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Combined Intrastromal Voriconazole and Amphotericin B Treatment for Persistent Fungal Keratitis. Eye Contact Lens 2020; 46:269-273. [PMID: 32568930 DOI: 10.1097/icl.0000000000000723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the clinical outcomes of combined intrastromal voriconazole and intrastromal amphotericin B for the treatment of persistent fungal keratitis. METHOD Patients who received combined corneal intrastromal voriconazole (0.05 mg/0.1 mL) and intrastromal liposomal amphotericin B (0.01 mg/0.1 mL) injections in addition to topical therapy for treatment of persistent fungal keratitis were included in the study. Persistence was described as no improvement or progression in the clinical findings despite treatment with combined topical voriconazole (1 mg/0.1 mL) and topical amphotericin B drops (0.15 mg/0.1 mL) hourly for at least 10 days. The healing of keratitis was considered as the complete closure of epithelial defect with complete resolution of a corneal infiltrate. RESULTS Thirty-two eyes of 32 patients who met the inclusion criteria were included in this study. Predominant organisms in fungal isolates were Aspergillus species. Combination therapy of intrastromal amphotericin B and intrastromal voriconazole in addition to topical therapy resulted in complete resolution of persistent fungal keratitis in 28 (87.5%) patients. The mean number of intrastromal injections was 9.3±6.4 and ranged from 1 to 18. The mean best-corrected visual acuity values improved from 2.17±0.43 to 1.76±0.77 logarithm of the minimum angle of resolution units (P=0.003). The mean duration of complete epithelial closure was 45.3±16.3 days. Four patients required therapeutic penetrating keratoplasty because of persistence of fungal keratitis (3 patients) and progression of keratitis (1 patient). There was no need for evisceration. CONCLUSION Combination therapy with intrastromal voriconazole and intrastromal amphotericin B may be an effective adjunct treatment for persistent fungal keratitis.
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102
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Rammohan R, Suneetha V, Sen S, Rameshkumar G, Lalitha P. Fungal Infections of the Eye. CURRENT CLINICAL MICROBIOLOGY REPORTS 2020. [DOI: 10.1007/s40588-020-00142-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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103
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Lenk J, Raiskup F, Pillunat LE, Rößler S. [Scedosporium apiospermum-a rare pathogen of keratomycosis]. Ophthalmologe 2020; 117:1225-1228. [PMID: 32125497 DOI: 10.1007/s00347-020-01073-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This article presents the case of a 44-year-old contact lens wearer who presented with acute keratitis resistant to antibacterial treatment in the right eye. The anterior segment of the eye showed circular conjunctival hyperemia, a corneal white cell infiltrate with radiating margins and a central corneal erosion. Microbiological investigation of a corneal scraping revealed growth of Scedosporium apiospermum. Intensive antimycotic treatment and several corneal collagen crosslinking procedures were performed; however, because of rapidly evolving necrotizing ulcerative keratitis, a keratoplasty à chaud was carried out.
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Affiliation(s)
- Janine Lenk
- Augenklinik, Univ. Klinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Frederik Raiskup
- Augenklinik, Univ. Klinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Lutz E Pillunat
- Augenklinik, Univ. Klinikum Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Susann Rößler
- Institut für Medizinische Mikrobiologie und Hygiene, Institut für Virologie, Zentralbereich für Klinische Infektiologie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Deutschland
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104
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Abstract
Background:In microbial keratitis, infection of the cornea can threaten vision through permanent corneal scarring and even perforation resulting in the loss of the eye. A literature review was conducted by Karsten, Watson and Foster (2012) to determine the spectrum of microbial keratitis. Since this publication, there have been over 2600 articles published investigating the causative pathogens of microbial keratitis.Objective:To determine the current spectrum of possible pathogens implicated in microbial keratitis relative to the 2012 study.Methods:An exhaustive literature review was conducted of all the peer-reviewed articles reporting on microbial pathogens implicated in keratitis. Databases including MEDLINE, EMBASE, Scopus and Web of Science were searched utilising their entire year limits (1950-2019).Results:Six-hundred and eighty-eight species representing 271 genera from 145 families were implicated in microbial keratitis. Fungal pathogens, though less frequent than bacteria, demonstrated the greatest diversity with 393 species from 169 genera that were found to cause microbial keratitis. There were 254 species of bacteria from 82 genera, 27 species of amoeba from 11 genera, and 14 species of virus from 9 genera, which were also identified as pathogens of microbial keratitis.Conclusion:The spectrum of pathogens implicated in microbial keratitis is extremely diverse. Bacteria were most commonly encountered and in comparison, to the review published in 2012, further 456 pathogens have been identified as causative pathogens of microbial keratitis. Therefore, the current review provides an important update on the potential spectrum of microbes, to assist clinicians in the diagnosis and treatment of microbial keratitis.
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105
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Arunga S, Wiafe G, Habtamu E, Onyango J, Gichuhi S, Leck A, Macleod D, Hu V, Burton M. The impact of microbial keratitis on quality of life in Uganda. BMJ Open Ophthalmol 2019; 4:e000351. [PMID: 31909191 PMCID: PMC6936408 DOI: 10.1136/bmjophth-2019-000351] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/04/2019] [Accepted: 12/01/2019] [Indexed: 11/16/2022] Open
Abstract
Background Microbial keratitis (MK) is a frequent cause of sight loss in sub-Saharan Africa. However, no studies have formally measured its impact on quality of life (QoL) in this context. Methods As part of a nested case–control design for risk factors of MK, we recruited patients presenting with MK at two eye units in Southern Uganda between December 2016 and March 2018 and unaffected individuals, individually matched for sex, age and location. QoL was measured using WHO Health-Related and Vision-Related QoL tools (at presentation and 3 months after start of treatment in cases). Mean QoL scores for both groups were compared. Factors associated with QoL among the cases were analysed in a linear regression model. Results 215 case-controls pairs were enrolled. The presentation QoL scores for the cases ranged from 20 to 65 points. The lowest QoL was visual symptom domain; mean 20.7 (95% CI 18.8 to 22.7) and the highest was psychosocial domain; mean 65.6 (95% CI 62.5 to 68.8). At 3 months, QoL scores for the patients ranged from 80 to 90 points while scores for the controls ranged from 90 to 100. The mean QoL scores of the cases were lower than controls across all domains. Determinants of QoL among the cases at 3 months included visual acuity at 3 months and history of eye loss. Conclusion MK severely reduces QoL in the acute phase. With treatment and healing, QoL subsequently improves. Despite this improvement, QoL of someone affected by MK (even with normal vision) remains lower than unaffected controls.
