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Original Investigation | Journal Club

Early Addition of Topical Corticosteroids in the Treatment of Bacterial Keratitis

Kathryn J. Ray, MA1,2; Muthiah Srinivasan, MD3; Jeena Mascarenhas, MD3; Revathi Rajaraman, MD4; Meenakshi Ravindran, MD5; David V. Glidden, PhD2; Catherine E. Oldenburg, MPH1; Catherine Q. Sun, BS1; Michael E. Zegans, MD6,7; Stephen D. McLeod, MD1,8; Nisha R. Acharya, MD1,8; Thomas M. Lietman, MD1,2,8
[+] Author Affiliations
1F. I. Proctor Foundation, University of California, San Francisco
2Department of Epidemiology and Biostatistics, University of California, San Francisco
3Aravind Eye Care System, Madurai, India
4Aravind Eye Care System, Coimbatore, India
5Aravind Eye Care System, Tirunelveli, India
6Department of Surgery (Ophthalmology), Dartmouth Medical School, Lebanon, New Hampshire
7Department of Microbiology and Immunology, Dartmouth Medical School, Lebanon, New Hampshire
8Department of Ophthalmology, University of California, San Francisco
JAMA Ophthalmol. 2014;132(6):737-741. doi:10.1001/jamaophthalmol.2014.292.
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Importance  Scarring from bacterial keratitis remains a leading cause of visual loss.

Objective  To determine whether topical corticosteroids are beneficial as an adjunctive therapy for bacterial keratitis if given early in the course of infection.

Design, Setting, and Participants  The Steroids for Corneal Ulcers Trial (SCUT) was a randomized, double-masked, placebo-controlled trial that overall found no effect of adding topical corticosteroids to topical moxifloxacin hydrochloride in bacterial keratitis. Here, we assess the timing of administration of corticosteroids in a subgroup analysis of the SCUT. We define earlier administration of corticosteroids (vs placebo) as addition after 2 to 3 days of topical antibiotics and later as addition after 4 or more days of topical antibiotics.

Main Outcomes and Measures  We assess the effect of topical corticosteroids (vs placebo) on 3-month best spectacle-corrected visual acuity in patients who received corticosteroids or placebo earlier vs later. Further analyses were performed for subgroups of patients with non-Nocardia keratitis and those with no topical antibiotic use before enrollment.

Results  Patients treated with topical corticosteroids as adjunctive therapy within 2 to 3 days of antibiotic therapy had approximately 1-line better visual acuity at 3 months than did those given placebo (–0.11 logMAR; 95% CI, –0.20 to –0.02 logMAR; P = .01). In patients who had 4 or more days of antibiotic therapy before corticosteroid treatment, the effect was not significant; patients given corticosteroids had 1-line worse visual acuity at 3 months compared with those in the placebo group (0.10 logMAR; 95% CI, –0.02 to 0.23 logMAR; P = .14). Patients with non-Nocardia keratitis and those having no topical antibiotic use before the SCUT enrollment showed significant improvement in best spectacle-corrected visual acuity at 3 months if corticosteroids were administered earlier rather than later.

Conclusions and Relevance  There may be a benefit with adjunctive topical corticosteroids if application occurs earlier in the course of bacterial corneal ulcers.

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