Why does prednisolone acetate require vigorous shaking?

Prednisolone acetate is a suspension, so vigorous shaking is needed to resuspend the drug for consistent dosing. Difluprednate is an emulsion and does not require shaking.

How should patients be counseled about cataract risk?

Cataract risk is mainly associated with long-term steroid use over months to years rather than short courses. Long-term patients should be counseled and monitored for posterior subcapsular cataract development.

Is it acceptable to start a topical steroid when the cause of a red eye is uncertain?

Usually no. Do not start topical steroids on an undifferentiated red eye until infectious causes such as HSV and fungal keratitis have been reasonably excluded or appropriately treated.

How soon can steroid drops raise IOP, and who is at higher risk?

Steroid-related IOP rise can occur within weeks in responders. Risk is higher in glaucoma patients, those with prior steroid response or family history, and with higher-potency or prolonged regimens, so baseline and follow-up IOP checks are important.

Ophthalmic Steroid Eye Drops

Topical corticosteroids used for ocular surface and intraocular inflammation

Topical Ophthalmic Steroids: Choosing Potency and Staying Safe

How to choose a steroid

Topical corticosteroids differ in anti-inflammatory potency, tissue penetration, and likelihood of increasing intraocular pressure (IOP). Selection should match the severity and location of inflammation and the patient's risk for steroid response.

High potency: difluprednate 0.05% (Durezol) delivers strong anti-inflammatory effect with convenient dosing and does not require shaking because it is an emulsion. It is commonly used for severe uveitis and significant post-operative inflammation, but it carries a higher risk of IOP elevation.
Standard potency: prednisolone acetate 1% remains a long-standing first choice for anterior uveitis and many post-operative regimens. It is a suspension and requires vigorous shaking to deliver consistent dosing.
Lower-risk options for surface disease include loteprednol and fluorometholone. Loteprednol is ester-based and rapidly metabolized, and fluorometholone tends to have lower penetration. Both are often used when long courses are anticipated or when steroid response risk is higher.

Indications and taper principles

Anterior uveitis: Often requires intensive initial dosing plus cycloplegia to reduce ciliary spasm and help prevent posterior synechiae. Once cells and flare improve, taper gradually over weeks rather than stopping abruptly.

Post-surgical inflammation: Many regimens use a structured taper over several weeks to control trauma-related inflammation and reduce risk of cystoid macular edema.

Stromal keratitis and immune keratopathies: May require prolonged, cautious tapers with close follow-up. In herpetic disease, concurrent antiviral coverage is often used to reduce the risk of epithelial reactivation.

IOP response and other safety monitoring

A subset of patients develop a clinically meaningful IOP rise during steroid therapy due to reduced trabecular outflow. Baseline and follow-up IOP checks are important for any patient on repeated, intensive, or prolonged topical steroids. If a steroid response is detected, options include reducing dose, switching to a lower-risk steroid (such as loteprednol), and adding an aqueous suppressant when needed. Cataract risk is mainly a concern with long-term or repeated courses, especially in patients requiring maintenance therapy.

Ocular Steroid Medications

Brand	Generic	Dosing	Amount	Ages	Pregnancy	Mechanism
Alrex Generic	loteprednol 0.2%	qid	5/10mL	Not Established	C	ester-based corticosteroid
Durezol Generic	difluprednate 0.05%	qid, taper	5mL	Not Established	C	difluorinated corticosteroid
FML Generic	fluorometholone 0.1%	bid-qid	5/10/15mL (gtt)3.5g (ung)	>2 years	C	ketone-based corticosteroid
Inveltys	loteprednol 1%	bid x14d	2.8mL	Not Established	C	ester-based corticosteroid
Lotemax Generic	loteprednol 0.5%Lotemax SM 0.38%	qid	2.5/5/10/15mL (gtt)3.5g (ung)5mL (gel)	Not Established	C	ester-based corticosteroid
Pred Forte Generic	prednisolone acetate 1%	bid-qid, taper	5/10/15mL	>1 month	C	ketone-based corticosteroid

Ophthalmic Steroid Medication FAQs

Why does prednisolone acetate require vigorous shaking?: Prednisolone acetate 1% is a suspension, so drug particles settle between uses. Without vigorous shaking, early drops may contain too little medication and later drops may contain too much. By contrast, difluprednate is an emulsion that stays more uniformly mixed and does not require shaking, which improves dosing consistency.
How should patients be counseled about cataract risk?: Topical steroids are associated with posterior subcapsular cataracts, most often with months to years of ongoing therapy. Short courses for acute inflammation (for example post-operative care or brief uveitis flares) carry much lower risk than chronic maintenance dosing. Patients using long-term steroids should be counseled that cataract formation is a known dose and duration-related complication and that regular dilated exams help detect progression.
Is it acceptable to start a topical steroid when the cause of a red eye is uncertain?: In general, no. Starting a steroid on an undifferentiated red eye can worsen occult infectious disease, including herpes simplex epithelial keratitis, fungal keratitis, and atypical microbial ulcers. In HSV epithelial disease, a small dendrite can progress to a larger geographic ulcer if a steroid is used without appropriate antiviral coverage. Steroids should be reserved for cases where infection has been reasonably excluded or is being appropriately treated under close follow-up.
How soon can steroid drops raise IOP, and who is at higher risk?: IOP elevation can occur within weeks in steroid responders, though timing varies by patient, potency, and dosing frequency. Higher-risk groups include patients with primary open-angle glaucoma, a family history of glaucoma, prior steroid response, and those needing higher-potency or prolonged courses. Baseline IOP measurement and a planned follow-up pressure check are good practice whenever topical steroids are used intensively or beyond a short course.