Which postoperative anti-inflammatory agent has the strongest association with steroid-induced intraocular pressure elevation?

• A. Fluorometholone 0.1%
• B. Difluprednate 0.05%
• C. Loteprednol 0.5%
• D. Prednisolone acetate 1%

Answer: (B)

The key idea is that how much a steroid elevates intraocular pressure depends on its potency and how much drug reaches the outflow pathways over time. Steroids raise IOP mainly by reducing the trabecular meshwork’s ability to drain aqueous humor, through changes in the extracellular matrix and cell function that increase resistance to outflow. A drug with high potency and good penetration, especially when delivered in a formulation that stays on the eye longer, will expose the drainage pathways to more active drug and is more likely to cause a steroid response.

Difluprednate 0.05% fits that profile. It is a very potent corticosteroid with strong anti-inflammatory effect and excellent ocular penetration, delivered as an emulsion that prolongs contact with ocular tissues. This combination leads to greater exposure of the trabecular meshwork to the drug, hence a higher risk of steroid-induced IOP elevation compared with the others listed.

Loteprednol etabonate is designed as a soft steroid that is rapidly deactivated in tissues, which lowers the likelihood of IOP rise. Fluorometholone tends to be less potent than difluprednate, and prednisolone acetate, while potent, does not reach the same level of penetration and exposure as difluprednate in typical postoperative regimens. Therefore, difluprednate has the strongest association with steroid-induced IOP elevation.