Steroids for keratitis?

Concern that corticosteroids may slow healing or worsen infections has made their use in treating corneal bacterial ulcers controversial for decades. But with up to one-quarter of bacterial keratitis patients ending up with <20/200 best corrected visual acuity, controlling scarring is also critical. Recent research suggests corticosteroids may be useful for treating the worst bacterial corneal ulcers and are most effective when used early, Thomas M Lietman MD told the American Academy of Ophthalmology 2017 Annual Meeting in New Orleans, USA. In the Steroids for Corneal Ulcers Trial (SCUT) conducted by Dr Lietman and his team at the University of California – San Francisco, USA, Dartmouth-Hitchcock Medical Center in New Hampshire, USA, and Aravind Eye Hospitals in India, 500 patients with culture-confirmed bacterial keratitis were treated with moxifloxacin for 48 hours, and then received either 1.0% prednisolone phosphate or a placebo on a tapering dose. Overall, mean visual acuity at three months was nearly equal in the treatment and placebo arms, with the treatment group less than one letter better, Dr Lietman reported. The only significant differences in adverse events were minor, with more steroid patients experiencing late re-epithelialisation (P=0.04), and, contrary to expectations, more placebo patients experiencing IOP spikes (P=0.04) (Arch Ophthalmol. 2012 Feb;130(2):143-50). STEROIDS ADVANTAGEOUS IN SOME CASES By organism, patients with pseudomonas infections in the steroid group had about one-half line better visual acuity with steroids, though the difference was not significant, while those with nocardia infections had about one line worse than placebo at three months. Removing nocardia cases from the mix, the steroid group overall had significantly better visual acuity at one year than the placebo group, Dr Lietman said. Patients with the most severe ulcers, whether measured by visual acuity of <20/400, ulcer depth or central location, did 1.7 lines better with steroids (P=0.03). Patients who began treatment at 48 hours after antibiotics were initiated also did better by 1.1 lines (P=0.01) than a subgroup that started 72 hours or more after antibiotics. “So that case that we’d all be scared of, that central pseudomonas ulcer, may be exactly the case where you want to use steroids, and you might want to add them early,” Dr Lietman said. Dr Lietman cautioned that all SCUT cases were proven bacterial in culture, and had no evidence of fungal, acanthamoeba or herpes involvement. “If you use steroids and it’s not bacterial you can get in trouble. But if bacteria grow on culture I think you can feel comfortable using steroids; or if you don’t want to you can defend that, too.” Thomas Lietman: tml@itsa.ucsf.edu

Tags: keratitis