Corticosteroids not superior to placebo for add-on treatment of bacterial keratitis

For the treatment of bacterial keratitis, adjunctive corticosteroids are not superior to placebo and adjunctive corneal cross-linking (CXL) is associated with increased scar size, according to a study published online July 24 in JAMA Ophthalmology.

N. Venkatesh Prajna, D.O., from the Aravind Eye Care System in Madurai, India, and colleagues examined the benefit of adjunctive topical difluprednate and CXL with riboflavin in addition to topical antibiotics in a placebo-controlled trial involving participants with smear- and/or culture-positive bacterial corneal ulcers with Snellen visual acuity of 20/40 or worse.

Two hundred eighty participants were enrolled and randomly assigned to topical moxifloxacin + topical placebo + sham CXL (standard-therapy arm) versus topical moxifloxacin + difluprednate + sham CXL (early-steroid arm) versus topical moxifloxacin + difluprednate + CXL (CXL arm).

The researchers observed no significant difference in six-month visual acuity with adjunctive topical steroids versus placebo or with adjunctive CXL and topical steroids versus topical steroids alone. After controlling for baseline infiltrate and/or scar size, adjunctive topical corticosteroids did not improve scar size at six months, while CXL plus corticosteroids increased scar size compared with steroids alone. After controlling for infiltrate depth, the risk for perforation or the need for therapeutic penetrating keratoplasty was lower, but not significantly so, in the early-steroid arm and in the CXL arm.

“Adjunctive topical corticosteroids were not superior to placebo, and adjunctive CXL had increased scar size with more pain, suggesting that these alternative therapies, on average, may not be superior to topical moxifloxacin monotherapy for treatment of bacterial keratitis,” the authors write.

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