Do topical steroids improve visual outcome in the treatment of bacterial keratitis?
Reviewed by Lona Jawaheer

The use of topical corticosteroids as an adjunctive treatment to antibiotics in the management of bacterial keratitis remains a controversial issue. The results of the Steroids for Corneal Ulcers Trial (SCUT) – a randomised, double-masked, placebo-controlled trial that recruited patients at two US centres and one centre in India – were published in 2012 and showed that adding topical corticosteroids to topical moxifloxacin hydrochloride in bacterial keratitis did not appear to have a beneficial effect on best spectacle corrected visual acuity (BSCVA) at three months. The authors of this article hypothesised that the trial did not take into account the timing of the corticosteroid / placebo treatment with respect to the start of the antibiotic drops, and that the true effect of corticosteroid treatment could therefore have been masked. The improvement in BSCVA at three months was calculated in the groups that received corticosteroids / placebo early (within two to three days of starting antibiotics) or late. In the early group, use of corticosteroids was associated with a –0.11 logMAR BSCVA improvement (n=311; 95%CI, –0.20 to –0.02; P=.01) compared with placebo group. In the late group, corticosteroid treated patients had one-line worse visual acuity than did the placebo-treated patients, although this effect was not significant (n=139; 0.10 logMAR; 95%CI, –0.02 to 0.23; P=.14). The benefit of early administration of corticosteroids was maintained for mild, moderate and severe ulcers. When patients with Nocardia keratitis were excluded from the multiple linear regression model, corticosteroids were beneficial when administered earlier and neutral when administered later. Corticosteroids have been shown to adversely affect outcome in cases of fungal or Acanthamoeba keratitis. In the SCUT trial, patients with Nocardia keratitis were also adversely affected by corticosteroids. Therefore, it is important to be certain of the diagnosis prior to starting corticosteroids. These results suggest that early administration of corticosteroids in bacterial corneal ulcers might result in a better visual outcome for the patient.

Early addition of topical corticosteroids in the treatment of bacterial keratitis.
Ray KJ, Srinivasan M, Mascarenhas J, et al.
JAMA OPHTHALMOLOGY
2014;132(6):737-41.