Prospective, Randomized Clinical Trial of
Povidone-Iodine 1.25% Solution Versus Topical
Antibiotics for Treatment of Bacterial Keratitis
SHERWIN J. ISENBERG, LEONARD APT, MARIO VALENTON, SAVITRI SHARMA, PRASHANT GARG,
PHILIP A. THOMAS, PRAGYA PARMAR, JAYARAMAN KALIAMURTHY, JOHANN M. REYES, DANIEL
ONG, PETER D. CHRISTENSON, MADELINE DEL SIGNORE, AND GARY N. HOLLAND
PURPOSE: To compare povidone-iodine 1.25%
ophthalmic solution with topical antibiotics for treatment
of bacterial keratitis in areas of the world where use of
effective topical antibiotics may not be an option.
STUDY DESIGN: Randomized, controlled, investigator-
masked clinical trial.
METHODS: We randomized 172 individuals with bacte-rial
keratitis to topical treatment with povidone-iodine or
antibiotics (neomycin–polymyxin B–gramicidin in the
Philippines; ciprofloxacin 0.3% in India). Using survival
analysis, we compared intervals from start of treatment to
‘‘presumed cure’’ (primary outcome measure, defined as a
closed epithelial defect without associated inflammatory
signs) and to ‘‘recovering’’ (residual epithelial defect
2
<1 mm with only minimal inflammation).
RESULTS: Median interval to presumed cure in the
Philippines was 7 days for povidone-iodine and 7 days
for neomycin–polymyxin B–gramicidin (95% confidence
interval [CI] for difference in median interval, L9.5 to 0.7
days) and in India was 12 days for povidone-iodine and
17 days for ciprofloxacin (95% CI, L35.2 to 3.2 days).
Hazard ratio (HR) for presumed cure among those
treated with povidone-iodine (vs antibiotics) was 1.46 in
the Philippines (95% CI, 0.90–2.36; P [ .13) and 1.70 in
India (95% CI, 0.73–3.94; P [ .22). Com-parisons of
intervals to recovering and HR for recovering also
revealed no significant differences between treatment
groups in either country.
CONCLUSIONS: There is no significant difference be-
tween the effect of topical povidone-iodine 1.25% and
topical antibiotics commonly available in the developing
Supplemental Material available at AJO.com.
See Accompanying Editorial Article on page xv.
Accepted for publication Oct 12, 2016.
From the Center To Prevent Childhood Blindness (S.J.I., L.A.)
and the Ocular Inflammatory Disease Center (G.N.H.), UCLA
Stein Eye Institute, and the Departments of Ophthalmology (S.J.I.,
L.A., G.N.H.) and Medicine (P.D.C.), David Geffen School of
Medicine at UCLA, Los Angeles, California; the Los Angeles
Biomedical Research Institute at Harbor-UCLA Medical Center,
Torrance, California (S.J.I., P.D.C., M.D.S.); the Philippine General
Hospital, Manila, Philippines (M.V., J.M.R., D.O.); the L.V. Prasad
Eye Institute, Hyderabad, India (S.S., P.G.); and the Joseph Eye
Hospital, Tiruchirapalli, India (P.A.T., P.P., J.K.).
Inquiries to Gary N. Holland, UCLA Stein Eye Institute, 100 Stein Plaza,
UCLA, Los Angeles, CA 90095-7000; e-mail: uveitis@jsei.ucla.edu
244 PUBLISHED BY ELSEVIER INC.
world for treatment of bacterial keratitis. Povidone-iodine
1.25%, which is widely available and inexpensive, can be
considered for treatment of bacterial keratitis when
antibiotic treatment is not practical. (Am J Ophthalmol
2016;176:244–253. Published by Elsevier Inc.)
I NFECTIOUS KERATITIS IS AN IMPORTANT CAUSE OF
blindness in the developing world, where a number of factors,
including malnutrition with vitamin A defi-ciency, substantially
increase the risk of corneal infection. In India, for example,
corneal disease, much of which is in-fectious keratitis, is 1 of
the top 10 causes of visual impair-ment, regardless of sex,
age, or socioeconomic factors.1 The problem is especially
severe in children; corneal scarring has traditionally been
considered to be the most common
reason for avoidable blindness in children worldwide.2,3
For antimicrobial agents to reduce the burden of infec-
tious keratitis in resource-poor areas of the world, they
must meet certain criteria, including effectiveness against
a broad spectrum of organisms, a favorable safety profile,
ease of preparation, and minimal expense. Studies
suggest that povidone-iodine meets these criteria. With
rare exception, it is effective against all bacteria, viruses,
and fungi in vitro, given sufficient contact time; true
bacterial resistance to povidone-iodine probably does not
exist.4 With regard to safety, povidone-iodine has been
associ-ated with few allergic reactions. In previous studies,
povidone-iodine ophthalmic solution was shown to be
effective for prophylaxis against infection when used dur-
ing preoperative preparation or as a postoperative antimi-
crobial treatment.5,6 A study in Kenya showed that
povidone-iodine ophthalmic solution was an effective
prophylactic agent for prevention of ophthalmia neonato-
rum.7 In a randomized controlled trial to investigate its use
for treatment of infectious conjunctivitis, povidone-iodine
ophthalmic solution appeared to be as effective as
antibiotics for bacterial cases and was more effective
against chlamydia.8
In this study, we investigated whether povidone-iodine
1.25% ophthalmic solution could be used to treat bacterial
keratitis, by comparing its efficacy to topical antibiotics in
prospective, randomized clinical trials conducted in the
Philippines and in India. If shown to be effective, it
0002-9394/$36.00
http://dx.doi.org/10.1016/j.ajo.2016.10.004
potentially could decrease the incidence of corneal
scarring and vision loss in many parts of the world.
METHODS
THIS STUDY WAS APPROVED BY THE HUMAN SUBJECTS PRO-
tection Committee of the Los Angeles Biomedical
Research Institute at Harbor-UCLA Medical Center and by
the institutional review boards at each participating hos-
pital before initiation of the study. Subjects or their parents
or guardians provided written informed consent in their
native languages. Assent was also obtained from subjects
18 years old and younger. The clinical trial conformed to
the tenets of the Declaration of Helsinki, and was regis-
tered at clinicaltrials.gov (registration number:
NCT00386958; URL: https://register.clinicaltrials.gov).
Sample size calculations were based on a pilot study of
individuals in Manila meeting inclusion criteria for the
current study and treated with neomycin–polymyxin B–
gramicidin; median time to achieving criteria of the pri-mary
outcome measure for the proposed study was 7 days. It
was assumed that the median time for ciprofloxacin would
be identical. Calculations planned for separate compari-
sons of the primary outcome measure between
investigative and control subgroups in both countries, for a
total of 4 study arms. It was determined that 40 study
participants per arm (160 total study participants) would
provide at least 80% power to detect differences in 10-day
cumulative probabilities of reaching the study endpoint of
at least 0.32 in each country, corresponding to a hazard
ratio of 2.7, at a .05 level of significance.
PATIENT POPULATIONS: Recruitment of study partici-pants
began in November 2002; all follow-up examinations were
complete in January 2006. Inclusion criteria were age >1
month; keratitis duration (as reported by the patient or family)
<14 days; no prior treatment of the keratitis; and an epithelial
defect 2–8 mm in greatest dimension that did not extend to the
limbus. The presence of bacteria had to be confirmed by
culture or by microscopic examination of corneal scrapings
using gram stain within 24 hours of study entry for continued
participation. Exclusion criteria were treatment with topical or
systemic corticosteroid or immunosuppressive drugs within 14
days of study entry; corneal perforation or impending
perforation (based on the judgment of the treating
ophthalmologist); presence of dacryocystitis, neurotrophic
keratopathy, exposure keratitis, or keratitis sicca; human im-
munodeficiency virus infection; blindness of the unaffected
eye; and allergy or intolerance to povidone-iodine, iodine, or
the study antibiotics (by study site).
STUDY PROCEDURES AND DATA COLLECTION: To maximize
uniformity between study sites, all investigators met in
Manila, Philippines, to agree on standardized
VOL. 176 TRIAL OF POVIDONE-IODINE TREATMENT FOR BACTERIAL KERATITIS
examination techniques, culture techniques, and data
reporting. Standardized dosing regimens and follow-up
schedules (described in detail in Supplemental Text avail-
able at www.ajo.com) were selected by consensus, based
on standards of care at each of the study centers. The
study sites were visited by the principal investigator (S.J.I.)
dur-ing recruitment to insure consistency between sites.
Eyes with infectious keratitis were randomized to
receive either topical povidone-iodine 1.25% or the control
