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  • . . . Introduction
  • 1. Gastro-Intestinal System
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  • 10. Musculoskeletal and Joint Disease
  • 11. Eye
    • 11.1 Administration of drugs to the eye
    • 11.2 Control of microbial contamination
    • 11.3 Anti-infective eye preparations
    • 11.4 Corticosteroids and other anti-inflammatory preparations
    • 11.5 Mydriatics and cyclopegics
    • 11.6 Treatment of glaucoma
    • 11.7 Local anaesthetics
    • 11.8 Miscellaneous ophthalmic preparations
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  • 15. Anaesthesia
  • Appendix 1. Drugs for emergency use in General Practice
  • Appendix 2. Palliative Care
  • Appendix 3. Oral Nutritional Supplements (ONS)
  • Appendix 4. Gluten-free and cow's milk protein-free products
  • Medicines No Longer included in the GJF
  • Medicines not recommended for use in NHS Grampian
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11.4 Corticosteroids and other anti-inflammatory preparations

In this section

• Corticosteroids
• Intravitreal corticosteroids
• Other anti-inflammatory preparations
• Prescribing points for corticosteroids

Corticosteroids

Betamethasone sodium phosphate 0.1% (eye drops, eye ointment) is an inexpensive preparation suitable for the treatment of inflammation. Other similar preparations used are prednisolone sodium phosphate 0.5% (eye drops, single use eye drops), and dexamethasone 0.1% (eye drops, single use eye drops).

Betamethasone sodium phosphate 0.1% with neomycin sulphate 0.5% (eye drops, proprietary name Betnesol-N®) is a combined corticosteroid/antibiotic preparation. It is used for mild marginal keratitis and short-term after minor ocular surgery.

SPECIAL INDICATIONS

Prednisolone acetate 1% (eye drops, proprietary name Pred-Forte®) has a higher intra-ocular penetration than prednisolone sodium phosphate, betamethasone or dexamethasone.

Prednisolone sodium phosphate 0.03% (eye drops) is available as a "special" for the treatment of conditions such as herpes keratitis, where very mild corticosteroid therapy is required.

Fluorometholone 0.1%, polyvinyl alcohol 1.4% (eye drops, proprietary name FML®) is a non-penetrating corticosteroid preparation which may be used for resistant vernal conjunctivitis.

Maxitrol® (eye drops containing dexamethasone 0.1%, neomycin 0.35%, polymyxin B sulphate 6000 units/mL) is also available for short-term local treatment of inflammation. Used for mild marginal keratitis and short-term after minor ocular surgery.

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Intravitreal corticosteroids

Dexamethasone intravitreal implant (dexamethasone 700micrograms in disposable applicator, Ozurdex®)  is used in adult patients with macular oedema (i) following central retinal vein occlusion (CRVO) and (ii) in patients with branch retinal vein occlusion (BRVO) who are not clinically suitable for laser treatment including patients with dense macular haemorrhage or patients who have received and failed on previous laser treatment. Restriction: must be administered by a qualified ophthalmologist experienced in intravitreal injections, hospital use only [SMC 652/10].

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Other anti-inflammatory preparations

Sodium cromoglicate 2% eye drops has a prophylactic action, and is used to treat allergic conjunctivitis. Treatment may take several weeks to achieve maximal effect and it is important that patients continue to use the drops regularly even when symptoms improve. It can be bought over the counter from a pharmacy for acute seasonal and perennial allergic conjunctivitis. 
Dose (adults and children): one drop into each eye four times daily.

SPECIAL INDICATIONS

Olopatadine 1mg/1mL (eye drops, Opatanol®) is an antihistamine which is an alternative treatment for adults and children with ocular signs and symptoms of seasonal allergic conjunctivitis. 
Dose (adults and children 3 years and over): one drop into each eye twice daily (8 hourly). Treatment may be maintained for up to four months, if considered necessary.

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PRESCRIBING POINTS FOR CORTICOSTEROIDS

• Topical corticosteroid preparations are used to treat inflammatory conditions such as uveitis and scleritis and also to reduce post-operative inflammation.
• Topical corticosteroids are applied frequently for the first 1-2 days, once inflammation is controlled the frequency of application is reduced.
• Topical corticosteroid preparations should only be used under expert supervison. There are three important cautions to their use:
  • a 'red eye', where the diagnosis is unconfirmed, may be due to herpes simplex virus and a corticosteroid may aggravate the condition, leading to corneal ulceration, with possible damage to vision and even loss of the eye. Bacterial, fungal and amoebic infections pose similar hazards when corneal lesions are not epithelialised.
  • 'steroid glaucoma' can follow the use of corticosteroid eye preparations in susceptible individuals.
  • a steroid-induced cataract can follow prolonged use in adults, however in children onset may occur even after very short period of treatment.
• Systemic corticosteroids may be useful for severe inflammatory ocular conditions including non-infectious panuveitis, scleritis, corneal melts and acute corneal graft rejection. The risk of producing a "steroid cataract" increases with the dose and duration of corticosteroid use. For further information on prescribing corticosteroids, see section 6.
• Topical combination preparations containing a corticosteroid with an anti-infective drug are sometimes used after ocular surgery to reduce inflammation and prevent infection, use of combination products is otherwise rarely justified.

PAEDIATRIC NOTES - CORTICOSTEROIDS AND OTHER ANTI-INFLAMMATORY PREPARATIONS

All of the recommended drugs may be used in children but it is particularly important that corticosteroids are used under the supervision of an ophthalmologist.
Long-term topical corticosteroid therapy should be avoided due to possible development of adrenal suppression, raised intra-ocular pressure, steroid-induced cataract and herpes keratitis. A steroid-induced cataract can follow prolonged use in adults, however in children onset may occur even after a very short period of treatment.

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