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Affiliation(s)
- Simon Arunga
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK, UK.,Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Geoffrey Wiafe
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Esmael Habtamu
- London School of Hygiene and Tropical Medicine International Centre for Eye Health, London, UK.,Carter Center, Addis Ababa, Ethiopia
| | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - David Macleod
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Victor Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Burton
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
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106
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Arunga S, Kintoki GM, Mwesigye J, Ayebazibwe B, Onyango J, Bazira J, Newton R, Gichuhi S, Leck A, Macleod D, Hu VH, Burton MJ. Epidemiology of Microbial Keratitis in Uganda: A Cohort Study. Ophthalmic Epidemiol 2019; 27:121-131. [PMID: 31830848 PMCID: PMC7446037 DOI: 10.1080/09286586.2019.1700533] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To describe the epidemiology of Microbial Keratitis (MK) in Uganda. Methods We prospectively recruited patients presenting with MK at two main eye units in
Southern Uganda between December 2016 and March 2018. We collected information on
clinical history and presentation, microbiology and 3-month outcomes. Poor vision was
defined as vision < 6/60). Results 313 individuals were enrolled. Median age was 47 years (range 18–96) and 174 (56%) were
male. Median presentation time was 17 days from onset (IQR 8–32). Trauma was reported by
29% and use of Traditional Eye Medicine by 60%. Majority presented with severe
infections (median infiltrate size 5.2 mm); 47% were blind in the affected eye (vision
< 3/60). Microbiology was available from 270 cases: 62% were fungal, 7% mixed
(bacterial and fungal), 7% bacterial and 24% no organism detected. At 3 months, 30% of
the participants were blind in the affected eye, while 9% had lost their eye from the
infection. Delayed presentation (overall p = .007) and
prior use of Traditional Eye Medicine (aOR 1.58 [95% CI 1.04–2.42], p = .033) were responsible for poor presentation. Predictors of poor vision
at 3 months were: baseline vision (aOR 2.98 [95%CI 2.12–4.19], p < .0001), infiltrate size (aOR 1.19 [95%CI 1.03–1.36], p < .020) and perforation at presentation (aOR 9.93 [95% CI
3.70–26.6], p < .0001). Conclusion The most important outcome predictor was the state of the eye at presentation,
facilitated by prior use of Traditional Eye Medicine and delayed presentation. In order
to improve outcomes, we need effective early interventions.
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Affiliation(s)
- Simon Arunga
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK.,Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Guyguy M Kintoki
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - James Mwesigye
- Department of Microbiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joel Bazira
- Department of Microbiology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rob Newton
- Department of epidemiology, Uganda Virus Research Institute, Entebbe, Uganda
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - David Macleod
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Victor H Hu
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK
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107
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Al-Hatmi AMS, de Hoog GS, Meis JF. Multiresistant Fusarium Pathogens on Plants and Humans: Solutions in (from) the Antifungal Pipeline? Infect Drug Resist 2019; 12:3727-3737. [PMID: 31819555 PMCID: PMC6886543 DOI: 10.2147/idr.s180912] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/22/2019] [Indexed: 12/15/2022] Open
Abstract
The fungal genus Fusarium contains numerous plant pathogens causing considerable economic losses. In addition, Fusarium species are emerging as opportunistic human pathogens causing both superficial and systemic infections. Appropriate treatment of Fusarium infections in a clinical setting of neutropenia is currently not available. ESCMID and ECMM joint guidelines, following the majority of published studies, suggest early therapy with amphotericin B and voriconazole, in conjunction with surgical debridement and reversal of immunosuppression. In this review, we elaborate on the trans-kingdom pathogenicity of Fusarium. Intrinsic resistance to several antifungal drugs and the evolution of antifungal resistance over the years are highlighted. Recent studies present novel compounds that are effective against some pathogenic fungi including Fusarium. We discuss the robust and dynamic antifungal pipeline, including results from clinical trials as well as preclinical data that might appear beneficial for patients with invasive fusariosis.
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Affiliation(s)
- Abdullah MS Al-Hatmi
- Ministry of Health, Directorate General of Health Services, Ibri, Oman
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
- Centre of Expertise in Mycology Radboud University Medical Centre/Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
- Centre of Expertise in Mycology Radboud University Medical Centre/Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Jacques F Meis
- Centre of Expertise in Mycology Radboud University Medical Centre/Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
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108
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Narayana S, Krishnan T, Ramakrishnan S, Austin A, Lietman T, Rose-Nussbaumer J. Reply. Ophthalmology 2019; 126:e86-e87. [DOI: 10.1016/j.ophtha.2019.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 10/25/2022] Open
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109
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Singhal D, Sahay P, Maharana PK. Re: Narayana et al.: Mycotic antimicrobial localized injection: a randomized clinical trial evaluating intrastromal injection of voriconazole (Ophthalmology. 2019;126:1084-1089). Ophthalmology 2019; 126:e85-e86. [DOI: 10.1016/j.ophtha.2019.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 05/15/2019] [Accepted: 07/02/2019] [Indexed: 10/25/2022] Open
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Watson SL, Cabrera-Aguas M, Keay L, Khoo P, McCall D, Lahra MM. The clinical and microbiological features and outcomes of fungal keratitis over 9 years in Sydney, Australia. Mycoses 2019; 63:43-51. [PMID: 31556179 DOI: 10.1111/myc.13009] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/18/2019] [Accepted: 09/22/2019] [Indexed: 11/27/2022]
Abstract
To describe the clinical features, management and outcomes in patients with fungal keratitis at the Sydney Eye Hospital, Australia, over a 9-year period to guide appropriate initial therapy. A retrospective case review was conducted. Patients diagnosed with fungal keratitis from 1 January 2009 to 31 December 2017 were identified from hospital coding and pathology databases. Data were extracted from the medical records. A total of 55 episodes from 51 patients were included. Mean age was 60 ± 20 years (range: 19-91 years), and 33 were male. The fungal species was not identified in two patients. Predisposing factors included ocular surface disease in 17 eyes (32%); corneal disease, 15 (28%); corneal trauma, 12 (23%); and contact lens wear, 13 (24.5%). Fusarium spp. (15, 27%) and Candida parapsilosis (10, 18%) were the most common isolates. The median visual acuity at presentation was 1.3 logMAR (range: 0 to 3) and after treatment 0.7 logMAR (range: -0.02 to 3) (P = .008). Despite medical therapy, most commonly with natamycin and topical and oral voriconazole, surgical intervention was required in 21 eyes (40%); including antifungal injections in 9 (16%); corneal transplantation, 16 (30%); evisceration, 2 (4%); and enucleation, 1 (2%). A poor visual outcome was recorded in 27 of 43 (63%) patients. Fungal keratitis remains a cause of significant ocular morbidity; the majority of patients face a poor outcome despite intense medical and at times surgical treatment. In our setting, fungal keratitis was more commonly associated with corneal or ocular surface disease.