topical antibiotic, based on the study site, as described
below. Stratified randomization by involved eye was
performed, based on location and age group (<18 years of
age vs >18 years of age), using lists generated before
study initiation. Corneal foreign bodies were removed
before treatment.
Povidone-iodine 1.25% solution (Purdue Frederick,
Norwalk, Connecticut, USA) was prepared by dilution, us-
ing balanced salt solution (Alcon Laboratories Inc, Fort
Worth, Texas, USA). Control antibiotics were based on
standards of care at each site at the time of the study. In
the Philippines, neomycin–polymyxin B–gramicidin
ophthalmic solution (Bausch & Lomb Pharmaceuticals,
Tampa, Florida, USA) was used; at the 2 Indian sites
(Hyderabad and Tiruchirapalli), ciprofloxacin 0.3%
ophthalmic solution (Ciprodac, Cadila Pharmaceuticals
Ltd, Ahmedabad, India) was used. The only other eye
medication that was permitted was atropine ophthalmic
solution (Akorn, Inc, Buffalo Grove, Illinois, USA),
administered to the affected eye(s) twice daily. Concentra-
tions were based on age, as follows: 0.25% solution for
patients aged <1 year; 0.5% solution for ages 1–3 years;
and 1% for ages 3 years and older.
All patients were hospitalized for at least 7 days, as was
customary at the study sites during the period of the study.
To ensure compliance, all medications were administered
by study nurses. Each application of drug was recorded,
and records were subsequently reviewed by study
personnel. Physicians and microbiologists were masked to
treatment assignment during the course of the study;
because study nurses applied medications well before the
daily eye exam-inations, physicians had no opportunity to
see the transient brown color imparted by povidone-iodine.
At daily eye examinations the following variables were
assessed: visual acuity; pain; associated ocular surface
and adnexal inflammatory signs (discharge, chemosis,
redness, eyelid swelling); corneal signs (epithelial defect,
size of stromal infiltrate, tissue loss, tissue firmness,
keratic precip-itates); and anterior chamber cells.
Standardized scores were used for each variable
(Supplemental Table 1, avail-able at www.AJO.com). A
daily status assessment was made on the basis of
examination findings; study eyes were categorized as
‘‘failure,’’ ‘‘worsening,’’ ‘‘persistence,’’ ‘‘improving,’’ or
‘‘presumed cure.’’ In post hoc analyses, some patients
were reassigned a score of ‘‘recovering’’ at last
examination, as described below. Criteria for each cate-
gory are outlined in the Supplemental Material (available at
www.ajo.com).
245
 Within the first 48 hours, if there was either deteriora-
tion in all study variables or appearance of a
descemetocele, then treatment was changed and the
patient was removed from the study, as outlined in our
dosing and follow-up schedules (Supplemental Text,
available at www.ajo. com). After 48 hours, treatment
was changed and the pa-tient removed from the study
when a status of ‘‘failure’’ was assigned. If the status of
a study eye was not improved or better by day 10 of
treatment, the patient was also removed from the study.
Therapy after removal from the study was based on
best medical judgment. Change in epithelial defect size
alone was never used to make treat-ment decisions.
DATA ANALYSIS AND STATISTICAL TECHNIQUES: Data
from the Philippines and from India were considered sepa-
rately. Intercenter differences between the 2 study sites in
India were not considered, as both are located in the
south-ern part of the country and were believed to see a
similar spectrum of disease. In the primary analysis, we
used the Kaplan-Meier technique to compare times to
presumed cure between study participants receiving
povidone-iodine and those receiving the control antibiotic
in each country. The Kaplan-Meier technique was also
used to es-timate the probability of presumed cure for each
subgroup at 10 days of treatment, the time at which study
partici-pants without improvement were censored.
Several secondary comparisons were performed.
Because some patients left the hospital and were lost to
follow-up before the primary study endpoint was achieved,
use of the post hoc outcome measure ‘‘recovering’’ allowed
us to compare patients at discharge for a beneficial
treatment ef-fect, based on criteria that are often used
clinically for plan-ning hospital discharge (Supplemental
Material at www. ajo.com). The same Kaplan-Meier
analyses described above were repeated using recovering
as the outcome var-iable.
Despite potential problems associated with comparing
proportions between groups when there is differential
9,10
case follow-up, we felt that it was acceptable to
compare last examinations as an interval analysis,
because most patients’ last examinations occurred at a
fairly uniform time point in the course of treatment: at
discharge, between days 7 and 10 of treatment. In one
comparison, we assumed that patients lost to follow-up
never achieved the primary outcome, and the proportion of
study participants who had achieved the status of pre-
sumed cure were compared between treatment arms,
using the Fisher exact test. In a similar interval
comparison, the proportions of study participants who had
achieved the sta-tus of recovering or presumed cure by
last examination were compared between treatment arms.
In a risk factor analysis using Cox proportional hazards
models, we investigated the effect of the following host and
disease factors on the primary outcome measure (status of
presumed cure): sex, age, laterality, visual acuity, gram
246 AMERICAN JOURNAL OF OPHTHALMOLOGY
stain characteristic, ulcer size, ulcer depth, and inflamma-tion
score. Those factors that were significantly associated with the
primary outcome variable in univariable compar-isons were
then included in multivariable regressions to determine the
influence of those factors on the relationship between
povidone-iodine and presumed cure, and to deter-mine the
independence of each factor’s effect. Subgroup analyses were
also performed in which the relationship be-tween povidone-
iodine and presumed cure was determined for study
participants grouped on the basis of ulcer size. Hazard ratios
>1 favored treatment with povidone-iodine.
RESULTS
A TOTAL OF 413 INDIVIDUALS WERE SCREENED FOR THE
study from 2002 through 2006, 172 of whom were random-
ized to be treated with either povidone-iodine (40 individ-
uals in the Philippines, 38 in India) or the control antibiotic
(49 in the Philippines; 45 in India). The Supplemental
Figure (Supplemental Material available at www.ajo.com)
provides detailed information about screening, enrollment,
and treatment groups in a Consoli-dated Standards for
Reporting Trials flow diagram. The rea-sons that 241
screened individuals did not reach randomization (125
individuals in the Philippines, 116 in India) include the
following: lack of organisms seen on initial corneal
scraping (n ¼ 159, 66%); ulcer size (n ¼ 23, 9.5%);
duration of keratitis (n ¼ 15, 6.3%); corneal or scleral
perforation (n ¼ 23, 9.5%); or a combina-tion of these
reasons (n ¼ 21, 8.7%). Of those with multi-ple reasons for
exclusion, 6 also had evidence of fungal infection (hyphae
observed on initial corneal scraping). Demographic,
medical, and ophthalmic data for study par-ticipants are
included in Table 1. In the Philippines, 11 study participants
were less than 18 years of age; in India, 5 study
participants were less than 18 years of age. Supplemental
Table 2 (Supplemental Material available at AJO.com) lists
the causal bacteria for groups based on treatment
assignment and study site. The 3 most common bacteria
isolated from study eyes in the Philippines were various
Moraxella species (n ¼ 44, 49%), Pseudomonas aeru-
ginosa (n ¼ 12, 13%), and Staphylococcus aureus (n ¼
10, 11%); in India, they were Streptococcus pneumoniae
(n ¼ 18, 21%), Pseudomonas aeruginosa (n ¼ 17, 20%),
and Staphylococcus epidermidis (n ¼ 13, 16%). There
were signif-icantly more Moraxella spp. infections in the
Philippines (44 of 89 cases [49%]) than in India (2 of 83
cases [2.4%], P < .0001).
Median corneal ulcer size was 2.75 mm 2. For study pur-
poses, we considered ulcers larger than the median area
to be large. There were significantly more large ulcers at
presentation among study participants in India (n ¼ 55,
66%) than among study participants in the Philippines (n ¼
32, 36%; P < .0001). In India, the mean ulcer size
APRIL 2016
 TABLE 1. Demographic and Clinical Characteristics for 172 Individuals Enrolled in a Randomized Clinical Trial of Treatment for Bacterial
Keratitis With Povidone-Iodine or Topical Antibiotics at Sites in the Philippines and India

