Ophthalmic Steroids

Concise summaries of common ophthalmic corticosteroid eye drops and ointments used in optometric and ophthalmologic practice in Singapore, including practical guidance on pharmacology, potency, dosing, patient selection, IOP monitoring, and referral thresholds.

Last updated: March 2026

What are ophthalmic steroids?

Ophthalmic steroids (topical ocular corticosteroids) are pharmaceutical preparations — eye drops, suspensions, and ointments — applied directly to the ocular surface or periocular tissues to suppress inflammation mediated by the arachidonic acid cascade, phospholipase A2 activation, and downstream prostaglandin, leukotriene, and cytokine release. They are among the most commonly prescribed therapeutic agents in ophthalmology.

In Singapore, with its high contact-lens wearing population, year-round humid climate favouring microbial keratitis, and busy surgical throughput at public institutions such at public eye care institutions, topical steroids play a central role in managing post-operative inflammation, anterior uveitis, severe allergic disease, and inflammatory lid margin conditions. Because all ophthalmic steroids are Prescription-Only Medicines (POM) in Singapore, optometrists must refer patients requiring steroid therapy to a registered medical practitioner.^[1,4]

Drug classes

Low-potency corticosteroids — limited anterior chamber penetration and lower IOP-raising potential; preferred for conjunctival/episcleral disease (e.g., fluorometholone 0.1%, fluorometholone 0.25%).
High-potency corticosteroids — excellent anterior chamber penetration; essential for uveitis and post-surgical inflammation but carry significant IOP and cataractogenic risk (e.g., prednisolone acetate 1%, dexamethasone 0.1%).
Retrometabolic ‘soft’ steroids — engineered to undergo rapid inactivation in ocular tissue after exerting their anti-inflammatory effect, substantially reducing systemic and IOP-related side effects (e.g., loteprednol etabonate 0.5%).
Steroid–antibiotic combinations — combine a corticosteroid with one or more broad-spectrum antibiotics for concurrent inflammatory and bacterial indications; require strict clinical justification for both components (e.g., tobramycin/dexamethasone, neomycin/polymyxin B/dexamethasone).

Who are they for?

Topical ophthalmic steroids are indicated wherever localised ocular inflammation requires pharmacological suppression and the risk–benefit ratio favours topical steroid therapy over watchful waiting or non-steroidal alternatives alone. In Singapore's tertiary eye care centres, the most frequent indications are post-operative anterior segment inflammation, anterior uveitis, and severe forms of allergic eye disease — all conditions requiring specialist oversight.

Patient profiles / common conditions

Anterior uveitis (iritis / iridocyclitis)

Most common intraocular inflammatory disease managed in Singapore ophthalmology; typically requires Pred Forte hourly dosing with slow taper; HLA-B27 associations common.

Post-operative inflammation

Routine after cataract surgery, keratoplasty, trabeculectomy, and refractive procedures; typically FML or Lotemax; taper over 4–6 weeks.

Severe allergic conjunctivitis (VKC / AKC)

Vernal and atopic keratoconjunctivitis with shield ulcers or corneal involvement; steroids adjunct to mast cell stabilizers; specialist co-management essential.

Episcleritis / scleritis (anterior)

Mild episcleritis may respond to topical fluorometholone; true scleritis usually requires systemic therapy — refer promptly to ophthalmologist.

Marginal keratitis / phlyctenulosis

Hypersensitivity response to Staphylococcal antigens; low-potency steroid (FML) combined with lid hygiene; confirm no active infection first.

Chemical / toxic conjunctivitis

Short-course topical steroid to suppress acute inflammatory response after irrigation; ophthalmology review for severe chemical burns.

Caution — contact lens wearers

Contact lens wear should be suspended during any course of topical steroid therapy. Steroids suppress corneal immune surveillance, significantly increasing the risk of microbial keratitis — particularly Pseudomonas aeruginosa and Acanthamoebakeratitis in soft lens wearers in Singapore's humid climate. Resume lens wear only once the treating ophthalmologist confirms the ocular surface is quiescent and the steroid has been fully tapered. Most topical steroid formulations also contain BAK preservative, which adsorbs onto soft lenses and causes toxic keratopathy.

