Overview
Ophthalmic anti-inflammatory and antibiotic drops are among the most commonly prescribed medications in eye care. Understanding the differences between steroids and NSAIDs, knowing the major antibiotic classes, and recognizing important side effects are core competencies for ophthalmic assistants.
Corticosteroid Eye Drops
Mechanism: Corticosteroids inhibit the inflammatory cascade broadly by suppressing multiple inflammatory mediators, cytokines, and immune cell activity. They are the most potent topical anti-inflammatory agents available.
Common agents:
- Prednisolone acetate 1% (Pred Forte): The most commonly used ophthalmic steroid. Excellent corneal penetration.
- Dexamethasone: Potent steroid, available as drops and ointment.
- Loteprednol (Lotemax): A "soft" steroid designed to produce fewer side effects (lower risk of IOP elevation), often used for mild inflammation and allergic conditions.
- Fluorometholone (FML): Lower potency, used for surface inflammation.
Indications: Post-surgical inflammation, uveitis (iritis, iridocyclitis), severe allergic conjunctivitis, corneal graft rejection prophylaxis.
Side effects with prolonged use:
- Elevated IOP (steroid response): Occurs in approximately 30-40% of the general population. Can lead to steroid-induced glaucoma if not monitored.
- Posterior subcapsular cataract: With chronic use over months
- Increased infection risk: Steroids suppress the immune response, potentially worsening infections
- Delayed wound healing
NSAID Eye Drops
Mechanism: Non-steroidal anti-inflammatory drugs inhibit cyclooxygenase (COX) enzymes, blocking prostaglandin production. They reduce inflammation and pain without the steroid-related side effects.
Common agents: Ketorolac (Acular), diclofenac (Voltaren), nepafenac (Nevanac), bromfenac (Prolensa).
Indications:
- Post-surgical pain and inflammation
- Prevention of cystoid macular edema after cataract surgery
- Allergic conjunctivitis (ketorolac)
- Pupil maintenance during surgery (prevent intraoperative miosis)
Side effects: Stinging on instillation, delayed corneal healing with prolonged use, rarely corneal melting in susceptible patients.
Antibiotic Eye Drops
Purpose: Treat bacterial infections or prevent infection after trauma or surgery.
Major classes and representatives:
- Fluoroquinolones: Moxifloxacin (Vigamox), gatifloxacin (Zymaxid). Broad-spectrum, excellent corneal penetration. Fourth-generation fluoroquinolones are first-line for bacterial keratitis and post-surgical prophylaxis.
- Aminoglycosides: Tobramycin, gentamicin. Good gram-negative coverage. Can be toxic to corneal epithelium with prolonged use.
- Macrolides: Azithromycin (AzaSite), erythromycin. Often used for blepharitis and chlamydial conjunctivitis.
- Polymyxin B combinations: Polytrim (polymyxin B + trimethoprim). Commonly used for routine bacterial conjunctivitis.
Antiviral Eye Drops
Purpose: Treat viral keratitis, primarily herpes simplex keratitis.
Common agents: Ganciclovir gel (Zirgan), trifluridine (Viroptic).
Oral antivirals (acyclovir, valacyclovir) are often used in conjunction with or instead of topical agents, especially for stromal or recurrent disease.
Key Takeaways
- Steroids are the most potent anti-inflammatory agents but carry risks of IOP elevation, cataract, and infection
- NSAIDs reduce inflammation without steroid-related side effects and are commonly used after cataract surgery
- Fourth-generation fluoroquinolones (moxifloxacin, gatifloxacin) are first-line for serious bacterial infections
- Any patient on topical steroids needs regular IOP monitoring
- Steroids must never be used on suspected herpes keratitis without concurrent antiviral treatment