Early Addition of Topical Corticosteroids in the Treatment of Bacterial Keratitis

Ray, Kathryn J.; Srinivasan, Muthiah; Mascarenhas, Jeena; Rajaraman, Revathi; Ravindran, Meenakshi; Glidden, David V.; Oldenburg, Catherine E.; Sun, Catherine Q.; Zegans, Michael E.; McLeod, Stephen D.; Acharya, Nisha R.; Lietman, Thomas M.

doi:10.1001/jamaophthalmol.2014.292

Cited by 51 publications

(32 citation statements)

References 16 publications

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“…Timing of steroid administration also proved to be a significant factor, with patients randomized to corticosteroids after only 2–3 days of antibiotics having better BSCVA at 3 months than those randomized to placebo (approximately 1 line better BSCVA; P =0.01). 62 …”

Section: Bacterial Keratitismentioning

confidence: 99%

Update on the Management of Infectious Keratitis

2017

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Infectious keratitis is a major global cause of visual impairment and blindness, often affecting marginalized populations. Proper diagnosis of the causative organism is critical, and while culture remains the prevailing diagnostic tool, newer techniques such as in vivo confocal microscopy are helpful for diagnosing fungal keratitis and Acanthameoba. Next generation sequencing holds the potential for early and accurate diagnosis even for organisms that are difficult to culture by conventional methods. Topical antibiotics remain the best treatment for bacterial keratitis, and a recent review found all commonly prescribed topical antibiotics to be equally effective. However outcomes remain poor secondary to corneal melting, scarring and perforation. Adjuvant therapies aimed at reducing the immune response responsible for much of the morbidity associated with keratitis include topical corticosteroids. The large, randomized controlled Steroids for Corneal Ulcers trial found that while steroids provided no significant improvement overall, they did appear beneficial for ulcers that were central, deep or large, non-Nocardia or classically invasive P. aeruginosa, patients with low baseline vision, and when started early after the initiation of antibiotics. Fungal ulcers often have worse clinical outcomes than bacterial ulcers, with no new treatments since the 1960’s when topical natamycin was introduced. The randomized controlled Mycotic Ulcer Treatment Trial showed a benefit of topical natamycin over topical voriconazole for fungal keratitis, particularly among those caused by Fusarium. The second Mycotic Ulcer Treatment Trial showed that oral voriconazole did not improve outcomes overall although there may have been some effect among Fusarium ulcers. Given an increase in non-serious adverse events the authors concluded that they could not recommend oral voriconazole at this time. Viral keratitis differs from bacterial and fungal cases in that is often recurrent and is common in developed countries. The first Herpetic Eye Disease Study (HEDS) showed a significant benefit of topical corticosteroids and oral acyclovir for stromal keratitis. HEDS II showed that oral acyclovir decreased the recurrence of any type of HSV keratitis by approximately half. Future strategies to reduce the morbidity associated with infectious keratitis are likely to be multidimensional with adjuvant therapies aimed at modifying the immune response to infection holding the greatest potential to improve clinical outcomes.

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Section: Bacterial Keratitismentioning

confidence: 99%

Update on the Management of Infectious Keratitis

2017

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“…A recent analysis of the SCUT data revealed that participants who were treated with topical corticosteroids within 2–3 days of antibiotic therapy had approximately 1-line better visual acuity at 3 months than those given placebo (p=0.01). In patients who had ≥4 days of antibiotic therapy before corticosteroid treatment, the effect was not significant (p=0.14) 26. In this subanalysis, ulcer severity did not influence whether there was an improvement with earlier steroid use.…”

Section: Topical Corticosteroidsmentioning

confidence: 54%

Established and emerging ancillary techniques in management of microbial keratitis: a review

2016

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Microbial keratitis is a sight-threatening condition and an ocular emergency, because of the potential for rapid progression. Intensive topical antimicrobials are the mainstay and the gold standard of treatment for microbial keratitis. However, despite appropriate diagnosis and therapy, treatment failure is still common, and can result in significant morbidity due to corneal perforation and/or scarring. For this reason, clinicians continue to seek novel treatment techniques in order to expand the armamentarium of tools available to manage microbial keratitis, and in doing so improve clinical outcomes. In this review, we examine the evidence for some established, as well as a few emerging ancillary techniques used to manage microbial keratitis. These include topical corticosteroids, corneal collagen cross-linking, intrastromal antimicrobials, amniotic membrane transplantation and miscellaneous other techniques. Of these, collagen cross-linking shows some promise for selected cases of infectious keratitis, although more research in the area is required before it is accepted as mainstream treatment for this potentially blinding condition.

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“…Another subset suggested that early administration of adjunctive topical corticosteroids may contribute to a better visual outcome in non- Nocardia corneal ulcers 48. Specifically, administering corticosteroids within 2–3 days of presentation was associated with approximately one line of improvement of BSCVA compared with placebo, while receiving corticosteroids 4 days or later after enrolment resulted in no significant difference from placebo.…”

Section: Clinical Trialsmentioning

confidence: 99%

Corticosteroids as a therapy for bacterial keratitis: an evidence-based review of ‘who, when and why’

Tallab

Stone

2016

Br J Ophthalmol

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Corticosteroids have been proposed as an adjunct to antibiotics for the treatment of bacterial keratitis, with significant controversy regarding the appropriate use of this therapy. Recent prospective randomised controlled trials have provided additional evidence to guide clinical decision-making. A review of the epidemiology and mechanisms of pathogenesis, preliminary animal studies, retrospective human studies and prospective randomised clinical trials that address the potential risks and benefits of corticosteroids in patients with bacterial keratitis was performed. Four prospective randomised controlled trials were identified. Three small studies found no benefit of topical corticosteroids, but were underpowered to evaluate adverse events. The Steroids for Corneal Ulcers Trial (SCUT) study and subgroup analyses provide evidence for a relative gain of one line of best spectacle-corrected visual acuity in patients with non-Nocardia bacterial keratitis, especially when corticosteroids were initiated within 3 days of presentation; no increase in adverse events was noted. No evidence was found to support the concern for corneal thinning attributable to corticosteroids in the absence of an inadequately treated infectious process. In patients with culture-proven non-Nocardia bacterial keratitis, corticosteroids provide one line of vision improvement over antimicrobials alone, with no increase in adverse events. This benefit should not be extrapolated to patients with other aetiologies of keratitis, such as fungus, herpes viruses, acanthamoeba or atypical mycobacteria, and these entities should be excluded before considering adjunctive steroid therapy.

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Early Addition of Topical Corticosteroids in the Treatment of Bacterial Keratitis

Abstract: Triamcinolone acetonide (40 mg in 1 mL) was accidentally injected into the optic nerve with a 25-gauge 1-in needle in a 55-year-old woman. Fundus photography of the optic disc showed overlying protruding triamcinolone acetonide suspension (A) and subsequent atrophy 6 months later (B).

Cited by 51 publications

References 16 publications

Update on the Management of Infectious Keratitis

Update on the Management of Infectious Keratitis

Established and emerging ancillary techniques in management of microbial keratitis: a review

Corticosteroids as a therapy for bacterial keratitis: an evidence-based review of ‘who, when and why’

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