When should they be prescribed?

Acute inflammatory conditions

High-potency agents such as prednisolone acetate 1% (Pred Forte) are initiated promptly for acute anterior uveitis, typically at hourly dosing during waking hours in the first 24–48 hours. The steroid choice, starting frequency, and taper schedule are determined by the treating ophthalmologist based on cell and flare grading, fibrin formation, and underlying aetiology. Never commence steroid therapy before excluding herpetic keratitis or active bacterial infection, as steroids will exacerbate both.

Post-operative / prophylactic use

Topical steroids are prescribed routinely after intraocular surgery (cataract, keratoplasty, refractive) to suppress the surgical inflammatory response and prevent cystoid macular oedema. Standard post-cataract protocols in Singapore typically include FML 0.1% or loteprednol QID for four weeks with a step-down taper. For penetrating keratoplasty, steroids may be continued long-term to reduce rejection risk — under strict specialist supervision.

Escalation and referral thresholds

Escalate to higher-potency agents (prednisolone, dexamethasone) when low-potency steroids fail to control anterior chamber inflammation adequately after 48–72 hours. Any new or worsening anterior uveitis, vision loss, corneal oedema, hypopyon, or IOP rise >5 mmHg above baseline during steroid therapy warrants same-day ophthalmology review. Suspected herpetic, fungal, or Acanthamoeba infection in a contact lens wearer is a clinical emergency — refer immediately and do not initiate or continue steroids until the diagnosis is confirmed.

Condition / Severity	Recommended agent	Duration / Action
Mild conjunctival / episcleral inflammation	FML 0.1% BD–QID	1–2 weeks; taper; review at 2 weeks
Post-operative (routine cataract / refractive)	FML 0.1% or Lotemax QID	4 weeks; taper; ophthalmologist-directed
Steroid-responder / glaucoma suspect	Lotemax 0.5% QID (preferred)	2–4 weeks; IOP check every 2 weeks
Moderate anterior uveitis	Pred Forte 1% QID — hourly (acute)	4–6 weeks taper; ophthalmologist co-manage
Severe uveitis / hypopyon / VKC with shield ulcer	Pred Forte 1% hourly + urgent referral	Same-day ophthalmology; do not delay

Where are they available in Singapore?

In Singapore, all topical ophthalmic corticosteroids — including standalone steroid preparations and steroid–antibiotic combination products — are classified as Prescription-Only Medicines (POM) under the Medicines Act and regulated by the Health Sciences Authority (HSA). There are no OTC or Pharmacy-only (P) topical ophthalmic steroids available in Singapore. Supply without a valid prescription from a registered medical practitioner is unlawful.

Scope of practice — Singapore optometrists

Under the Optometrists and Opticians Act (Cap. 213A) and the regulatory framework of the Optometrists and Opticians Board (OOB), Singapore-registered optometrists are authorised to examine eyes, assess visual function, and prescribe optical appliances (spectacles and contact lenses). They do not hold the authority to prescribe, supply, administer, or initiate therapeutic medications of any class — including all topical ophthalmic steroids. Any patient presenting to an optometrist with a condition requiring steroid therapy must be referred to a registered medical practitioner — typically an ophthalmologist at a public or private eye centre, or a GP with ophthalmic experience — before any steroid treatment is commenced.^[4,5]

