A mid-peripheral corneal ulcer. Steroid therapy would be safe, but not effective.  Image: Joel A. Silbert, O.D.
Should you add a topical steroid when treating a corneal ulcer—or shouldn’t you? On one hand, corticosteroids are thought to reduce immune-mediated damage, and they’ve been shown to be beneficial in some systemic bacterial infections.

On the other hand, you’re submitting the patient to all the risks of a topical steroid for a treatment without proof.

Unfortunately, no large randomized controlled trial has ever been conducted to prove the safety and efficacy of topical steroids in the treatment of bacterial corneal ulcers. Until now.

The Steroids for Corneal Ulcers Trial (SCUT), funded by the National Eye Institute, enrolled 500 patients with corneal ulcers who were first treated with an antibiotic (Vigamox [moxifloxacin 0.5%, Alcon]). Patients were adjunctively given either topical prednisolone sodium phosphate 1.0% or topical placebo.

At three months, patients on the steroid and those on placebo had equal improvement in best spectacle-corrected visual acuity. Also, steroids showed no increased risk of corneal perforation and no increase in intraocular pressure. The researchers concluded that adjunctive use of steroids is essentially safe for patients with bacterial corneal ulcers, but is not effective for improving visual outcomes.

But, there was one intriguing finding: Topical steroid treatment did improve visual acuity in patients with the worst visual acuity and central ulcer location at baseline.

So, “patients with severe ulcers, who have the most to gain in terms of visual acuity, may benefit from the use of corticosteroids as adjunctive therapy,” the authors wrote. “Of interest, physicians may most fear using corticosteroids in these patients.” However, they add, a larger study examining only severe corneal ulcers is needed to confirm this supposition.

Srinivasan M, Mascarenhas J, Rajaraman R, et al; for the Steroids for Corneal Ulcers Trial Group. Corticosteroids for Bacterial Keratitis: The Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol. 2011 Oct 10. [Epub ahead of print]