Philippines Site India Sites

Characteristic Povidone-Iodine (N ¼ 40) Neomycin–Polymyxin B–Gramicidin (N ¼ 49) Povidone-Iodine (N ¼ 38) Ciprofloxacin (N ¼ 45)

Male sex (n [%]) 34 (85%) 39 (80%) 27 (71%) 28 (62%)

Proportion right eyes (n [%]) 19 (48%) 19 (39%) 20 (53%) 21 (47%)
Age in years (mean 6 SD) 34 6 15 36 6 18 46 6 19 40 6 18
Preexisting disease
Corneala (eyes [%]) 0 1 (2%) 5 (13%) 6 (13%)
b 1 (3%) 2 (4%) 1 (3%) 5 (11%)
Other ocular (eyes [%])
Systemicc (patients [%]) 0 2 (4%) 2 (5%) 2 (4%)

a
Corneal diseases included the following: preexisting corneal scars (n ¼ 6); spheroidal degeneration (n ¼ 2); aphakic corneal edema (n ¼
1); keratoconjunctivitis sicca (n ¼ 1); neurotrophic keratitis associated with herpes zoster ophthalmicus (n ¼ 1); corneal graft (n ¼ 1).
b
Other ocular diseases included the following: chronic narrow-angle glaucoma (n ¼ 1); blepharitis/recurrent hordeola (n ¼ 4); cataract (n ¼ 2);
status post lensectomy, vitrectomy, and retinal detachment repair with scleral buckling following trauma (n ¼ 1); lagophthalmos (n ¼ 1).
c
Systemic diseases included the following: diabetes mellitus (n ¼ 3); rheumatoid arthritis (n ¼ 1); hypertension (n ¼ 1); Hansen disease (n ¼ 1).