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Affiliation(s)
- Stephanie L Watson
- Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Sydney Eye Hospital, Sydney, NSW, Australia
| | - Maria Cabrera-Aguas
- Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Sydney Eye Hospital, Sydney, NSW, Australia
| | - Lisa Keay
- Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,School of Optometry, University of New South Wales, Sydney, NSW, Australia
| | - Pauline Khoo
- Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Sydney Eye Hospital, Sydney, NSW, Australia
| | | | - Monica M Lahra
- New South Wales Health Pathology Microbiology, Randwick, NSW, Australia.,School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
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111
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Arunga S, Asiimwe A, Apio Olet E, Kagoro-Rugunda G, Ayebazibwe B, Onyango J, Newton R, Leck A, Macleod D, Hu VH, Seeley J, Burton MJ. Traditional eye medicine use in microbial keratitis in Uganda: a mixed methods study. Wellcome Open Res 2019; 4:89. [PMID: 31633056 PMCID: PMC6784788 DOI: 10.12688/wellcomeopenres.15259.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Traditional eye medicine (TEM) is frequently used to treat microbial keratitis (MK) in many parts of Africa. Few reports have suggested that this is associated with a worse outcome. We undertook this large prospective study to determine how TEM use impacts presentation and outcome of MK and to explore reasons why people use TEM for treatment in Uganda. Methods: In a mixed method prospective cohort study, we enrolled patients presenting with MK at the two main eye units in Southern Uganda between December 2016 and March 2018 and collected information on history, TEM use, microbiology and 3-month outcomes. We conducted qualitative interviews with patients, carers traditional healers on reasons why people use TEM. Outcome measures included presenting vision and at 3-months, comparing TEM Users versus Non-Users. A thematic coding framework was deployed to explore reasons for use of TEM. Results: Out of 313 participants enrolled, 188 reported TEM use. TEM Users had a delayed presentation; median presenting time 18 days versus 14 days, p= 0.005; had larger ulcers 5.6 mm versus 4.3 mm p=0.0005; a worse presenting visual acuity median logarithm of the minimum angle of resolution (Log MAR) 1.5 versus 0.6, p=0.005; and, a worse visual acuity at 3 months median Log MAR 0.6 versus 0.2, p=0.010. In a multivariable logistic regression model, distance from the eye hospital and delayed presentation were associated with TEM use. Reasons for TEM use included lack of confidence in conventional medicine, health system breakdown, poverty, fear of the eye hospital, cultural belief in TEM, influence from traditional healers, personal circumstances and ignorance. Conclusion: TEM users had poorer clinical presentation and outcomes. Capacity building of the primary health centres to improve access to eye care and community behavioural change initiatives against TEM use should be encouraged.
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Affiliation(s)
- Simon Arunga
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Allen Asiimwe
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
| | - Eunice Apio Olet
- Department of Biology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Grace Kagoro-Rugunda
- Department of Biology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Robert Newton
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
- University of York, UK, York, YO10 5DD, UK
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - David Macleod
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Victor H. Hu
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Janet Seeley
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
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112
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Prajna NV, Radhakrishnan N, Lalitha P, Austin A, Ray KJ, Keenan JD, Porco TC, Lietman TM, Rose-Nussbaumer J. Cross-Linking-Assisted Infection Reduction: A Randomized Clinical Trial Evaluating the Effect of Adjuvant Cross-Linking on Outcomes in Fungal Keratitis. Ophthalmology 2019; 127:159-166. [PMID: 31619359 DOI: 10.1016/j.ophtha.2019.08.029] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To determine if there is a benefit to adjuvant corneal crosslinking (CXL) and to compare natamycin versus amphotericin B for filamentous fungal keratitis. DESIGN Outcome-masked, 2×2 factorial design, randomized controlled clinical trial. PARTICIPANTS Consecutive patients presenting with moderate vision loss from a smear-positive fungal ulcer at Aravind Eye Hospital, Madurai, India. METHODS Study eyes were randomized to 1 of 4 treatment combinations using an adaptive randomization protocol. The treatment arms included (1) topical natamycin 5% alone, (2) topical natamycin 5% plus CXL, (3) topical amphotericin B 0.15% alone, and (4) topical amphotericin 0.15% plus CXL. MAIN OUTCOME MEASURES The primary outcome of the trial was microbiological cure at 24 hours on repeat culture. Secondary outcomes included best spectacle-corrected visual acuity (BSCVA) at 3 weeks and 3 months, percentage of study participants with epithelial healing at 3 days, 3 weeks, and 3 months, infiltrate or scar size at 3 weeks and 3 months, 3-day smear and culture, and adverse events. RESULTS Those randomized to CXL regardless of medication (topical natamycin or amphotericin) had 1.32-fold increased odds of 24-hour culture positivity, although this was not statistically significant (95% confidence interval [CI], 0.57-3.06; P = 0.51). We were also unable to find a difference in 24-hour culture positivity between those randomized to amphotericin and those randomized to natamycin when evaluating as a group regardless of whether or not they received CXL (coefficient 1.10; 95% CI, 0.47-2.54; P = 0.84). The BSCVA was approximately 0.22 logarithm of the minimum angle of resolution (logMAR) (2.2 Snellen lines) worse on average at 3 weeks among those receiving CXL regardless of medication (95% CI, -0.04 to 0.40; P = 0.04) and 0.32 logMAR (3.2 Snellen lines) worse visual acuity at 3 months after controlling for baseline visual acuity (95% CI, 0.03-0.54; P = 0.02). There was no difference in infiltrate or scar size, percentage of epithelialized or adverse events when comparing CXL with no CXL or the 2 topical medications. CONCLUSIONS There appears to be no benefit of adjuvant CXL in the primary treatment of moderate filamentous fungal ulcers, and it may result in decreased visual acuity.
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Affiliation(s)
| | | | | | - Ariana Austin
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; UCSF Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; UCSF Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; UCSF Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; UCSF Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; UCSF Department of Ophthalmology, University of California, San Francisco, San Francisco, California; The Permanente Medical Group, Redwood City, California.
