Eye Steroids and Infection Regimens: Potency, Tapers and Antiviral Doses
Last updated: October 2026
Steroid strength and pressure risk, a standard taper, and the systemic and topical regimens for common eye infections. Check renal function before high-dose antivirals and adjust for children by weight.
Topical steroids: strength and IOP risk
| Drug | Relative anti-inflammatory strength | Risk of IOP rise | Typical use |
|---|---|---|---|
| Difluprednate 0.05% | Very high | High | Severe postoperative inflammation, uveitis |
| Prednisolone acetate 1% | High | High | Anterior uveitis, postoperative, graft rejection (shake well) |
| Dexamethasone 0.1% | High | High | Postoperative, allergic and inflammatory disease |
| Fluorometholone 0.1% | Moderate | Lower | Ocular surface inflammation, episcleritis, after PRK |
| Loteprednol 0.5% / 0.2% | Moderate / mild | Lower | Allergic conjunctivitis, dry eye flares, steroid responders |
| Prednisolone sodium phosphate 0.5–1% (solution) | Moderate (less penetration) | Moderate | Surface inflammation |
- Standard taper after cataract surgery or mild uveitis: four times a day for 1 week, three times for 1 week, twice for 1 week, once for 1 week, then stop. For severe uveitis, start hourly and taper more slowly once the anterior chamber is quiet.
- Check IOP 2–6 weeks after starting; steroid responders are more common in children, high myopes and patients with glaucoma.
- Never start a steroid for a red eye without slit-lamp examination: it worsens herpes simplex epithelial keratitis, fungal keratitis and Acanthamoeba.
Infection regimens (adults)
| Condition | Treatment | Notes |
|---|---|---|
| Bacterial conjunctivitis | Broad-spectrum antibiotic drops (for example moxifloxacin 0.5% three times daily) for 5–7 days | Often self-limiting; swab if hyperacute, neonatal or recurrent |
| Adenoviral keratoconjunctivitis | Lubricants, cold compresses, hygiene | Short steroid course only for pseudomembranes or visually significant infiltrates |
| Adult chlamydial conjunctivitis | Azithromycin 1 g orally once, or doxycycline 100 mg twice daily for 7 days | Treat sexual partners; screen for other sexually transmitted infections |
| Gonococcal conjunctivitis | Ceftriaxone 1 g IM once, plus frequent saline irrigation | Examine the cornea daily; treat chlamydia as well unless excluded |
| HSV epithelial keratitis | Ganciclovir 0.15% gel five times daily until healed, then three times daily for a week; or acyclovir 3% ointment five times daily; or oral acyclovir 400 mg five times daily | No steroid during active epithelial disease |
| HSV stromal keratitis | Topical steroid with oral acyclovir 400 mg twice daily (or valacyclovir 500 mg daily) as cover | HEDS: long-term acyclovir 400 mg twice daily roughly halves recurrences |
| Herpes zoster ophthalmicus | Acyclovir 800 mg five times daily for 7–10 days, or valacyclovir 1 g three times daily for 7 days, started within 72 hours of rash | Reduce dose in renal impairment; treat uveitis with topical steroid; recommend zoster vaccination later |
| Preseptal cellulitis | Amoxicillin–clavulanate orally | Admit if any sign of orbital cellulitis, or in young children who are unwell |
| Orbital cellulitis | IV antibiotics (for example ceftriaxone plus metronidazole; add vancomycin if MRSA risk) and urgent CT | ENT input for sinus disease; watch vision and pupils |
| Bacterial, fungal and Acanthamoeba keratitis | See the fortified drops card | Scrape and culture before starting |
Neonates
- Gonococcal ophthalmia neonatorum: ceftriaxone 25–50 mg/kg IV or IM once (maximum 250 mg), with saline irrigation; treat the mother and partner.
- Chlamydial: oral erythromycin 50 mg/kg/day in four divided doses for 14 days (watch for pyloric stenosis in infants under 6 weeks); topical treatment alone is not enough.
- HSV: IV acyclovir with paediatric input, as systemic spread is common.
Related: fortified drops, microbial keratitis work-up, dendrites and pseudo-dendrites, drugs in pregnancy.
Key sources
- Herpetic Eye Disease Study Group. Acyclovir for the prevention of recurrent herpes simplex virus eye disease. N Engl J Med 1998;339:300–6
- Centers for Disease Control and Prevention. Sexually Transmitted Infections Treatment Guidelines, 2021
- American Academy of Ophthalmology. Conjunctivitis Preferred Practice Pattern (2023)
- Cohen EJ, Jeng BH. Herpes zoster: a brief definitive review. Cornea 2021;40:943–9
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