Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Topical and periocular corticosteroids: benefits and risks

Corticosteroids remain the mainstay of treatment for many inflammatory conditions of the ocular surface, anterior and posterior segment, given as drops, periocular or intravitreal injections, or implants [S8]. Their main local risks are raised intraocular pressure (IOP) and cataract [S8], and in infectious keratitis they can suppress the host response needed to clear infection [S10].

Key points - Steroid-induced IOP elevation and cataract are the most significant local risks of topical and systemic corticosteroids [S8]; injected and implanted routes may exacerbate them [S8]. - Topical steroids are safe as an adjunct in bacterial keratitis with broad-spectrum antibiotics and in herpetic keratitis with antivirals, but observational studies found harm in fungal and Acanthamoeba keratitis when started before anti-amoebic therapy [S10]. - In dry eye, topical steroids probably give small to moderate symptom relief beyond lubricants, but may increase IOP elevation (RR 5.96) [S9]. - Loteprednol etabonate was designed to have less effect on IOP than prednisolone acetate or dexamethasone [S1]. - In most cases of uveitis, corticosteroids are not appropriate as long-term therapy [S7].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Red eye with a corneal infiltrate or ulcer of unknown cause: steroids may hinder clearance of infection, and observational studies show harm in fungal and Acanthamoeba keratitis [S10].
• Raised IOP during steroid treatment, especially in known steroid responders, glaucoma or pre-existing optic nerve damage [S5] [S8].
• Long-term or repeated steroid courses without IOP and lens monitoring [S7] [S8].
• Systemic effects with systemic steroids, such as osteonecrosis and adrenal insufficiency [S7].

Recognise it: benefits and harms by route

• Topical drops are the route of choice for ocular surface and anterior segment disease [S8].
• Periocular, intravitreal and suprachoroidal injections can be effective for posterior segment disease [S8].
• Raised IOP after cataract surgery. Early postoperative IOP rise is frequent; risk factors include residual viscoelastic, glaucoma, pseudoexfoliation, axial length over 25 mm, tamsulosin and topical steroids in steroid responders [S5]. Stopping the corticosteroid usually returns IOP to normal in steroid responders [S5].
• Older steroids such as dexamethasone and prednisolone acetate are often associated with clinically significant IOP rises of 10 mmHg or more, as reported in [S1].

Confirm it: monitoring

• IOP elevation is the most significant local risk, so check IOP during treatment where a tonometer is available [S8].
• Examine the lens for cataract on longer courses [S8].
• Before starting steroids for keratitis, consider the likely organism: their safety depends largely on the efficacy of the antimicrobial against that organism [S10].

Manage it

Before acting on this section, check the national and local guidelines, product information and regulatory approvals that apply where you practise. See the medical disclaimer.

Tier A (primary care / no specialist)

• Avoid starting topical steroid drops for an undiagnosed red eye: steroids reduce the host immune response and can worsen untreated infection [S10].
• Ask about steroid drops in any patient with a painful red eye or new loss of vision, and refer for IOP measurement [S8].
• Dosing is not covered here: follow your local formulary.

Tier B (general eye clinic)

• After cataract surgery. A meta-analysis of 6 RCTs (883 patients) found difluprednate cleared anterior chamber cells faster than prednisolone acetate after small incision cataract surgery and gave clearer corneas after phacoemulsification; there was no difference at 1 month and no significant difference in ocular hypertension (OR 1.23) [S6]. Certainty was low to moderate [S6].
• Dry eye. A Cochrane review of 22 RCTs (4169 participants) found small to moderate symptom benefit over lubricants; trials lasted mostly weeks, so long-term effects on IOP and cataract are uncertain [S9].
• Paediatric blepharokeratoconjunctivitis. Only one small RCT (137 children aged 0 to 6 years) was found, with very low certainty evidence and no important differences between loteprednol/tobramycin, loteprednol, tobramycin and placebo [S3].
• Bacterial keratitis. Adjunctive steroids with broad-spectrum antibiotics are safe; benefit has not been shown conclusively, although more advanced ulcers may do better [S10]. No RCTs have assessed steroids in fungal or Acanthamoeba keratitis [S10].
• IOP spikes in steroid responders. Stop or reduce the steroid; one review suggests topical IOP-lowering combinations in high-risk patients [S5].

Tier C (specialist centre)

• Uveitic macular oedema. In the POINT RCT, intravitreal triamcinolone and the dexamethasone implant reduced central subfield thickness more than periocular triamcinolone (39% and 46% vs 23% at 8 weeks), with modestly higher risk of IOP of 24 mmHg or more [S4].
• Chronic non-infectious posterior, intermediate or panuveitis. A fluocinolone acetonide implant probably reduced recurrence (RR 0.29) but increased the need for cataract surgery (RR 2.98) and IOP-lowering surgery (RR 7.48) over two years; the review could not conclude that implants are superior to systemic therapy [S2].
• Plan steroid-sparing long-term therapy in uveitis [S7].

Refer when

Pitfalls

• Prescribing steroid drops for a red eye without first excluding infection, especially fungal or Acanthamoeba keratitis [S10].
• Forgetting that intravitreal and implant routes carry higher IOP and cataract risk [S2] [S4] [S8].
• Assuming short dry eye trials prove long-term safety [S9].
• Relying on corticosteroids as long-term uveitis therapy [S7].

Evidence notes

• In the dry eye review, nearly half the trials were at high risk of bias from selective reporting, and 8 were sponsored exclusively by industry [S9].
• The implant review included two studies, both at high risk of performance and detection bias [S2].
• Loteprednol comparisons with difluprednate need confirmatory studies [S1].
• Not covered by these sources: steroid doses and tapering, steroids in pregnancy and children beyond BKC, combination antibiotic-steroid drops in primary care, and steroid misuse from over-the-counter sale.

Related articles

• Anterior Uveitis
• Herpes simplex keratitis

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.