11.4.1 Corticosteroids

Drugs used, not listed here:

Steroid eye drops are used for non-infected inflammatory conditions of the eye and should usually be prescribed only after consultation with an ophthalmologist to minimise risk of masking an underlying condition, exacerbating an infection or causing steroid glaucoma.

Topical steroid should not be used for undiagnosed red eye. Particular care is needed with unilateral red eye especially with symptoms of pain, photophobia or blurring. Such patients should be referred. If red eye is due to herpes simplex, corticosteroids will aggravate this condition possibly leading to loss of vision or even loss of the eye.

Steroid eye drops can raise intra-ocular pressure (IOP) and therefore precipitate glaucoma in patients pre-disposed to chronic simple glaucoma. Evidence suggests that fluorometholone is less likely to raise IOP though this may be due to reduced penetration of the cornea.

All steroids have the potential to cause cataract formation. It is recommended that any patient who may require long term steroid has an annual review by an optometrist.

Choice of steroid is determined by indication. Potent steroids: Pred Forte® and dexamethasone are used for iritis. Fluorometholone is used for surface diseases. Other indications are often managed with the moderate potency products prednisolone 0.5% or betamethasone.

Dose frequency should vary according to the severity of inflammation, being tailed off gradually to avoid rebound inflammation.

Betamethasone
  • Eye drops 0.1% (£2.32 = 10ml)
  • Eye ointment 0.1%

Indications

  • Local treatment of inflammation (short-term)

Dose

  • Drops: every 1–2 hours until controlled then reduce frequency
  • Ointment: apply 2–4 times daily or at night when used with eye drops
Fluorometholone
  • Ophthalmic suspension 0.1% (£1.71 = 5ml)

Indications

  • Local treatment of inflammation (short-term)

Dose

  • Every hour for 24-48 hours then reduce frequency to 2-4 times daily
Prednisolone 0.5%

Indications

  • Local treatment of inflammation (short-term)

Dose

  • Every 1-2 hours until controlled then reduce frequency

Notes

  1. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above)
Prednisolone 1%
  • Eye drops (prednisolone acetate) 1% (£3.66 = 10ml)

Indications

  • Local treatment of inflammation (short-term)

Dose

  • Every 1-2 hours until controlled then reduce frequency
Dexamethasone

Indications

  • Local treatment of inflammation (short-term)

Notes

  1. See below for intravitreal preparation
  2. Where a preferred brand is recommended for a particular presentation, prescribing by brand helps ensure cost-efficient use of local NHS resources (see preferred brand link above).
Hydrocortisone
  • Single dose eye drops preservative free (hydrocortisone sodium phosphate) 3.35mg/ml (£10.99 = 30 x 0.4ml)

Indications

  • Local treatment of mild non-infectious allergic or inflammatory conjunctival diseases (short-term)

Notes

  1. Two drops two to four times daily until controlled then reduce frequency
With antibacterials
Maxitrol

(Dexamethasone with (hypromellose), neomycin and polymyxin B sulfate)

  • Eye drops (£1.68 = 5ml)
  • Eye ointment (£1.44 = 3.5g)

Indications

  • Post-operative inflammation when bacterial infection is likely

Dose

  • Drops: every 30–60 minutes until controlled then reduce frequency to 4–6 times daily
  • Ointment: (with neomycin) apply 3–4 times daily or at night when used with eye drops

Notes

  1. Eye drops: Each 1 ml contains dexamethasone 1mg, hypromellose 5mg, neomycin 3,500 units and polymyxin B sulfate 6,000 units
  2. Eye ointment: Each gram contains dexamethasone 1mg, neomycin 3,500 units and polymyxin B sulfate 6,000 units
Loteprednol
  • Ophthalmic suspension 0.5%

Indications

  • Post-operative inflammation following ocular surgery
  • Local treatment of inflammation when patients have a clinically significant rise in intraocular pressure with other formulary treatment options (unlicensed indication)

Notes

  1. If used for 10 days or more, intraocular pressure should be monitored
  2. The routine commissioning of loteprednol is accepted in Devon for the treatment of patients with steroid responsive inflammatory eye conditions who have a known clinically significant rise in intraocular pressure with other steroid eye drops (see Commissioning Policy for more details)

Intravitreal corticosteroids

Dexamethasone
  • Intravitreal implant 700 micrograms

Notes

  1. NICE TA229: Dexamethasone intravitreal implant for the treatment of macular oedema secondary to retinal vein occlusion (July 2011):
    1. Dexamethasone intravitreal implant (Ozurdex) is recommended as an option for the treatment of macular oedema following central retinal vein occlusion.
    2. Dexamethasone intravitreal implant (Ozurdex) is recommended as an option for the treatment of macular oedema following branch retinal vein occlusion when:
      • treatment with laser photocoagulation has not been beneficial, or
      • treatment with laser photocoagulation is not considered suitable because of the extent of macular haemorrhage
  2. NICE TA460: Dexamethasone intravitreal implant (Ozurdex) is recommended as an option for treating non-infectious uveitis in the posterior segment of the eye in adults only if there is active disease (that is, current inflammation in the eye) and worsening vision with a risk of blindness (July 2017)
  3. NICE TA824: Dexamethasone intravitreal implant (Ozurdex) is recommended as an option for treating visual impairment caused by diabetic macular oedema in adults only if their condition has not responded well enough to, or if they cannot have non-corticosteroid therapy (September 2022)
Fluocinolone acetonide
  • Intravitreal implant in applicator 190 micrograms

Notes

  1. NICE TA301: Fluocinolone acetonide intravitreal implant (Iluvien) is recommended as an option for treating chronic diabetic macular oedema that is insufficiently responsive to available therapies, only when the criteria of the NICE TA are met (November 2013)
  2. NICE TA590: Fluocinolone acetonide intravitreal implant (Iluvien) is recommended as an option for preventing relapse in recurrent non-infectious uveitis affecting the posterior segment of the eye (July 2019)
  3. NICE TA613: Fluocinolone acetonide intravitreal implant (Iluvien) is not recommended as an option for treating chronic diabetic macular oedema that is insufficiently responsive to available therapies in an eye with a natural lens (phakic eye) (November 2019)

 

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