research in practice

Steroids and Corneal Ulcers

Should you use steroids when treating infectious corneal ulcers?

Mile Brujic, O.D.,

Crystal Brimer, O.D.

Through the years, a debate has raged: Should we prescribe topical steroids in addition to antibiotics to patients who have bacterial corneal ulcers? To review, proponents of adjunctive steroid therapy claim that once proper anti-infective activity has occurred against the ensuing organism, the addition of a steroid will suppress the immune response and potentially prevent significant scarring. Opponents say the premature introduction of a steroid may increase the duration of the current infection or increase the risk of a recurrent infection.

Recently, a large-scale study showed that the addition of a steroid did not affect clinical outcomes of ulcer resolution when compared with the treatment of antibiotics alone. Further, the study confirmed that adjunctive steroid treatment poses no safety threat when initiated at least 48 hours after effective antibiotic dosing.¹

The supporting research

A researcher reviewed related studies from 1950 to 2000 to determine the overall effect of adjunctive corticosteroid treatment in bacterial keratitis.² Half of the 24 studies he reviewed showed no advantage or disadvantage with utilization of the steroid, 37.5% demonstrated a favorable outcome, and 12.5% verified an unfavorable outcome.³ Other researchers performed a double-masked clinical trial comparing the effect of an adjunct steroid vs. placebo in 42 culture-positive ulcer patients. The reviewing researcher noted delayed re-epithelialization in the steroid group, but found no statistically significant difference in best-corrected visual acuity (BCVA) or scar size after three weeks or three months.⁴ That said, the study was too small to be definitive, so the reviewing researcher repeated the study, collecting 500 cases.

In this study, culture-positive bacterial ulcer patients were treated with one drop of moxifloxacin q.h. while awake during the first 48 hours. They then tapered to one drop in each eye q2h until re-epithelialization, followed by q.i.d. dosing until three weeks after enrollment. After 48 hours of effective antibiotic treatment, patients were randomized to receive either topical prednisolone sodium phosphate 1% or placebo in addition to their antibiotic. The steroid and placebo were each added at q.i.d. dosing for one week, and then tapered to b.i.d. at the start of week two and q.d. at week three.

No statistically significant difference in BCVA or infiltrate scar size was noted between the two treatment groups at three weeks or three months. Nor did re-epithelialization rates show a statistical difference between the two groups.

Subgroup analysis was remarkable. In patients with poor-entering vision (counting fingers or worse), steroid-treated patients had 0.17 better logMAR acuity, which is close to a two-line improvement in vision. The study group patients who had ulcers completely covering the central 4mm of their pupil demonstrated 0.2 better logMAR acuity compared with the placebo group, again a two-line improvement.

What this means for patients

Steroids have long been utilized as the mainstay treatment for patients who have non-infectious infiltrative keratitis. For an infectious keratitis, we now have conclusive resolution to a long debate.

The treatment protocol for most patients with infectious ulcers will be simplified, requiring them to utilize one medication as opposed to two. This can have a dramatic effect on both patient compliance and expense. But those who may appreciate this data the most are those with extremely poor entrance vision and/or large centrally located ulcers. With topical steroid application, these patients may see a two-line improvement in their visual outcome. And now we can confidently prescribe steroids, knowing its safety has been substantiated.

Real world application

For most bacterial ulcer patients, there is no benefit to adjunctive steroid treatment. But for those who have poor entrance vision and /or a 4mm or larger infiltrate encompassing their central cornea, it can be beneficial.

Of course, first you must confirm the success of your antibiotic treatment before prescribing the steroid. We advise that you prescribe a fourth-generation fluoroquinolone q.h. to be used during waking hours, as in the study, for the first 48 hours. Once you verify ulcer resolution is underway, consider prescribing a steroid, and tapering it after one week to maximize visual outcome. Avoid prescribing steroids to patients who may demonstrate poor wound healing, such as the immunocompromised, diabetics or considerable stromal thinning patients.³ OM

1. Srinivasan M, Mascarenhas J, Rajaraman R, et al. Corticosteroids for Bacterial Keratitis: The Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2012 Feb;130(2):143-150. Epub 2011 Oct 10.
2. Wilhelmus KR. Indecision about Corticosteroids for bacterial keratitis: an evidence- based update. Ophthalmology. 2002 May;109(5):835-42.
3. Hindman HB, Patel SB, Jun AS. Rationale for adjunctive topical corticosteroids in bacterial keratitis. Arch Ophthalmol. 2009 Jan; 127(1): 97-102.
4. Srinivasan, Lalitha P, Mahalakshmi R, et al. Corticosteroids for bacterial Corneal ulcers. Br J Ophthalmol. 2009 Feb; 93(2):198-202.