Prescription-only (POM): All ophthalmic steroids including fluorometholone (FML, FML Forte), prednisolone acetate (Pred Forte), loteprednol (Lotemax), dexamethasone (Maxidex), and steroid–antibiotic combinations (Tobradex, Maxitrol) require a valid prescription from a registered medical practitioner.
Retail pharmacies: Licensed retail pharmacies (Guardian, Watsons, Unity, and independent registered pharmacies) may dispense POM steroids against a valid prescription. They may not supply without prescription.
Public hospital formularies: Singapore's public eye care institutions maintain comprehensive formularies including prednisolone acetate, fluorometholone, loteprednol, dexamethasone, and combination products — prescribed by ophthalmologists and dispensed in-house or via linked hospital pharmacies.
Private ophthalmology clinics: Private ophthalmologists in Singapore routinely prescribe and dispense topical steroids in-clinic as part of post-operative and uveitis management protocols.
HSA product verification: Current registration status and POM classification for all ophthalmic steroid products can be confirmed via the HSA product registration portal (hsa.gov.sg). Verify before referring for any specific product as registration status may change.^[4]

Why use topical agents over oral or systemic steroids?

Topical ophthalmic corticosteroids achieve high local drug concentrations directly at the site of inflammation — the conjunctiva, cornea, or anterior chamber — while minimising systemic absorption and the broad adverse-effect profile associated with oral or systemic corticosteroid therapy.

High local bioavailability

Direct application achieves therapeutic concentrations in the anterior chamber and aqueous humour that oral dosing cannot reliably achieve for anterior segment disease.

Reduced systemic side effects

Avoids the systemic sequelae of oral corticosteroids — adrenal suppression, hyperglycaemia, osteoporosis, weight gain, and hypertension — which are particularly relevant in Singapore's ageing population and diabetic patients.

Titratable potency

Clinicians can select agents by penetration profile and potency (fluorometholone → loteprednol → prednisolone → dexamethasone) to match the anatomical target and severity of inflammation.

Rapid dose adjustment

Frequency can be titrated from hourly (acute uveitis) to once daily (maintenance) with daily clinical feedback, allowing fine-grained control not possible with systemic dosing.

Oral or systemic steroids (e.g., prednisolone tablets, IV methylprednisolone) remain necessary for posterior segment inflammation, intermediate uveitis, orbital disease, or when topical therapy alone is insufficient — such as in severe panuveitis or scleritis.^[6] The decision to escalate to systemic therapy rests entirely with the treating ophthalmologist or rheumatologist.

How to use ophthalmic steroids — patient instructions

Instillation technique

Wash hands thoroughly with soap and water before handling the bottle or tube.
For suspensions (Pred Forte, Lotemax, FML): shake the bottle well for 10–15 seconds before each use to ensure uniform drug concentration.
Tilt head back slightly and gently pull down the lower eyelid to create a pocket (lower fornix).
Hold the bottle inverted and instil one drop into the lower fornix — avoid touching the dropper tip to the eye, eyelids, or any surface to prevent contamination.
Gently close the eye and apply nasolacrimal occlusion (fingertip to the inner corner of the eye) for 1–2 minutes to maximise ocular contact and reduce systemic absorption via the nasolacrimal duct.
If using more than one eye drop, wait at least 5 minutes between each preparation; apply ointments last. Recap the bottle or tube immediately; store at room temperature away from direct heat and light unless otherwise specified.

Contact lens guidance

Do not wear contact lenses during topical steroid therapy unless explicitly instructed by the prescribing ophthalmologist. Steroids suppress corneal immunity and increase risk of microbial keratitis — especially Pseudomonas aeruginosa and Acanthamoeba in CL wearers.
Most steroid formulations contain BAK preservative, which adsorbs onto soft contact lens material and causes direct toxicity to the corneal epithelium.
Advise patients to discard extended-wear lenses used during the inflammatory episode and fit new lenses only after the treating ophthalmologist confirms a quiescent ocular surface and the steroid has been fully tapered.

