Drugs used, not listed here:

• Adalimumab, see section 10.1.3 Drugs that suppress the rheumatic disease process
  • NICE TA460: Adalimumab and dexamethasone for treating non-infectious uveitis (July 2017)

Topical corticosteroids should normally only be used under expert supervision.

Topical ophthalmic steroids placed in descending order of potency:

• prednisolone acetate 1% (most potent)
• dexamethasone 0.1%
• betamethasone 0.1%
• prednisolone sodium phosphate 0.5%
• fluorometholone 0.1% (least potent)

The severity of the inflammation determines the choice of steroid. Topical steroids should not be used for undiagnosed red eye. 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. A steroid cataract may follow prolonged use of topical steroids.

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.

Use of a combination product containing a steroid plus antibiotic is rarely justified and should not be routinely used, except post intraocular surgery e.g. cataract.

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

Dexamethasone

• Eye drops 0.1% (£1.42 = 5ml)
• Single use eye drops preservative-free 0.1% (£11.46 = 20 units (0.5ml))

Indications

• Local treatment of inflammation (short-term)

Notes

1. See below for intravitreal preparation.

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

Fluorometholone

• Eye drops 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

Hydrocortisone sodium phosphate

• Single dose eye drop preservative-free 3.35mg/ml (£10.99 = 30 unit dose (0.4ml))

Indications

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

Dose

• Two drops two to four times daily until controlled then reduce frequency

Prednisolone

• Sodium phosphate eye drops 0.5% (£2.57 = 10ml)
• Acetate eye drops 1% (£1.82 = 5ml)
• Sodium phosphate single use eye drops preservative-free 0.5% (£13.50 = 20 units (0.5ml))
• Eye drops 0.1% (unlicensed preparation)
• Eye drops 0.05% (unlicensed preparation)

Indications

• Local treatment of inflammation (short-term)

Dose

• Every 1-2 hours until controlled then reduce frequency

Loteprednol

• Eye drops 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

Betamethasone

• Sub-conjunctival 2mg in 0.5ml (using 4mg/ml solution for injection ampoules) (unlicensed preparation)

Dexamethasone

• Intravitreal implant 700micrograms

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 with device 190micrograms

Notes

1. NICE TA590: Fluocinolone acetonide intravitreal implant (Iluvien) is recommended, within its marketing authorisation, as an option for preventing relapse in recurrent non-infectious uveitis affecting the posterior segment of the eye, only if the company provides it according to the commercial arrangement (July 2019).
2. NICE TA953: Fluocinolone acetonide intravitreal implant (Iluvien) is recommended, within its marketing authorisation, as an option for treating visual impairment caused by chronic diabetic macular oedema that has not responded well enough to available treatments in adults, only if the company provides it according to the commercial arrangement (March 2024).
   1. For people with the condition in an eye with a natural (phakic) lens, if the person and their clinicians consider fluocinolone acetonide intravitreal implant to be 1 of a range of suitable treatments, after discussing the advantages and disadvantages of all the options, use the least expensive. Take account of administration costs, dosage, price per dose, duration of effect and commercial arrangements.

Methylprednisolone

• Intralesional injection 24mg in 0.6ml (unlicensed preparation)

Triamcinolone

• Intraorbital/intravitreal injection 40mg in 1ml

Notes

1. Aseptically produced by SDHCFT pharmacy