TABLE 2. Outcomes of Presumed Cure and Recovering for Bacterial Keratitis of 172 Eyes Grouped by Study Site and Randomized
Treatment Assignment

Presumed Curea Recoveringb

Philippines Site India Sites Philippines Site India Sites

c
Median intervals to event (days)
Povidone-iodine 7 12 5 9
Antibioticd 7 17 5 10
95% CIe 9.5 to 0.7 35.2 to 3.2 4.3 to 1.4 11.7 to 3.2
Povidone-iodine (vs antibiotic)
HR for event 1.46 1.70 1.16 1.20
95% CI 0.90–2.36 0.73–3.94 0.72–1.85 0.63–2.2
P valuef .13 .22 .54 .59

CI ¼ confidence interval; HR ¼ hazard ratio.

a
Primary outcome measure; presumed cure was defined as closure of the associated epithelial defect and the absence of inflammatory
signs other than minimal injection.
b
Determined in post hoc analysis, as a means of comparing the speed with which improvement occurred; recovering defined as the
presence of a residual epithelial defect no larger in area than 1 mm 2, no more than moderate injection, and no more than a score of mild for
all other in-flammatory signs. Patients were often discharged from the hospital when the status of recovery was achieved.
c
Interval from start of treatment to event.
d
Neomycin–polymyxin B–gramicidin at the Philippines site and ciprofloxacin at the India sites.
e
95% CI for the difference in days to event, calculated by subtracting the median interval for the antibiotic treatment group from the medial
interval for the povidone-iodine treatment group; negative values indicate shorter intervals to event for the povidone-iodine treatment group.
f
Cox proportional hazards survival analysis.

2
at discharge was 3.7 6 1.4 mm for study participants
2
treated with povidone-iodine and 3.8 6 1.5 mm for
con-trols.
Seven study participants were not followed until hospital
discharge (1 in the Philippines, who was removed from the
study when dacryocystitis was diagnosed (povidone-iodine
group) and 6 in India (5 in the povidone-iodine group, 1 in
the ciprofloxacin group), all of whom chose not to continue
the study for personal reasons). There were no statistically
significant differences in the prevalence of
participants discontinued from the study before
hospital discharge be-tween the 4 study arms.
Table 2 shows analyses related to outcomes of presumed
cure and recovering. Hazard ratios for each outcome favored
povidone-iodine, both in the Philippines and in In-dia, although
differences were not significant. The Figure shows a Kaplan-
Meier analysis for presumed cure between treatment arms in
each country. In the Philippines, the

VOL. 176 TRIAL OF POVIDONE-IODINE TREATMENT FOR BACTERIAL KERATITIS 247


FIGURE. Kaplan-Meier plot showing cumulative probability
of presumed cure for 172 clinical trial participants with
bacterial keratitis, grouped by study site and randomized
treatment as-signments. There was no statistically
significant difference be-tween treatments at each site (P
[ .13 for the Philippines site; P [ .22 for the India sites).
10-day probability of presumed cure for study participants
treated with povidone-iodine was 0.91 (95% confidence in-
terval [CI], 0.76–0.98); for study participants treated with
neomycin–polymyxin B–gramicidin, it was 0.86 (95% CI,
0.73–0.95). In India, the 10-day probability of presumed
cure for participants treated with povidone-iodine was 0.38
(95% CI, 0.21–0.62); for participants treated with cip-
rofloxacin, it was 0.14 (95% CI, 0.05–0.34). Overall, the
presumed cure rate was superior in the Philippines when
compared with India (10-day presumed cure probabilities
of 0.88 vs 0.25, respectively, P < .0001).
Table 3 shows the proportion of study participants
achieving endpoints during the course of follow-up (a score
of presumed cure or failure) and, for those not achieving
an endpoint, the scores that had been assigned at hospital
discharge or last examination before loss to follow-up. In a
secondary analysis, we assumed that all study participants
who were lost to follow-up or had not achieved the primary
study outcome measure by the time of hospital discharge
never achieved cure, while those with scores of presumed
cure did in fact have eradication of infection. In this
analysis, 30 of 40 individuals (75.0%) treated with
povidone-iodine and 39 of 49 individuals (80%) treated
with neomycin–polymyxin B–gramicidin in the Philippines
achieved cure (P ¼ .62), as shown in Table 3. In the same
analysis, 12 of 38 individ-uals (32%) treated with povidone-
iodine and 10 of 45 in-dividuals (22%) treated with
ciprofloxacin in India achieved cure (P ¼ .45). There was
also no statistical dif-ference in the proportion of study
participants achieving a score of at least recovering
(recovering or presumed cure) before loss to follow-up or
hospital discharge (P ¼ .41 in the Philippines; P > .99 in
India). When we compared those with some evidence of
improvement before loss to
248 AMERICAN JOURNAL OF OPHTHALMOLOGY
follow-up or discharge (scores of improved, recovering,
or presumed cure) between treatment groups, there
was a significant difference in the Philippines (32 of 40
[80%] of study participants treated with povidone-iodine
vs 47 of 49 [96%] treated with neomycin–polymyxin B–
grami-cidin [P ¼ .04]), attributable to a higher proportion
of treatment failures in the povidone-iodine treatment
group; however, there was no significant difference
between treat-ment groups in India (P ¼ .62).
There were a total of 14 treatment failures. In the
Philippines, 7 of 40 study participants (18%) who received
povidone-iodine failed treatment (5 with Moraxella spp. in-
fections, 1 Streptococcus pneumonia infection, and 1 with
Pseudomonas aeruginosa infection), while 1 of 49 who
received neomycin–polymyxin B–gramicidin failed treat-
ment (infected with Moraxella sp.). In India, 2 study partic-
ipants who received povidone-iodine failed treatment (1
with Pseudomonas aeruginosa infection, 1 with Strepto-
coccus pneumoniae infection), while 4 who received cipro-
floxacin failed treatment (3 with Pseudomonas aeruginosa
infections; 1 with Streptococcus pneumoniae infection).
Supplemental Table 3 (Supplemental Material available
at AJO.com) shows the proportion of eyes with gram-
positive bacterial infections and the proportion of eyes with
gram-negative bacterial infections that were pre-sumed
cured or that achieved a score of recovering by last
examination. There was no overall statistically signifi-cant
difference in treatment effect based on whether infect-ing
bacteria were gram-positive or gram-negative. In the
Philippines, however, the proportion of gram-negative
bacterial infections that achieved scores of recovering or
presumed cure were lower for eyes treated with providone-
iodine (15 of 23 cases [65%]) than for eyes treated with
neomycin–polymyxin B–gramicidin (32 of 35 cases [91%],
P ¼ .029, Fisher exact test).
Table 4 shows relationships of host and disease factors
that might influence the outcome of presumed cure in each
country. In univariate comparisons, eyes with large ulcers
were less likely to achieve a score of presumed cure
during the period of study in both countries. Also, eyes of
subjects with visual acuity worse than 0.05 were less likely
to achieve scores of presumed cure during the period of
study than those with visual acuity better than 0.30,
although the association was borderline in India.
In multivariable regressions, hazard ratios for
povidone-iodine treatment were attenuated slightly after
adjusting for ulcer size (1.40 in the Philippines, 1.56 in
India), but not after adjusting for visual acuity (1.46 in
the Philippines; 1.89 in India). Eyes with poorer visual
acuity tended to have larger ulcers, and poorer visual
acuity lost its statistical association with lack of
presumed cure, after adjustment for ulcer size.
In subgroup analysis, hazard ratios for povidone-iodine
treatment in the Philippines were 1.34 (95% CI: 0.74–
2.43) for smaller ulcers and 1.53 (95% CI: 0.65–3.56) for
larger ulcers (P ¼ .80 for interaction). In India, the
APRIL 2016
 TABLE 3. Status of Bacterial Keratitis at Most Recent Examination for 172 Eyes Categorized by Study Site and Randomized Treatment
Assignment

Philippines Site India Sites

Status Povidone-Iodine (N ¼ 40) Neomycin–Polymyxin B–Gramicidin (N ¼ 49) Povidone-Iodine (N ¼ 38) Ciprofloxacin (N ¼ 45)

Presumed curea 30 (75%) 39 (80%) 12 (32%) 10 (22%)

b 1 (2.5%) 4 (8%) 7 (18%) 11 (24%)
Recovering
Improvingc 1 (2.5%) 4 (8%) 8 (21%) 14 (31%)
Persistenced 1 (2.5%) 1 (2%) 3 (8%) 3 (7%)
Worsenede 0 0 6 (11%) 2 (4%)
Failuref 7 (18%) 1 (2%) 2 (5%) 4 (9%)
Dropped outg 0 0 0 1 (2%)

a
Primary outcome measure; presumed cure was defined as closure of the associated epithelial defect and the absence of inflammatory
signs other than minimal injection.
b
Determined in post hoc analysis, as a means of comparing the speed with which improvement occurred; recovering defined as the
presence of a residual epithelial defect no larger in area than 1 mm 2, no more than moderate injection, and no more than a score of mild for
all other in-flammatory signs. Patients were often discharged from the hospital when the status of recovery was achieved.
c
Improving was defined as a lack of additional melt over 2 examinations and a quantitative decrease in severity of the following factors
since baseline: infiltrate, inflammation, and epithelial defect.
d
Persistence was defined as all cases with any sign of active keratitis that did not fulfill criteria for status of recovered, improved,
worsened, or failed.
e
Worsened was defined as a deterioration in any factor.
f
Failure was defined as a deterioration in 2 or more signs of inflammation or increase in size or additional melt on 2 consecutive daily
exam-inations after 48 hours of treatment. Failure required a change in therapy.
g
Individual who chose not to participate in the clinical trial after randomization but before start of assigned treatment.

TABLE 4. Associations Between Host or Disease Factors and Cure of Bacterial Keratitis for 172 Individuals Treated in a Randomized
Clinical Trial and Categorized by Study Site

Philippines Site India Sites

Factor HRa 95% CIa P Value HRa 95% CIa P Value

Sex (male vs female) 0.91 0.46–1.71 .77 1.09 0.45–2.62 .86

Age (>18 y vs < 18 y) 1.11 0.47–2.59 .82 0.31 0.07–1.43 .13
Affected eye (right vs left) 1.19 0.74–1.90 .48 0.84 0.34–2.09 .71
Visual acuity
0.30 to 1.6b 1.00 1.00
0.05 to 0.29 1.10 0.59–2.06 .76 0.53 0.19–1.51 .23
<0.05 0.52 0.28–0.96 .04 0.38 0.13–1.14 .08
Organism (gram-positive vs gram-negative) 1.23 0.71–2.11 .46 1.54 0.50–4.70 .45
Size (>2.75 mm2 vs <2.75 mm2) 0.33 0.18–0.60 .0002 0.33 0.11–0.97 .04
Ulcer depth
0–25%b 1.00 1.00
26%–50% 0.83 0.38–1.82 .64 1.07 0.24–4.84 .93
51%–100%c — — — 0.55 0.09–3.21 .51
Inflammation score (>3 vs <3) 1.22 0.70–2.12 .49 0.94 0.37–2.41 .90

CI ¼ confidence interval; HR ¼ hazard ratio.

a
Hazard ratio and 95% confidence interval determined by Cox regression.
b
Reference group.
c
Only 3 subjects at the Philippines site had ulcer depths >50%.

hazard ratio for larger ulcers was 0.73 (95% CI: 0.25– treated with ciprofloxacin had achieved a score of
2.15). A hazard ratio for smaller ulcers could not be calcu- presumed cure (median 8 days of treatment). Seven
lated in India, because none of the 12 study participants of the 16 small ulcers in India (44%) treated with

VOL. 176 TRIAL OF POVIDONE-IODINE TREATMENT FOR BACTERIAL KERATITIS 249

povidone-iodine achieved a score of presumed cure with a
median 10 days of treatment (P ¼ .01; 0% vs 44%).
Supplemental Table 4 (Supplemental Material available
at AJO.com) shows visual acuity at study entry and final
study visit for all subgroups. There were no substantial dif-
ferences in visual acuity between treatment groups during
the relatively short study interval.
No serious adverse events or side effects were
reported from any study site.
DISCUSSION
REDUCTION OF BLINDNESS FROM INFECTIOUS KERATITIS IN
the developing world will depend in part on the early use of
effective treatments to reduce the extent of corneal scar-
ring, yet in many resource-poor areas of the world antibi-
otics are either not available or too expensive to be
obtained routinely. Povidone-iodine is a potential alterna-
tive treatment to help achieve this goal. It can be prepared
from preexisting powders or solutions, which are available
worldwide and are inexpensive. In Kenya, a 5-ml bottle of
the solution costs less than US$0.10 to prepare.7 After
penetration, povidone-iodine affects bacteria by interact-
ing strongly with double bonds of saturated fatty acids in
cell walls and organelle membranes. It also oxidizes amino
acids and nucleotides, causing cell wall lipid membranes to
form pores.11
Povidone-iodine has been used successfully as an anti-
infective agent in other ophthalmic situations. It has been
shown to decrease microbial contamination of donor eyes
before tissue transplantation.12 It was shown to be effective
for prophylaxis before ophthalmic surgery,13 and is now
commonly used worldwide as a preoperative prepar-ative
solution. It is also shown to be an effective anti-infective
14
when applied to the eye following surgery. Povidone-
iodine reduces bacterial counts when applied to the
conjunctivae of neonates.15 In a study of 3117 new-borns
in Kenya, it was shown that povidone-iodine 5% so-lution
was as or more effective than silver nitrate solution or
erythromycin ointment for prophylaxis against ophthalmia
neonatorum, while also being safe. In a masked and
controlled treatment trial involving 464 children in the
Philippines, no differences were found between povidone-
iodine and neomycin–polymyxin B–gramicidin for treatment
of bacterial conjunctivitis and povidone-iodine was more
effective against chlamydial conjuncti-vitis.8
In contrast, there has been conflicting information about
the effect of povidone-iodine on bacterial keratitis, and re-
ported results may have been influenced by confounding
factors. In 1969, Hale reported successful outcomes in 4
cases of pseudomonal keratitis treated with topical
povidone-iodine in combination with topical antibiotics.16 In
1985, Schuhman and Vidic found ‘‘good improvement’’
250 AMERICAN JOURNAL OF OPHTHALMOLOGY
in 35 of 40 patients with conjunctivitis and keratoconjunc-
tivitis who were treated with povidone-iodine; in some
cases, betamethasone was also used.17 In a clinical trial in
Nepal, there was no observed benefit of using povidone-
iodine in addition to standard antibiotics, when compared
with treatment with standard antibiotics alone18; no
microbiologic analyses were performed. In another study, a
single application of povidone-iodine 5% was no more
effective than placebo in reducing the frequency of positive
cultures among patients with corneal ulcers 19; approxi-
mately half of the study participants were already using
topical antibiotics at enrollment.
Animal studies have also provided conflicting informa-
tion. In a rabbit model of staphylococcal keratitis,
povidone-iodine was more effective than saline controls
but less effective than topical ofloxacin.20 In another study,
povidone-iodine was more effective than topical genta-
micin.21 In a different rabbit model, povidone-iodine was
not effective when a broth of Pseudomonas spp. was
placed onto an abraded cornea.22 Because of its potential
benefit for treatment of bacterial keratitis, but considering
uncer-tainty based on these prior studies, a prospective
random-ized clinical trial of povidone-iodine vs topical
antibiotics was deemed appropriate.
We chose to use a 1.25% concentration of povidone-
iodine to prevent complaints of stinging, which might
reduce compliance, as was observed in the
aforementioned conjunctivitis trial.8 Povidone-iodine has
been found to be effective against pathogenic bacteria,
such as Staphylo-coccus aureus and Pseudomonas spp.,
in concentrations as low as 0.1%. 23 An in vitro study found
povidone-iodine to be effective against Neisseria
gonorrhoeae, Chlamydia trachomatis, and herpes simplex
virus type II in a concentra-tion of 1.0%.24
The choice of control medications was deliberate. In the
Philippines, neomycin–polymyxin B–gramicidin
ophthalmic solution is a common first-line drug for treat-
ment of bacterial keratitis, as is true in other developing
countries. In India, ciprofloxacin is often used for mono-
therapy. Ciprofloxacin manufactured in India is also
used in other resource-poor countries, because it is
25
less expen-sive than antibiotics available in the West.
We chose to study the effect of povidone-iodine both in
the Philippines and in India; infectious keratitis is a major
health care problem in both countries, and cases are
repre-sentative of those seen throughout the developing
world. Despite the use of standard protocols and study
definitions at all sites, we recognized that conditions were
likely to vary between countries with regard to the
spectrum of causal bacteria and potential unrecognized
host and other confounding factors. Also, there was likely
to be interob-server variations with regard to interpretation
of examina-tion findings. We therefore prospectively
decided to analyze results from each country separately.
As shown in the Figure, the cumulative risk of presumed
cure at any given time point was lower in India than in the
APRIL 2016
Philippines for both arms of the study, but the relative ef-
fect of povidone-iodine vs controls was similar in both
countries. The smaller proportion of study participants in
India scored as presumed cure when compared with study
participants in the Philippines, and the larger proportion
scored as recovering in the interval comparison (Table 3),
may reflect delayed healing because of the larger ulcer
sizes at presentation in India. Also, it was our impres-sion
that ophthalmologists in India were more willing to
