How do we even classify what the ulcer is? How much steroid do we use? Does a steroid even help?
This article briefly covers corneal ulcers and the adjunct treatment with a steroid during the healing process.
Should you use a steroid on a healing corneal ulcer?
The answer: It depends!
I recently had a chat with some colleagues after they had a tricky corneal ulcer case, and they weren’t sure if it was appropriate to start a topical steroid to reduce corneal scarring. It got me thinking about what the studies show. A randomized controlled study [R] helps break down this issue
What the study shows:
The SCUT study showed that there is a benefit of a steroid addition to a corneal ulcer UNLESS
- It is caused by a Nocardia infection.
Well, how do we know it’s caused by Nocardia?
We need further microbial testing to determine the pathogen (gram stain / modified acid-fast stain) aka – you won’t be doing it in office.
The best time to add in a steroid on a corneal ulcer is when
- It’s not caused by a Nocardial infection (great)
- It’s within the first 48-72 hours of AB treatment and the infection is controlled
- The corneal ulcer is LARGE / CENTRAL / SEVERE
Aka, if a corneal ulcer is small and in the periphery the addition of a steroid really won’t do too much. After chatting with some colleagues regarding the topic, they seem to agree with the SCUT study in how they handle corneal ulcers and steroids.
Conclusion: How you should handle a corneal ulcer
Determine if vision threatening (>1.5mm / central / unresponsive to initial treatment)
- you better start two fortified AB q1h!
Borderline vision threatening (1-1.5mm in diameter, mild AC reaction, small infiltrate with epithelial defect)
- add around the clock fourth generation Fluoroquinolones, with a possible overnight ointment (depending on severity)
Small (<1mm) / peripheral ulcers
- Fluoroquinolone Q1H while awake with AB ointment for overnight\
Steroids QID for one week with a taper to borderline vision threatening / vision threatening after the infection has been resolved to prevent scar formation and improve BCVA after recovery.
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