Role of steroids in the treatment of bacterial keratitis

Abstract

Bacterial keratitis can lead to severe visual impairment from corneal ulceration, subsequent scarring, and possible perforation. The mainstay of treatment is topical antibiotics, whereas the use of adjunctive topical corticosteroid drops remains a matter of debate. Herein, we review the rationale for and against the use of topical corticosteroids and we assess their effectiveness and safety in the published randomized controlled trials that have evaluated their role as adjunctive therapy for bacterial corneal ulcers. In the largest study to date, the Steroids for Corneal Ulcers Trial, topical corticosteroid drops were neither helpful nor harmful for the 500 participants as a whole. However, subgroup analyses suggested that topical corticosteroids may be beneficial upon early administration (within 2-3 days after starting antibiotics) for more central corneal ulcers with poorer vision at presentation, for invasive Pseudomonas strains, and for non-Nocardia ulcers. These results are discussed within the limitations of the study.

Keywords: antibiotic; corneal ulcer; endophthalmitis; eye infection; perforation; topical corticosteroids.

Figure 1

Slit lamp photograph of the right eye of 35-year-old contact lens wearer with Pseudomonas keratitis. Notes: (A) At presentation, a suppurative infiltrate encompassing most of the cornea as well as a 3.5 mm hypopyon is seen. (B) One month after treatment with fortified topical antibiotics, cornea collagen cross-linking, amniotic membrane transplantation, and topical corticosteroids, the infiltrate is much smaller and peripheral corneal neovascularization and scarring are observed. (C) Six months later, diffuse scarring limits the patient’s vision. (D) Anterior segment OCT at 1 year shows significant peripheral and central thinning. (E) One year after penetrating keratoplasty, the patient’s vision is 20/60. Abbreviation: OCT, optical coherence tomography.