Monitoring & red-flag referral

IOP monitoring (mandatory): Check IOP at 2 weeks and 4 weeks of any topical steroid course. Discontinue or step down if IOP rises >5 mmHg above baseline or exceeds 21 mmHg. Steroid-responders may show IOP rise within days — patients with a personal or family history of glaucoma are at highest risk.
Lens surveillance: For patients on long-term steroids (>6 weeks), examine for posterior subcapsular cataract formation at each visit. Children are particularly susceptible.
Infection surveillance: Worsening pain, mucopurulent discharge, corneal infiltrate, or dendrite formation during steroid therapy must trigger same-day ophthalmology review — steroids can mask and rapidly accelerate herpetic or bacterial keratitis.
Taper compliance: Counsel patients never to stop steroids abruptly after courses longer than 2 weeks — rebound inflammation can be severe. Follow the prescribed taper schedule precisely.
Red-flag referral (same-day / urgent): New vision loss, hypopyon, corneal oedema, severe pain, IOP >30 mmHg, or any suspicion of herpetic, fungal, or Acanthamoeba infection — refer immediately to the nearest public hospital eye emergency or ophthalmology centre.

Common ophthalmic steroids in Singapore

All agents listed are, or have been, registered with HSA Singapore or are available through registered importers. Verify current product registration and POM status at hsa.gov.sg before referring or recommending any specific product.

Brand (Generic)	Mechanism / Class	Dosing	Min. Age	Side Effects & Precautions	Clinical Notes
FML Fluorometholone 0.1% suspension POM	Low-potency corticosteroid; limited corneal penetration; reduced IOP-raising risk	1 drop BD–QID; taper over 2–4 weeks	≥2 years (with supervision)	Raised IOP, posterior subcapsular cataract, secondary infection risk	First-line topical steroid for conjunctival and episcleral inflammation where deep anterior chamber penetration is not required; lower IOP risk than dexamethasone or prednisolone; shake well before use
FML Forte Fluorometholone 0.25% suspension POM	Low-to-moderate potency corticosteroid; greater anti-inflammatory effect than FML 0.1%	1 drop BD–QID; taper as required	≥2 years (with supervision)	Raised IOP, cataract; higher IOP-raising risk than FML 0.1%	Step-up option for moderate conjunctival or episcleral inflammation where FML 0.1% is insufficient; still limited anterior chamber penetration compared with prednisolone or dexamethasone
Pred Forte Prednisolone acetate 1% POM	High-potency corticosteroid; excellent anterior chamber penetration via corneal epithelium	1 drop every 1–2 hours (acute uveitis) tapering to QID; taper slowly over weeks	≥2 years (with supervision)	Significant IOP elevation, posterior subcapsular cataract, secondary bacterial/fungal/viral infection, delayed wound healing, corticosteroid-induced glaucoma	Gold-standard for anterior uveitis and post-operative inflammation; must be shaken well before use (suspension); mandatory IOP monitoring at 2 and 4 weeks; taper slowly to prevent rebound uveitis; avoid abrupt cessation
Lotemax Loteprednol etabonate 0.5% POM	Retrometabolic soft corticosteroid; rapidly biotransformed to inactive metabolites within ocular tissue, limiting systemic and IOP-related effects	1–2 drops QID; taper over 2–4 weeks	≥18 years	Lower IOP-raising risk vs. prednisolone or dexamethasone; mild transient stinging on instillation; blurred vision	Preferred steroid for steroid-responders, glaucoma suspects, and allergic conjunctivitis requiring topical steroid; HSA-approved for post-operative ocular inflammation; safer profile for moderate-term use; shake well before use
Maxidex Dexamethasone 0.1% drops / ointment POM	High-potency corticosteroid; superior anterior chamber and vitreous penetration; solution formulation provides consistent dosing without shaking	Drops: 1–2 drops 4–6× daily (acute); taper. Ointment: TDS–QID or at bedtime	≥2 years	High IOP-raising potential, cataract, secondary infection; significant steroid-responder risk; ointment may cause transient blurring	Reserved for severe anterior segment inflammation requiring maximum topical potency; available in drop and ointment formulation — ointment is useful for bedtime dosing or periocular/lid disease; IOP monitoring mandatory
Tobradex Tobramycin 0.3% + Dexamethasone 0.1% POM	Steroid–antibiotic combination: aminoglycoside (tobramycin) + high-potency corticosteroid (dexamethasone)	1–2 drops every 4–6 hours initially; taper steroid component over 2–4 weeks	≥2 years	IOP elevation, cataract, risk of masking or worsening occult bacterial/fungal infection, tobramycin resistance with overuse	Indicated when ocular inflammation co-exists with confirmed or high-probability bacterial infection (e.g., post-operative blepharokeratoconjunctivitis, contact-lens-related Pseudomonas risk); not for viral keratitis or suspected fungal infection; both components must be clinically justified — antimicrobial stewardship applies
Maxitrol Neomycin 0.35% + Polymyxin B 6,000 IU/mL + Dexamethasone 0.1% POM	Triple combination: broad-spectrum antibacterial (neomycin + polymyxin B) + high-potency corticosteroid (dexamethasone)	Drops: 1–2 drops 4–6× daily. Ointment: TDS–QID or at bedtime	≥2 years	IOP elevation, cataract, neomycin contact sensitisation (allergy risk up to 8–10%), secondary infection, anaphylaxis (rare)	Post-operative use or severe blepharoconjunctivitis with bacterial risk; neomycin has significant sensitisation potential — avoid in patients with known neomycin allergy or prior sensitisation; available in drop and ointment form; confirm neomycin allergy history before prescribing

