Steroids for Corneal Ulcers Trial

Thomas M. Lietman500 enrolled

Overview

The purpose of this study is to determine whether adding topical steroids improves the outcomes of bacterial corneal ulcers, especially visual acuity.

Antimicrobial treatment of a bacterial corneal ulcer is generally effective in eradicating infection. However, "successful" treatment is not always associated with a good visual outcome. The scarring that accompanies the resolution of infection leaves many eyes blind. Some cornea specialists advocate the use of topical corticosteroids along with antibiotics in an effort to reduce immune-mediated tissue damage and scarring. Others fear using steroids to reduce the cornea's immune response will prolong or even exacerbate infection. Ophthalmologists have been divided on this issue for more than 30 years, and both approaches are acceptable according to the American Academy of Ophthalmology's Preferred Practice Patterns. Evidence from animal and human reports is mixed. A single randomized trial saw a non-significant benefit to steroids but was drastically underpowered (20 patients per study arm). The study is a randomized, double-masked, placebo-controlled trial to determine whether adding topical steroids improves the outcomes of bacterial corneal ulcers. Five hundred bacterial corneal ulcers presenting to the Aravind Eye Hospitals, the University of California, San Francisco (UCSF) Proctor Foundation, and the Dartmouth-Hitchcock Medical Center will be randomized to receive antibiotic plus steroid or antibiotic plus placebo. Participants will be followed closely until re-epithelialization and then rechecked at three weeks, three months and 12 months post enrollment. A subset of patients will be contacted for a follow-up visit four years post enrollment. The primary outcome is best spectacle-corrected visual acuity three months after enrollment, using best spectacle-corrected enrollment visual acuity as a co-variate. A pilot study was conducted from January 2005 to August 2005 at Aravind Eye Hospital to assess the feasibility and safety and to estimate the sample size of a larger main trial. Forty-two patients with culture-proven bacterial keratitis were enrolled. They were treated and followed up as in the main trial, up to three months from enrollment.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

QUADRUPLE

Enrollment

500

Conditions

Corneal Ulcer Eye Infections, Bacterial

Interventions

AntibioticsDRUG

moxifloxacin 0.5% every one hour for 48 hours while awake and then every 2 hours until re-epithelialization

Topical corticosteroidDRUG

prednisolone phosphate 1% with preservative four times a day for 1 week, then twice a day for 1 week, and finally once a day for 1 week

PlaceboDRUG

0.9% NaCl and preservative (same as in steroid) four times a day for 1 week, then twice a day for 1 week, and finally once a day for 1 week

Eligibility

Sex: ALLMin age: 16 Years

Medical Language ↔ Plain English

Inclusion Criteria At Presentation: * Presence of a corneal ulcer at presentation At Enrollment: * Presence of bacteria on blood or chocolate agar culture * Antibiotic given for \> 48 hours * The patient must be able to verbalize a basic understanding of the study after it is explained to the patient, as determined by physician examiner. This understanding must include a commitment to return for f/u visits. * Appropriate consent Exclusion Criteria At Presentation: * Overlying epithelial defect \< 0.75 mm at its greatest width at presentation * Corneal perforation or impending perforation * Evidence of fungus on KOH, Giemsa at time of presentation * Evidence of acanthamoeba by stain * Evidence of herpetic keratitis by history or exam * Corneal scar not easily distinguishable from current ulcer * Use of a topical steroid in the affected eye during the course of the present ulcer, including use after the symptoms of the ulcer started but before presentation * Use of systemic prednisolone during the course of the present ulcer * Age less than 16 years (before 16th birthday) * Bilateral ulcers * Previous penetrating keratoplasty * Pregnancy (by history or urine test) * Immediate steroid use necessary due to surgery or other condition At Enrollment: * Evidence of fungus on culture at time of enrollment * Absence of bacteria on blood or chocolate agar culture * Best spectacle-corrected vision worse than 6/60 in the fellow eye * Corneal perforation or descemetocele * Known allergy to study medications (steroid or preservative) * No light perception in the affected eye * Not willing to come to follow-up visits * Not willing to participate

Locations (5)

Proctor Foundation, UCSF

San Francisco, California, United States

Dartmouth Hitchcock Medical Center

Lebanon, New Hampshire, United States

Aravind Eye Hospital

Coimbatore, Tamil Nadu, India

Aravind Eye Hospital

Madurai, Tamil Nadu, India

Outcomes

Primary Outcomes

Best Spectacle-corrected Visual Acuity (BSCVA) in logMAR at 3 Months, Using Best Spectacle-corrected Enrollment Visual Acuity as a Co-variate

LogMAR (logarithm of the Minimum Angle of Resolution) is a measure of visual acuity in which the smaller values indicate better visual acuity.

Time frame: 3 months from enrollment

Secondary Outcomes

Infiltrate/Scar Size, Correcting for Infiltrate/Scar Size at Enrollment

Time frame: 3 months from enrollment

Best Hard Contact Lens Corrected Visual Acuity Measured in logMAR, Correcting for Best Spectacle Corrected Visual Acuity at Enrollment

LogMAR (logarithm of the Minimum Angle of Resolution) is a measure of visual acuity in which the smaller values indicate better visual acuity.

Time frame: 3 months from enrollment

Time to Resolution of Epithelial Defect

This outcome measured time from enrollment to resolution of the epithelial defect in days for up to 21 days. For three weeks patients were examined every 3 days for size of epithelial defect until the defect was gone.

Time frame: From enrollment up to 21 days

Ocular Perforations

Time frame: At the time of perforation

Best Spectacle-corrected Visual Acuity (BSCVA) in logMAR at 12 Months, Using Best Spectacle-corrected Enrollment Visual Acuity as a Co-variate

LogMAR (logarithm of the Minimum Angle of Resolution) is a measure of visual acuity in which the smaller values indicate better visual acuity.

Time frame: 12 months from enrollment

Best Spectacle-corrected Visual Acuity (BSCVA) in logMAR Using MIC (Minimum Inhibitory Concentration) to Moxifloxacin as a Covariate

Data from ClinicalTrials.gov

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