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113
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Vasantha Ruban V, Anbukkarasi M, Anand T, Thomas PA, Geraldine P. Oxidative stress in corneal tissue in experimental keratitis due to Aspergillus flavus: Effect of topical voriconazole therapy. BIOCATALYSIS AND AGRICULTURAL BIOTECHNOLOGY 2019. [DOI: 10.1016/j.bcab.2019.101323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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114
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In Vitro Activity of Chlorhexidine Compared with Seven Antifungal Agents against 98 Fusarium Isolates Recovered from Fungal Keratitis Patients. Antimicrob Agents Chemother 2019; 63:AAC.02669-18. [PMID: 31182529 PMCID: PMC6658757 DOI: 10.1128/aac.02669-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/03/2019] [Indexed: 12/17/2022] Open
Abstract
Fungal keratitis is a common but severe eye infection in tropical and subtropical areas of the world. In regions with a temperate climate, the frequency of infection is rising in patients with contact lenses and following trauma. Early and adequate therapy is important to prevent disease progression and loss of vision. The management of Fusarium keratitis is complex, and the optimal treatment is not well defined. We investigated the in vitro activity of chlorhexidine and seven antifungal agents against a well-characterized collection of Fusarium isolates recovered from patients with Fusarium keratitis. The fungus culture collection of the Center of Expertise in Mycology Radboudumc/CWZ was searched for Fusarium isolates that were cultured from cornea scrapings, ocular biopsy specimens, eye swabs, and contact lens fluid containers from patients with suspected keratitis. The Fusarium isolates that were cultured from patients with confirmed keratitis were all identified using conventional and molecular techniques. Antifungal susceptibility testing was performed according to the EUCAST broth microdilution reference method. The antifungal agents tested included amphotericin B, voriconazole, posaconazole, miconazole, natamycin, 5-fluorocytosine, and caspofungin. In addition, the activity of chlorhexidine was determined. The fungal culture collection contained 98 Fusarium isolates of confirmed fungal keratitis cases from 83 Dutch patients and 15 Tanzanian patients. The isolates were collected between 2007 and 2017. Fusarium oxysporum (n = 24, 24.5%) was the most frequently isolated species followed by Fusarium solani sensu stricto (n = 18, 18.4%) and Fusarium petroliphilum (n = 11, 11.2%). Amphotericin B showed the most favorable in vitro inhibition of Fusarium species followed by natamycin, voriconazole, and chlorhexidine, while 5-fluorocytosine, posaconazole, miconazole, and caspofungin showed no relevant inhibiting effect. However, chlorhexidine showed fungicidal activity against 90% of F. oxysporum strains and 100% of the F. solani strains. Our study supports the clinical efficacy of chlorhexidine and therefore warrants its further clinical evaluation for primary therapy of fungal keratitis, particularly in low and middle income countries where fungal keratitis is much more frequent and, currently, antifungal eye drops are often unavailable.
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Rees CA, Bao R, Zegans ME, Cramer RA. Natamycin and Voriconazole Exhibit Synergistic Interactions with Nonantifungal Ophthalmic Agents against Fusarium Species Ocular Isolates. Antimicrob Agents Chemother 2019; 63:e02505-18. [PMID: 31010869 PMCID: PMC6591621 DOI: 10.1128/aac.02505-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/18/2019] [Indexed: 11/20/2022] Open
Abstract
The in vitro activities of two antifungal drugs in combination with four nonantifungal ophthalmic agents were evaluated using a broth microdilution method and a collection of eight Fusarium ocular isolates that exhibited resistance to both natamycin (MICs, 14 to 32 μg/ml) and voriconazole (MICs, 4 to >128 μg/ml). Synergistic and indifferent interactions were observed for natamycin and 5-fluorouracil and natamycin with timolol dependent on the Fusarium isolate tested. Isolate-dependent synergistic and indifferent interactions were also observed for natamycin with EDTA and natamycin with dorzolamide. Synergistic or indifferent interactions were observed for voriconazole with timolol and voriconazole with 5-fluorouracil depending on Fusarium isolate. Taken together, these data suggest that commonly used ophthalmic agents enhance the in vitro activity of antifungal drugs against drug-recalcitrant ocular fungal pathogens.
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Affiliation(s)
- Christiaan A Rees
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Ruina Bao
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Michael E Zegans
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Robert A Cramer
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Abstract
PURPOSE To report the outcomes of cyanoacrylate tissue adhesive (CTA) application in corneal thinning and perforation. METHODS A retrospective interventional case series of 137 patients receiving CTA for corneal thinning and perforation in 140 eyes between 2001 and 2018 at a single center was reviewed. Success rate and factors associated with glue failure were analyzed. RESULTS Median age of the cohort was 63 years and 69 (50%) were women. One hundred fifteen patients (84%) had at least 1 systemic condition, 46 (34%) had autoimmune diseases. Eighty-nine eyes (64%) presented with perforation and 51 (36%) with thinning. The perforation/thinning was central/paracentral in 82 eyes (59%) and peripheral in 57 eyes (41%). Median size of perforation was 3.1 mm. Causes of perforation and thinning were microbial infection in 75 (55%), sterile melt in 49 (35%), laceration in 10, and keratoprosthesis melt in 8 eyes. Median glue retention was 58 days. Success rate of glue application (defined as intact globe without surgical intervention) was 72%, 61%, and 46% at 10, 30, and 90 days after glue application, respectively. Larger size of perforation/thinning, perforation (vs. thinning), and single glue application (vs. multiple) were correlated with higher failure rate. Systemic conditions, use of topical corticosteroid, etiologies, and location of perforation/thinning were not significantly correlated with glue failure. CONCLUSIONS CTA application was moderately effective in stabilizing corneal perforation and thinning in the very short-term. Multiple applications are often required. Maintenance of globe integrity after glue application decreases with time and the need for surgical intervention remains high.
