Ophthalmic Corticosteroid (Ester-Class) Pregnancy: Use with caution — systemic absorption negligible but topical steroids generally avoided in first trimester; consult specialist

Loteprednol Etabonate 0.5%

Brand names: Lotemax, Eysuvis

Adult dose

Dose: Post-operative: 1–2 drops four times daily; Allergic conjunctivitis: 1–2 drops four times daily for up to 14 days

Route: Topical ophthalmic

Frequency: Four times daily (post-op); or as prescribed

Max: 2 drops four times daily

Ester-class steroid — metabolised to inactive metabolites at site of action; lower risk of IOP elevation and cataract formation vs prednisolone or dexamethasone; licensed for post-operative ocular inflammation and allergic conjunctivitis; do not discontinue abruptly post-surgery — taper

Paediatric dose

Route: Topical

Frequency: As directed by specialist

Max: Not formally licensed in children under 18 — specialist use

Used off-label by paediatric ophthalmologists for post-surgical inflammation

Dose adjustments

Renal

No adjustment required (negligible systemic absorption)

Hepatic

No adjustment required

Clinical pearls

Ester vs ketone steroids: loteprednol etabonate is a retrometabolic ester — undergoes predictable deactivation to inactive carboxylic acid at the site of action; this local deactivation limits IOP elevation and cataractogenesis compared to prednisolone or dexamethasone (ketone class) which have more durable systemic and intraocular activity
Post-cataract surgery: increasingly preferred over prednisolone acetate as first-line topical steroid — equivalent anti-inflammatory efficacy with significantly lower risk of IOP spikes (steroid responders); clinically important since most cataract patients are elderly with pre-existing glaucoma or glaucoma risk
IOP monitoring: despite lower risk, IOP should still be monitored in all patients on prolonged topical steroids — 'steroid responder' phenotype affects 30–40% of population; loteprednol reduces but does not eliminate this risk
LASIK/refractive surgery: loteprednol commonly used post-LASIK for 1–4 weeks — lower IOP elevation risk is important as IOP measurement post-LASIK is unreliable due to altered corneal biomechanics; IOP elevation masked by flap could cause glaucomatous damage
Eysuvis (0.25% loteprednol): FDA-approved 2020 specifically for dry eye disease flares — short-term (2 weeks) anti-inflammatory rescue therapy for acute symptomatic flares; different concentration and indication from Lotemax 0.5%

Contraindications

Active viral ocular infection (herpes simplex keratitis)
Fungal ocular disease
Mycobacterial infection
Untreated bacterial infection
Hypersensitivity to loteprednol or benzalkonium chloride

Side effects

Transient blurring of vision
Eye discomfort
IOP elevation (lower risk than prednisolone/dexamethasone)
Posterior subcapsular cataract (rare — less than ketone-class steroids)
Delayed wound healing
Secondary infection

Interactions

Other ophthalmic preparations — administer at least 5 minutes apart
Systemic corticosteroids — theoretical additive HPA suppression (negligible topical systemic absorption)

Monitoring

IOP at baseline and 2–4 weeks
Corneal clarity and wound healing
Intraocular pressure in patients with pre-existing glaucoma
Visual acuity

Reference: BNFc; BNF 90; SPC Lotemax 0.5%; Comstock et al. Ophthalmology 2011; FDA Approval Eysuvis 2020; ESCRS Cataract Surgery Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways