Study Finds No Added Benefit of Corticosteroids or Corneal Cross-Linking in Bacterial Keratitis Treatment

A new study published on July 24 in JAMA Ophthalmology reveals that adjunctive corticosteroids offer no significant visual benefit over placebo in the treatment of bacterial keratitis. Moreover, the addition of corneal cross-linking (CXL) with riboflavin was associated with an increase in corneal scar size, raising questions about the efficacy of these combination treatments when added to standard antibiotic therapy.

Trial Design and Treatment Arms

Led by Dr. N. Venkatesh Prajna of the Aravind Eye Care System in Madurai, India, the randomized, placebo-controlled clinical trial evaluated 280 participants diagnosed with smear- or culture-positive bacterial corneal ulcers with baseline Snellen visual acuity of 20/40 or worse. Patients were randomized into three treatment groups:

       • Standard Therapy Arm: Topical moxifloxacin + placebo + sham CXL

       • Early Steroid Arm: Topical moxifloxacin + difluprednate + sham CXL

       • CXL Arm: Topical moxifloxacin + difluprednate + CXL with riboflavin

Visual Acuity and Scarring Outcomes

The study found no statistically significant improvement in six-month visual acuity with adjunctive topical corticosteroids compared to placebo. Similarly, no added benefit was observed when CXL was combined with corticosteroids, as compared to corticosteroids alone.

Importantly, adjunctive CXL was associated with increased scar size, even after adjusting for baseline infiltrate and scar size. While the incidence of corneal perforation or the need for therapeutic penetrating keratoplasty was lower in both the early-steroid and CXL arms, these differences were not statistically significant.

The researchers concluded:

“Adjunctive topical corticosteroids were not superior to placebo, and adjunctive CXL had increased scar size with more pain, suggesting that these alternative therapies, on average, may not be superior to topical moxifloxacin monotherapy for treatment of bacterial keratitis.”

Reference:

N. Venkatesh Prajna et al, Steroids and Cross-Linking for Ulcer Treatment, JAMA Ophthalmology (2025). DOI: 10.1001/jamaophthalmol.2025.2188