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Arunga S, Asiimwe A, Apio Olet E, Kagoro-Rugunda G, Ayebazibwe B, Onyango J, Newton R, Leck A, Macleod D, Hu VH, Seeley J, Burton MJ. Traditional eye medicine use in microbial keratitis in Uganda: a mixed methods study. Wellcome Open Res 2019; 4:89. [PMID: 31633056 PMCID: PMC6784788 DOI: 10.12688/wellcomeopenres.15259.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2019] [Indexed: 11/08/2023] Open
Abstract
Background: Traditional eye medicine (TEM) is frequently used to treat microbial keratitis (MK) in many parts of Africa. Few reports have suggested that this is associated with a worse outcome. We undertook this large prospective study to determine how TEM use impacts presentation and outcome of MK and to explore reasons why people use TEM for treatment in Uganda. Methods: In a mixed method prospective cohort study, we enrolled patients presenting with MK at the two main eye units in Southern Uganda between December 2016 and March 2018 and collected information on history, TEM use, microbiology and 3-month outcomes. We conducted qualitative interviews with patients, carers traditional healers on reasons why people use TEM. Outcome measures included presenting vision and at 3-months, comparing TEM Users versus Non-Users. A thematic coding framework was deployed to explore reasons for use of TEM. Results: 188 out of 313 participants reported TEM use. TEM Users had a delayed presentation; median presenting time 18 days versus 14 days, p= 0.005; had larger ulcers 5.6 mm versus 4.3 mm p=0.0005; a worse presenting visual acuity median logarithm of the minimum angle of resolution (Log MAR) 1.5 versus 0.6, p=0.005; and, a worse visual acuity at 3 months median Log MAR 0.6 versus 0.2, p=0.010. In a multivariable logistic regression model, distance from the eye hospital and delayed presentation were associated with TEM use. Reasons for TEM use included lack of confidence in conventional medicine, health system breakdown, poverty, fear of the eye hospital, cultural belief in TEM, influence from traditional healers, personal circumstances and ignorance. Conclusion: TEM users had poorer clinical presentation and outcomes. Capacity building of the primary health centres to improve access to eye care and community behavioural change initiatives against TEM use should be encouraged.
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Affiliation(s)
- Simon Arunga
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Allen Asiimwe
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
| | - Eunice Apio Olet
- Department of Biology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Grace Kagoro-Rugunda
- Department of Biology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Robert Newton
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
- University of York, UK, York, YO10 5DD, UK
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - David Macleod
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Victor H. Hu
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Janet Seeley
- MRC/UVRI, LSHTM Uganda Research Unit, Entebbe, Entebbe, Uganda
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, UK, WCIE 7TH, UK
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Gong Y, Xin M. Incidence of recurrent fungal keratitis after primary keratoplasty and visual outcome and prognosis after intervention for the recurrence. Medicine (Baltimore) 2019; 98:e15910. [PMID: 31192926 PMCID: PMC6587617 DOI: 10.1097/md.0000000000015910] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
There are no standardized protocols or guidelines for the treatment of recurrent fungal keratitis after therapeutic keratoplasty. This study aimed to investigate the incidence of recurrent fungal keratitis after the primary keratoplasty and the visual outcome and prognosis after intervention for the recurrence.This was a retrospective study. Patients with recurrent fungal keratitis after lamellar keratoplasty (LK) or penetrating keratoplasty (PK) were treated with different antifungal regimens at Shandong Eye Hospital and Qingdao Eye Hospital between Januray 2004 and December 2015. The operative techniques included PK, focal excision, tectonic keratoplasty with a patch graft, lensectomy and vitrectomy, and combined operation. Patients were followed at 1, 2, and 3 months, and then every 6 months after surgery for 2 years. Best corrected visual acuity was assessed and recurrence was recorded. Good prognosis was defined as the presence of visual acuity.Fungal keratitis recurred in 112 of 1448 patients (112/1448, 7.7%) treated initially with PK or LK. The good prognosis rates for different sites of recurrent fungal keratitis were: overall, 93 of 112 (83.0%); recipient bed, 64 of 69 (92.8%); anterior chamber, 14 of 14 (100%); posterior segment, 10 of 16 (62.5%); and atypical, 5 of 13 (38.5%). There was no significant difference in the timing of recurrence between the good and poor prognosis groups (P = .518). Recurrence rates were similar between patients with PK (8.6%) and those with LK (6.0%; P > .05), but the good prognosis rate in patients with post-LK recurrence (96.8%) was higher than that in patients with post-PK recurrence (77.8%, P = .017).Individualized treatment according to recurrent sites of fungal keratitis can achieve a good prognosis in most patients.
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Affiliation(s)
- Yuerong Gong
- Shandong University, Jinan
- Department of Ophthalmology, Binzhou Medical University Hospital, Binzhou
| | - Meng Xin
- Yantai Affiliated Hospital of Binzhou Medical University, Yantai, Shandong, China
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Arunga S, Kintoki GM, Gichuhi S, Onyango J, Newton R, Leck A, Macleod D, Hu VH, Burton MJ. Delay Along the Care Seeking Journey of Patients with Microbial Keratitis in Uganda. Ophthalmic Epidemiol 2019; 26:311-320. [PMID: 31088316 PMCID: PMC7446038 DOI: 10.1080/09286586.2019.1616775] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Purpose To describe the care seeking journey and causes of delay among patients with Microbial Keratitis in Uganda. Methods A prospective cohort of patients presenting with microbial keratitis at the two main eye units in Southern Uganda (2016–2018). We collected information on demographics, home address, clinical history, and presentation pathway including, order of facilities where patients went to seek care, treatment advice, cost of care, and use of Traditional Eye Medicine. Presentation time was noted. We compared “direct” presenters versus “indirect” presenters and analysed predictors of delay. Results About 313 patients were enrolled. All were self-referred. Only 19% of the patients presented directly to the eye hospital. Majority (52%) visited one facility before presenting, 19% visited two facilities, 9% visited three facilities, and 2% visited four facilities. The cost of care increased with increase in the number of facilities visited. People in a large household, further distance from the eye hospital and those who used Traditional Eye Medicine were less likely to come directly to the eye hospital. Visiting another facility prior to the eye hospital and use of Traditional Eye Medicine aOR 1.58 (95%CI 1.03–2.43), p = .038 were associated with delayed presentation to the eye hospital. Conclusion This study provided information on patient journeys to seek care. Delay was largely attributable to having visited another health facility: a referral mechanism for microbial keratitis was non-existent. There is need to explore how these health system gaps can be strengthened.