Legend

POMPrescription Only Medicine — Sold or supplied to the public on prescription only.

PPharmacy Medicine — Sold or supplied from any licensed retail pharmacy under pharmacist supervision.

OTCGeneral Sales List (GSL) — Sold or supplied to the public without restriction.

Dosing reflects standard adult doses unless noted. Always refer to the approved product insert for full prescribing information. BD = twice daily, TDS = three times daily, QID = four times daily, OD = once daily, PRN = as needed.

References

[1] Jabs DA, Nussenblatt RB, Rosenbaum JT; Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Am J Ophthalmol. 2005;140(3):509–516. PMID: 16196117.
[2] Wong TY, Loon SC, Saw SM. The epidemiology of age related eye diseases in Asia. Br J Ophthalmol. 2006;90(4):506–511. PMID: 16547337. PMC: PMC1857000.
[3] Thong BYH. Allergic conjunctivitis in Asia. Asia Pac Allergy. 2017;7(2):57–64. PMID: 28487836. PMC: PMC5410412.
[4] Republic of Singapore. Optometrists and Opticians Act 2007 (No. 16 of 2007). Singapore Statutes Online. Available at: sso.agc.gov.sg/Act/OOA2007 (accessed March 2026).
[5] George PP, Chng OSY, Siow K, et al. Is there scope for expanding the optometrist's scope of practice in Singapore? A survey of optometrists and opticians. Cont Lens Anterior Eye. 2019;42(3):258–264. PMID: 30819628.
[6] Nussenblatt RB, Palestine AG. Uveitis: Fundamentals and Clinical Practice. 3rd ed. Philadelphia: Mosby; 2004.
[7] Bartlett JD, Horwitz B, Laibovitz R, Howes JF. Intraocular pressure response to loteprednol etabonate in known steroid responders. J Ocul Pharmacol. 1993;9(2):157–165. PMID: 8345288.
[8] Comstock TL, DeCory HH. Advances in corticosteroid therapy for ocular inflammation: loteprednol etabonate. Int J Inflamm. 2012;2012:789623. PMID: 22536546. PMC: PMC3321285.
[9] Abelson MB, Butrus SI, Weston JH. Tolerance and absence of rebound vasodilation following topical ophthalmic decongestant usage. Ophthalmology. 1984;91(11):1364–1367. PMID: 6514297.
[10] Holland EJ, Fingeret M, Mah FS. Use of topical steroids in conjunctivitis: a review of the evidence. Cornea. 2019;38(8):1062–1067. PMID: 31107284.

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