10. Drug Interactions

Interacting Agent	Effect
Ocular NSAIDs	May increase risk of corneal thinning or ulceration
Mydriatics (e.g., atropine)	Combined risk of increased IOP
Live ocular vaccines	Avoid concurrent use due to immunosuppressive effects
Systemic corticosteroids	Additive suppression of immune response

11. Special Populations

Population	Considerations
Pediatric patients	↑ risk of IOP elevation; use only when necessary
Elderly	Monitor for cataracts, glaucoma
Pregnant/lactating	Use only if benefits outweigh potential risks
Glaucoma patients	Prefer loteprednol or fluorometholone; monitor IOP

12. Postoperative Use in Ophthalmic Surgeries

Surgical Procedure	Steroid Role
Cataract surgery	Control anterior chamber inflammation, reduce CME
Refractive surgery (LASIK)	Minimize corneal haze, pain, and inflammation
Glaucoma filtering surgery	Modulate healing response, reduce scarring
Corneal transplantation	Prevent graft rejection
Retinal procedures (e.g., vitrectomy)	Manage posterior segment inflammation

13. Summary Table of Common Agents

Agent	Brand	Formulation	Potency	Best For
Prednisolone acetate	Pred Forte	Suspension	High	Uveitis, post-op
Dexamethasone	Maxidex	Suspension	High	Post-op, acute inflammation
Fluorometholone	FML, Flarex	Suspension, ointment	Moderate	Mild/moderate ocular inflammation
Loteprednol	Lotemax, Alrex	Suspension, gel	Moderate	Chronic use, steroid responders
Difluprednate	Durezol	Emulsion	Very High	Severe inflammation, post-surgery
Hydrocortisone	HydroDrops	Solution	Low	Allergic conjunctivitis
Triamcinolone	Triesence (inject)	Injectable	High	Posterior segment diseases (e.g., macular edema)