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Affiliation(s)
- Simon Arunga
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine , London , UK.,Department of Ophthalmology, Mbarara University of Science and Technology , Mbarara , Uganda
| | - Guyguy M Kintoki
- Department of Ophthalmology, Mbarara University of Science and Technology , Mbarara , Uganda
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi , Nairobi , Kenya
| | - John Onyango
- Department of Ophthalmology, Mbarara University of Science and Technology , Mbarara , Uganda
| | - Rob Newton
- Department of Ophthalmology, Uganda Virus Research Institute , Entebbe , Uganda
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine , London , UK
| | - David Macleod
- Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine , London , UK
| | - Victor H Hu
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine , London , UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine , London , UK
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Sahay P, Singhal D, Nagpal R, Maharana PK, Farid M, Gelman R, Sinha R, Agarwal T, Titiyal JS, Sharma N. Pharmacologic therapy of mycotic keratitis. Surv Ophthalmol 2019; 64:380-400. [DOI: 10.1016/j.survophthal.2019.02.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 02/06/2019] [Accepted: 02/06/2019] [Indexed: 11/28/2022]
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Das M, Menda SA, Panigrahi AK, Venkatesh Prajna N, Yen M, Tsang B, Kumar A, Rose-Nussbaumer J, Acharya NR, McCulloch CE, Lietman TM, McLeod SD, Keenan JD. Repeatability and Reproducibility of Slit Lamp, Optical Coherence Tomography, and Scheimpflug Measurements of Corneal Scars. Ophthalmic Epidemiol 2019; 26:251-256. [PMID: 31018742 DOI: 10.1080/09286586.2019.1600199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To determine the repeatability and reproducibility of anterior segment optical coherence tomography (AS-OCT) and Scheimpflug photography for several measurements of corneal scars, including scar size, scar depth, and corneal thickness. Methods: A series of patients treated for fungal keratitis at a tertiary eye care center in South India were recalled two years after successful treatment. Eyes with corneal scars had a slit lamp examination performed by two ophthalmologists masked to the other's examination. For AS-OCT and Scheimpflug photography, each eye had two scans taken by one technician and a third scan taken by a separate technician. Scar measurements were subsequently assessed from AS-OCT images by three graders masked to each other's results. Repeatability and reproducibility were assessed by calculating the intra-class correlation coefficient (ICC) from mixed effects linear regression models. Results: Fifty eyes had all measurements taken. The corneal scar size, measured as the geometric mean of the two longest perpendicular meridians, ranged from 0.8 to 5.4 (mean 2.8 mm, 95%CI 2.6 to 3.1). Scar size measurements taken by two separate individuals were most reproducible when the border of the scar was traced from the OCT (ICC 0.90, 95%CI 0.86 to 0.94), and least repeatable when assessed from slit lamp examination (ICC 0.80, 95%CI 0.70 to 0.90). Conclusions: AS-OCT and Scheimpflug imaging of corneal scars produced measurements with acceptable reproducibility that could be useful as cornea-specific outcomes for clinical trials.
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Affiliation(s)
- Manoranjan Das
- a Department of Cornea and External Disease , Aravind Eye Care System , Madurai , India
| | - Shivali A Menda
- b Department of Ophthalmology , University of California , San Francisco , USA
| | - Arun K Panigrahi
- a Department of Cornea and External Disease , Aravind Eye Care System , Madurai , India
| | - N Venkatesh Prajna
- a Department of Cornea and External Disease , Aravind Eye Care System , Madurai , India
| | - Michael Yen
- c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Betty Tsang
- c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Alisha Kumar
- c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Jennifer Rose-Nussbaumer
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Nisha R Acharya
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Charles E McCulloch
- d Department of Epidemiology & Biostatistics, University of California , San Francisco , USA
| | - Thomas M Lietman
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA.,d Department of Epidemiology & Biostatistics, University of California , San Francisco , USA.,e Institute for Global Health , University of California , San Francisco , USA
| | - Stephen D McLeod
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Jeremy D Keenan
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA
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Narayana S, Krishnan T, Ramakrishnan S, Samantaray PP, Austin A, Pickel J, Porco T, Lietman T, Rose-Nussbaumer J. Mycotic Antimicrobial Localized Injection: A Randomized Clinical Trial Evaluating Intrastromal Injection of Voriconazole. Ophthalmology 2019; 126:1084-1089. [PMID: 30904540 DOI: 10.1016/j.ophtha.2019.03.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/22/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To determine if there is a benefit to adjuvant intrastromal voriconazole (ISV) injections for primary treatment of filamentous fungal keratitis. DESIGN Outcome-masked, randomized controlled clinical trial. PARTICIPANTS Patients with moderate vision loss resulting from a smear-positive fungal ulcer. METHODS Study eyes were randomized to topical natamycin plus ISV injection versus topical natamycin alone. MAIN OUTCOME MEASURES The primary outcome of the trial was microbiological cure on 3-day repeat culture analysis. Secondary outcomes included microbiological cure on 7-day repeat culture analysis; 3-week and 3-month best spectacle-corrected visual acuity; infiltrate or scar size or both; rate of perforation; therapeutic penetrating keratoplasty (TPK); and other adverse events. RESULTS A total of 151 patients with smear-positive ulcers were screened and 70 were enrolled at Aravind Eye Hospital, Pondicherry, India. Baseline cultures grew Fusarium in 19 samples (27%), Aspergillus in 17 samples (24%), and other filamentous fungi in 19 samples (27%) and showed negative results in 13 samples (19%). Those randomized to ISV injection had 1.82 times the odds of 3-day culture positivity after controlling for baseline culture status (95% confidence interval [CI], 0.65-5.23; P = 0.26, bias-corrected logistic regression) and 1.98 times the odds of positive 7-day culture results, after controlling for baseline culture status (95% CI, 0.69-5.91; P = 0.20, bias-corrected logistic regression). Those randomized to ISV injection showed 0.5 logMAR lines (approximately 0.5 Snellen lines) of decreased visual acuity (95% CI, -2.6 to 3.6 lines; P = 0.75) and 0.55 mm worse infiltrate or scar size or both at 3 months after controlling for baseline values (95% CI, -0.13 to 1.25; P = 0.11). Intrastromal voriconazole injections showed a 2.85-fold increased hazard of perforation after controlling for baseline infiltrate depth (95% CI, 0.76-10.75; P = 0.12) but no difference in the rate of TPK (hazard ratio, 0.95; 95% CI, 0.44-2.04; P = 0.90). CONCLUSIONS There seems to be no benefit to adding ISV injections to topical natamycin in the primary treatment of moderate to severe filamentous fungal ulcers. Studies consistently suggest that voriconazole has a limited role in the treatment of filamentous fungal ulcers.
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Affiliation(s)
| | | | | | | | - Ariana Austin
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Julia Pickel
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Travis Porco
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Tom Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California.
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Non-GVHD ocular complications after hematopoietic cell transplantation: expert review from the Late Effects and Quality of Life Working Committee of the CIBMTR and Transplant Complications Working Party of the EBMT. Bone Marrow Transplant 2019; 54:648-661. [PMID: 30531955 PMCID: PMC6497536 DOI: 10.1038/s41409-018-0339-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/22/2018] [Indexed: 02/02/2023]
Abstract
Non-graft-versus-host disease (non-GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT), but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplant physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We have summarized incidence, risk factors, screening, prevention and treatment of individual complications and generated evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical symptoms, signs and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplant physicians and ophthalmologists should be knowledgeable of non-GVHD ocular complications and provide comprehensive collaborative team care.