discharge patients who only met criteria for a status of
improved than were ophthalmologists in the Philippines.
Although overall trends appeared to favor treatment with
povidone-iodine, our goal was not to show superiority of
povidone-iodine over antibiotics. In fact, there may be
specific causes of infection that are better treated with spe-
cific antibiotics. In secondary analyses, there were more
treatment failures before discharge among study partici-
pants treated with povidone-iodine than with neomycin–
polymyxin B–gramicidin, but the association was weak.
There was a suggestion that ciprofloxacin was more effec-
tive than povidone-iodine for infections by gram-negative
bacteria in India. These results should be viewed with
caution, however, because of the pitfalls associated with
differential loss to follow-up.9,10 Overall, we could not
identify a statistically significant difference between
povidone-iodine and control antibiotics in this study.
Furthermore, sensitivity testing and the full spectrum of an-
tibiotics used in the West are not available in much of the
developing world, where blindness from corneal infection
remains a major problem.
Although the majority of study participants were adults,
our results should be applicable to children, who are
dispro-portionately affected by infectious keratitis in the
devel-oping world. In our risk factor assessment, age was
not associated with the primary study outcomes. In a
different study from our site in Tiruchirapalli, India, that
involved 269 patients with corneal ulcers, adults and
children had similar rates of culture positivity, a similar
spectrum of bac-terial isolates, and similar predisposing
factors (most commonly trauma).25
Our conclusions regarding the utility of povidone-iodine
are supported by the fact that we obtained similar results in
2 different countries, with different spectrums of causal
bacteria, and that results were consistent across different
types of comparisons, using multiple outcome measures.
Nevertheless, there are several limitations to this study. A
large number of screened individuals were rejected, to
provide a homogeneous population for this initial, proof-of-
principle study; exclusions may account for the fact that we
saw no perforations, as in other corneal ulcer treatment
trials.26 Eligible individuals may not have been
representative of the total population with infectious
keratitis. Because of our selected population, and because
of variation in disease factors between different geographic
areas, it may not be possible to generalize our results to all
patients with infectious keratitis in all parts
VOL. 176 TRIAL OF POVIDONE-IODINE TREATMENT FOR BACTERIAL KERATITIS
of the world. Our study design was necessarily dictated, in
part, by cultural factors and clinical practices at the study
sites. As a result, follow-up was short, often without
confirmation of complete disease resolution. Presumed
cure was only a surrogate for confirmation that infection
was eradicated by treatments; however, based on experi-
ence at the study sites, it is believed that infection is elim-
inated and healing will ensue when the criteria for our
primary outcome measure is achieved. To compensate for
the fact that many study participants were discharged and
lost to follow-up before the primary study endpoint was
achieved, we performed a post hoc analysis of patients
who met criteria for ‘‘recovering,’’ which was thought to be
a clinically relevant status. Nevertheless, one must be
cautious in the interpretation of post hoc analyses. Visual
acuity has been a major outcome measure in some
corneal ulcer treatment trials, but comparisons have been
made at 3 months or later, when complete healing can be
ex-pected26; we therefore did not compare visual acuity
alone between groups as an outcome measure because of
the relatively short duration of our study.
One might argue that our study did not hold povidone-
iodine to an appropriate standard by comparing it to cipro-
floxacin. There has been concern over increasing bacterial
resistance to ciprofloxacin.27 A study from Hyderabad, In-
dia, found that 21% of Staphylococcus aureus isolates
from patients with infectious keratitis were resistant to
ciproflox-acin.28 In contrast, an Australian study found 96%
of bac-terial keratitis isolates were sensitive to
ciprofloxacin.29 Another study from Tiruchirapalli, India,
found that 81% of corneal ulcers healed in response to
topical ciprofloxa-cin, and that healing time was similar to
that of corneal ul-cers treated with topical gatifloxacin.30 It
is possible that results would have been better had we
treated with a fourth-generation fluoroquinolone, as in
other clinical tri-als.26 Nevertheless, we believe our
choices of control anti-biotics were realistic, considering
the options available in resource-poor areas of the world.
Emerging resistance of bacteria to many commercially
available antibiotics31,32 in fact makes use of povidone-
iodine more compelling in resource-poor areas of the
world. Newer drugs to which these organisms may be
susceptible, including fourth-generation fluoroquinolones,
will not be widely available in these areas.
In conclusion, we found no strong evidence that
povidone-iodine is inferior to antibiotics commonly avail-
able in the developing world for treatment of infectious
keratitis caused by a broad range of bacteria. We therefore
believe it is reasonable to consider use of povidone-iodine
as an alternative to topical antibiotics in areas of the devel-
oping world where antibiotics are prohibitively expensive or
otherwise unavailable to treat bacterial keratitis. Povidone-
iodine is inexpensive, readily available, and easy to
prepare. In addition, povidone-iodine colors the eye brown
for about 2 minutes, confirming proper adminis-tration. Use
of povidone-iodine may reduce the incidence
251
of vision loss caused by corneal scarring, which is a
partic-ularly important problem among children.
Despite the encouraging results of this initial study,
further investigations are warranted. Treatment of infec-
tious keratitis with povidone-iodine should be studied in
specific settings within the developing world where it is
most likely to be used. Its efficacy should also be
studied among patients with other disease factors, such
as kerato-malacia associated with vitamin A deficiency.
Additional outcome measures, including visual acuity
and severity of corneal scarring, should be investigated,
and compliance to treatment should be evaluated.