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Identification of the proteoforms of surface localized Rod A of Aspergillus flavus and determination of the mechanism of proteoform generation. J Proteomics 2019; 193:62-70. [DOI: 10.1016/j.jprot.2018.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/05/2018] [Accepted: 12/13/2018] [Indexed: 01/31/2023]
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Hsu HY, Ernst B, Schmidt EJ, Parihar R, Horwood C, Edelstein SL. Laboratory Results, Epidemiologic Features, and Outcome Analyses of Microbial Keratitis: A 15-Year Review From St. Louis. Am J Ophthalmol 2019; 198:54-62. [PMID: 30308206 DOI: 10.1016/j.ajo.2018.09.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/23/2018] [Accepted: 09/26/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the laboratory results and prognostic factors of poor clinical outcomes in microbial keratitis cases over 15 years at Saint Louis University. DESIGN Retrospective cohort and trend study. METHODS Microbiological and clinical information from culture-positive cases seen at Saint Louis University from 1999 to 2013 were reviewed retrospectively. Statistical analyses were used to determine microbiological and antibiotic susceptibility trends. Prognostic factors of poor clinical outcome from the literature were used to create multivariate regression models to describe our cohort. RESULTS Gram-positive organisms predominated (48%), followed by gram-negative organisms (34%) and fungi (16%). The most commonly isolated organism was Pseudomonas aeruginosa (21%). Oxacillin-resistant rates of Staphylococcus aureus and coagulase-negative staphylococci were 45% and 43%, respectively. Only the proportion of Pseudomonas changed significantly over time (P = .02). The only antibiotic found to lose efficacy over time was gentamicin for gram-positive organisms (P = .005). Multivariate logistic regression analyses revealed that major complications were associated with large ulcers (P < .006), fungal cases (P < .001), and comorbid ophthalmic conditions (P < .001). Poor healing was associated with large ulcers (P < .001) and fungal cases (P < .001). Lastly, poor visual outcome was associated with large ulcers (P < .01) and age ≥ 60 years (P < .02). CONCLUSIONS In the St Louis area, oxacillin-resistant organisms, Pseudomonas aeruginosa, and fungi are commonly recovered from microbial keratitis cases with a disproportionally high incidence. Hence, empiric antibiotic choice should reflect these trends. Special care needs to be taken for patients with large ulcers and fungal infections, as well as elderly patients with comorbid ophthalmic conditions, as these patients have worse clinical outcomes.
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Management Algorithm for Fungal Keratitis: The TST (Topical, Systemic, and Targeted Therapy) Protocol. Cornea 2019; 38:141-145. [PMID: 30334872 DOI: 10.1097/ico.0000000000001781] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the efficacy of the topical, systemic and targeted therapy (TST) protocol in management of fungal keratitis. METHOD All cases of treatment-naive smear- or culture-proven fungal keratitis presenting between June 2013 and May 2017 were recruited. The TST protocol included initial treatment with topical natamycin 5% with addition of oral ketoconazole or voriconazole in ulcers with size >5 mm, depth >50%, or impending perforation. Topical voriconazole 1% was included in case of poor response at 7 to 10 days. Intrastromal or intracameral antifungal injections were administered in case of poor response to combination therapy. Penetrating keratoplasty was performed in case of poor response to any of the regimen. RESULTS The study included 223 cases of fungal keratitis with a mean age of 43.6 ± 15.3 years and a male-to-female ratio of 1.8:1. The mean area of the ulcer and infiltrate at presentation was 25.52 ± 19 and 25.7 ± 14.4 mm, respectively. Corrected distance visual acuity at presentation was 2.05 ± 0.43 logMAR that improved to 1.6 ± 0.4 logMAR at 3 months. Fusarium (42.2%) was the most common microorganism isolated, followed by Aspergillus (32.8%). The mean healing time was 41.5 ± 22.2 days, with a final scar size of 14.6 ± 8.2 mm. The treatment success rate with the TST protocol was 79.8%. Corneal perforation developed in 7% of cases (n = 15), and keratoplasty was performed for 20.2% of cases (n = 45). CONCLUSIONS The TST protocol provides a stepwise treatment algorithm for management of cases of fungal keratitis with varying severity.
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Acharya M, Farooqui JH, Jain S, Mathur U. Pearls and paradigms in Infective Keratitis. Rom J Ophthalmol 2019; 63:119-127. [PMID: 31334389 PMCID: PMC6626937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Infective Keratitis is a commonly encountered sight-threatening ocular emergency. In developing countries, it is a major cause of corneal blindness. Empirical treatment without microbiological work up often leads to treatment failure. Indiscriminate use of steroid antibiotic combination worsens the situation and makes further management challenging. The correct line of management can be potentially sight saving for both the ophthalmologist and the patient. This article on Infective keratitis has been written keeping best practices and protocols in mind. In a very simple and concise form, it focuses on the salient features of clinical presentation of infective keratitis and the stepwise approach to subsequent management in a patient. It explains in detail the way to perform corneal scraping, the importance of the same and further management based on microbiologically proven result. The management part includes indications and methods for medical as well as surgical intervention. We aimed to share our experience in the management of patients presenting with infective keratitis in the clinic.
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Affiliation(s)
| | | | - Shikha Jain
- Ram Manohar Lohia Hospital, New Delhi, India
| | - Umang Mathur
- Dr. Shroff’s Charity Eye Hospital, New Delhi, India
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128
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Retamal J, Ordenes-Cavieres G, Grau-Diez A. Natamycin versus voriconazole for fungal keratitis. Medwave 2018; 18:e7388. [DOI: 10.5867/medwave.2018.08.7387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 12/11/2018] [Indexed: 11/27/2022] Open
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129
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Affiliation(s)
- Prashant Garg
- Tej Kohli Cornea Institute, KAR campus, L. V. Prasad Eye Institute, Hyderabad, India
| | - Aravind Roy
- Tej Kohli Cornea Institute, KVC campus, L. V. Prasad Eye Institute, Vijayawada, India
| | - Paavan Kalra
- Tej Kohli Cornea Institute, KAR campus, L. V. Prasad Eye Institute, Hyderabad, India
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130
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Inamoto Y, Petriček I, Burns L, Chhabra S, DeFilipp Z, Hematti P, Rovó A, Schears R, Shah A, Agrawal V, Ahmed A, Ahmed I, Ali A, Aljurf M, Alkhateeb H, Beitinjaneh A, Bhatt N, Buchbinder D, Byrne M, Callander N, Fahnehjelm K, Farhadfar N, Gale RP, Ganguly S, Hashmi S, Hildebrandt GC, Horn E, Jakubowski A, Kamble RT, Law J, Lee C, Nathan S, Penack O, Pingali R, Prasad P, Pulanic D, Rotz S, Shreenivas A, Steinberg A, Tabbara K, Tichelli A, Wirk B, Yared J, Basak GW, Battiwalla M, Duarte R, Savani BN, Flowers MED, Shaw BE, Valdés-Sanz N. Non-Graft-versus-Host Disease Ocular Complications after Hematopoietic Cell Transplantation: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2018; 25:e145-e154. [PMID: 30521975 DOI: 10.1016/j.bbmt.2018.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/28/2018] [Indexed: 01/18/2023]
Abstract
Non-graft-versus-host disease (GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT) but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplantation physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We summarize the incidence, risk factors, screening, prevention, and treatment of individual complications and generate evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical signs and symptoms and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplantation physicians and ophthalmologists should be knowledgeable about non-GVHD ocular complications and provide comprehensive collaborative team care.