FUNDING/SUPPORT: THIS STUDY WAS SUPPORTED BY THRASHER RESEARCH FUND, SALT LAKE CITY, UTAH, USA (S.J.I.), THE
Wendy and Theo Kolokotrones Family Fund, Los Angeles, California, USA (S.J.I.), Research to Prevent Blindness, New York, New York,
USA (S.J.I., G.N.H.), and the Skirball Foundation, New York, New York, USA (G.N.H.). Financial Disclosures: Gary N. Holland has served
on advisory boards for the following companies: Genentech, Incorporated (San Francisco, California, USA); Novartis International AG
(Basel, Switzerland); Santen, Incor-porated (Emeryville, California, USA); and XOMA (US) LLC (Berkeley, California, USA); and is
recipient of an RPB Physician-Scientist Award. The following authors have no financial disclosures: Sherwin J. Isenberg, Leonard Apt,
Mario Valenton, Savitri Sharma, Prashant Garg, Philip A. Thomas, Pragya Parmar, Jayaraman Kaliamurthy, Johann M. Reyes, Daniel
Ong, Peter D. Christenson, and Madeline Del Signore. All authors attest that they meet the current ICMJE criteria for authorship.

REFERENCES
1. Murthy GV, Vashist P, John N, Pokharel G, Ellwein LB.
Prevelence and causes of visual impairment and blindness in
older adults in an area of India with a high cataract surgical
rate. Ophthalmic Epidemiol 2010;17(4):185–195.
2. Gilbert C. New issues in childhood blindness.
Community Eye Health 2001;14:53–56.
3. Gogate P, Kalua K, Courtright P. Blindness in childhood
in developing countries: time for a reassessment?
PLoS Med 2009;5(12):e1000177.
4. Houang ET, Gilmore OJ, Reid C, Shaw EJ. Absence of
bacte-rial resistance to povidone iodine. J Clin Pathol
1976;29(8): 752–755.
5. Apt L, Isenberg SJ, Yoshimori R, Spierer A. Outpatient
topical use of povidone-iodine in preparing the eye for
sur-gery. Ophthalmology 1989;96(3):289–292.
6. Isenberg SJ, Apt L, Yoshimori R, Pham C, Lam NK. Efficacy of
topical povidone-iodine during the first week after ophthalmic
surgery. Am J Ophthalmol 1997;124(1):31–35.
7. Isenberg SJ, Apt L, Wood M. A controlled trial of
povidone-iodine as prophylaxis against ophthalmia
neonatorum. N Engl J Med 1995;332(9):562–566.
8. Isenberg SJ, Apt L, Valenton M, et al. A controlled trial
of povidone-iodine to treat infectious conjunctivitis in
children. Am J Ophthalmol 2002;134(5):681–688.
9. DiLoreto DA Jr, Bressler NM, Bressler SB, Schachat AP. Use
of best and final visual acuity outcomes in ophthalmological
research. Arch Ophthalmol 2003;121(11):1586–1590.
10. Jabs DA. Improving the reporting of clinical case
series. Am J Ophthalmol 2005;139(5):900–905.
11. Schreier H, Erdos G, Reimer K, Konig B, Konig W, Fleischer
W. Molecular effects of povidone-iodine on rele-vant
microorganisms: an electron-microscopic and biochem- ical
study. Dermatology 1997;195(Suppl 2):111–116.
12. Pels E, Vrensen GF. Microbial decontamination of human
donor eyes with povidone-iodine: penetration, toxicity, and
effectiveness. Br J Ophthalmol 1999;83(9):1019–1026.
13. Apt L, Isenberg S, Yoshimori R, Paez JH. Chemical
prepara-tion of the eye in ophthalmic surgery. III. Effect
of povidone-iodine on the conjunctiva. Arch
Ophthalmol 1984;102(5): 728–729.
14. Apt L, Isenberg SJ, Yoshimori R, et al. The effect of povidone-
iodine solution applied at the conclusion of ophthalmic
surgery. Am J Ophthalmol 1995;119(6):701–705.
15. Isenberg SJ, Apt L, Yoshimori R, Leake RD, Rich R.
Povi-done-iodine for ophthalmia neonatorum
prophylaxis. Am J Ophthalmol 1994;118(6):701–706.
16. Hale LM. The treatment of corneal ulcer with povidone-
iodine (Betadine). N C Med J 1969;30(2):54–56.
17. Schuhman G, Vidic B. Clinical experience with povidone-
iodine eye drops in patients with conjunctivitis and kerato-
conjunctivitis. J Hosp Infect 1985;6(Suppl A):173–175.
18. Katz J, Khatry SK, Thapa MD, et al. A randomised trial
of povidone-iodine to reduce visual impairment from
corneal ulcers in rural Nepal. Br J Ophthalmol
2004;88(12): 1487–1492.
19. Gregori NZ, Schiffman JC, Miller DM, Alfonso EC. Clinical trial
of povidone-iodine (Betadine) versus placebo in the pre-
treatment of corneal ulcers. Cornea 2006;25(5):558–563.
20. Melki SA, Safar A, Yaghouti F, et al. Effect of topical
povidone-iodine versus topical ofloxacin on
experimental Staphylococcus keratitis. Graefes Arch
Clin Exp Ophthalmol 2000;238(5):459–462.
21. Sharma LG, Goyal JK, Sharma U, Chandak GK, Nepalia LK.
Evaluation of topical povidone-iodine versus gentamycin in
staphylococcus coagulase positive corneal ulcers–an experi-
mental study. Indian J Ophthalmol 1990;38(1):30–32.
22. Michalova K, Moyes AL, Cameron S, et al. Povidone-iodine
(betadine) in the treatment of experimental Pseudomonas
aeruginosa keratitis. Cornea 1996;15(5):533–536.
23. Berkelman RL, Holland BW, Anderson RL. Increased
bacte-ricidal activity of dilute preparations of povidone-
iodine solu-tions. J Clin Microbiol 1982;15(4):635–639.
24. Benevento WJ, Murray P, Reed CA, Pepose JS. The sensi-
tivity of Neisseria gonorrhoeae, Chlamydia trachomatis, and
her-pes simplex type II to disinfection with povidone-iodine.
Am J Ophthalmol 1990;109(3):329–333.
25. Parmar P, Salman A, Kalavathy CM, Kaliamurthy J,
Thomas PA, Jesudasan CA. Microbial keratitis at
extremes of age. Cornea 2006;25(2):153–158.
26. Srinivasan M, Mascarenhas J, Rajaraman R, et al. Corticoste-
roids for bacterial keratitis: the Steroids for Corneal Ulcers
Trial (SCUT). Arch Ophthalmol 2012;130(2):143–150.

252 AMERICAN JOURNAL OF OPHTHALMOLOGY APRIL 2016

27. Goldstein MH, Kowalski RP, Gordon YJ. Emerging
fluoroqui-nolone resistance in bacterial keratitis: a 5-
year review. Ophthalmology 1999;106(7):1313–1318.
28. Sharma V, Sharma S, Garg P, Rao GN. Clinical resistance
of Staphylococcus keratitis to ciprofloxacin monotherapy.
In-dian J Ophthalmol 2004;52(4):287–292.
29. Ly CN, Pham JN, Badenoch PR, et al. Bacteria commonly
isolated from keratitis specimens retain antibiotic susceptibil-
ity to fluoroquinolones and gentamicin plus cephalothin. Clin
Experiment Ophthalmol 2006;34(1):44–50.
VOL. 176 TRIAL OF POVIDONE-IODINE TREATMENT FOR BACTERIAL KERATITIS
30. Parmar P, Salman A, Kalavathy CM, et al. Comparison
of topical gatifloxacin 0.3% and ciprofloxacin 0.3% for
the treatment of bacterial keratitis. Am J Ophthalmol
2006; 141(2):282–286.
31. Chaurasia S, Ramappa M, Ashar J, Sharma S. Neonatal
infec-tious keratitis. Cornea 2014;33(7):673–676.
32. Hernandez-Camarena JC, Graue-Hernandez EO, Ortiz-
Casas M, et al. Trends in microbiological and antibiotic
sensi-tivity patterns in infectious keratitis: 10-year
experience in Mexico City. Cornea 2015;34(7):778–785.
253