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Affiliation(s)
- Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan.
| | - Igor Petriček
- Department of Ophthalmology, Zagreb University Clinical Hospital, Zagreb, Croatia
| | - Linda Burns
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be the Match, Minneapolis, Minnesota
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Alicia Rovó
- Inselspital, Bern University Hospital, Bern, Switzerland
| | - Raquel Schears
- Division of Hematology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Ami Shah
- Division of Stem Cell Transplantation and Regenerative Medicine, Lucille Packard Children's Hospital, Stanford School of Medicine, Palo Alto, California
| | - Vaibhav Agrawal
- Indiana University Simon Cancer Center, Indianapolis, Indiana
| | - Aisha Ahmed
- University of California, San Francisco, California
| | - Ibrahim Ahmed
- Department of Hematology Oncology and Bone Marrow Transplantation, The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Asim Ali
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hassan Alkhateeb
- Division of Hematology, Mayo Clinic Rochester, Rochester, Minnesota
| | | | - Neel Bhatt
- Center for International Blood and Marrow Transplant Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Dave Buchbinder
- Division of Pediatrics Hematology, Children's Hospital of Orange County, Orange, California
| | - Michael Byrne
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Kristina Fahnehjelm
- Department of Clinical Neuroscience, Karolinska Institute, St Erik Eye Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nosha Farhadfar
- University of Florida Health Shands Hospital, Gainesville, Florida
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, Kansas
| | - Shahrukh Hashmi
- Department of Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | | | - Erich Horn
- University of Florida Health Shands Hospital, Gainesville, Florida
| | - Ann Jakubowski
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Jason Law
- Tufts Medical Center, Boston, Massachusetts
| | - Catherine Lee
- Utah Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Olaf Penack
- Divison of Hematology and Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | | | - Pinki Prasad
- Lousiana State University Children's Hospital, New Orleans, Louisiana
| | - Drazen Pulanic
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia; Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Seth Rotz
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aditya Shreenivas
- Division of Hematology and Oncology, Mount Sinai Hospital, New York, New York
| | - Amir Steinberg
- Division of Hematology and Oncology, Mount Sinai Hospital, New York, New York
| | - Khalid Tabbara
- Wilmer Eye Institute, Johns Hopkins Medicine, Baltimore, Maryland
| | - André Tichelli
- Hematology, University Hospital Basel, Basel, Switzerland
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Jean Yared
- Blood and Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, Maryland
| | - Grzegorz W Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Minoo Battiwalla
- Hematology Branch, Sarah Cannon Center for Blood Cancer, Nashville, Tennessee
| | - Rafael Duarte
- Hematopoietic Transplantation and Hemato-oncology Section, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bronwen E Shaw
- Center for International Blood and Marrow Transplant Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nuria Valdés-Sanz
- Department of Ophthalmology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
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131
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Al-Hatmi AMS, Castro MA, de Hoog GS, Badali H, Alvarado VF, Verweij PE, Meis JF, Zago VV. Epidemiology of Aspergillus species causing keratitis in Mexico. Mycoses 2018; 62:144-151. [PMID: 30256460 DOI: 10.1111/myc.12855] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/12/2018] [Accepted: 09/17/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The incidence of fungal keratitis has increased in recent years. While the epidemiology and clinical roles of various Candida and Fusarium species have been relatively well-identified in infections of the eye, data regarding keratitis caused by Aspergillus species are scant. Accurate and rapid diagnosis is important for successful management of this infection. OBJECTIVES To present the first molecular epidemiological data from Mexico during a 4-year period of cases admitted with Aspergillus keratitis to a tertiary care eye institution in Mexico City. PATIENTS/METHODS A total of 25 cases of keratitis were included in the study. Aspergillus isolates were identified by sequencing the calmodulin gene. Antifungal susceptibility was tested according to CLSI. RESULTS The aetiological agents belonged to Aspergillus flavus (n = 13), Aspergillus effusus (n = 1), Aspergillus tamarii (n = 4), Aspergillus sydowii (n = 1), Aspergillus protuberus (n = 3) and Aspergillus terreus (n = 3). All strains had low minimum inhibitory concentrations (MICs) of itraconazole and voriconazole (VCZ). Amphotericin B and natamycin showed moderate elevated MICs. CONCLUSIONS Early diagnosis and application of topical VCZ 1% were associated with good outcome. Monitoring of local epidemiological data plays an important role in clinical practice.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands.,Directorate General of Health Services, Ministry of Health, Ibri, Oman.,Centre of Expertise in Mycology, Radboud University Medical Centre / Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marino Alcantara Castro
- Laboratory of Microbiology, Asociacion para Evitar la Ceguera en Mexico Hospital "Dr. Luis Sanchez-Bulnes", Coyoacán, Mexico
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands.,Centre of Expertise in Mycology, Radboud University Medical Centre / Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Hamid Badali
- Department of Medical Mycology, Invasive Fungi Research Center (IFRC), School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Victor Flores Alvarado
- Laboratory of Microbiology, Asociacion para Evitar la Ceguera en Mexico Hospital "Dr. Luis Sanchez-Bulnes", Coyoacán, Mexico
| | - Paul E Verweij
- Centre of Expertise in Mycology, Radboud University Medical Centre / Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jacques F Meis
- Centre of Expertise in Mycology, Radboud University Medical Centre / Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital (CWZ), Nijmegen, The Netherlands
| | - Virginia Vanzzini Zago
- Laboratory of Microbiology, Asociacion para Evitar la Ceguera en Mexico Hospital "Dr. Luis Sanchez-Bulnes", Coyoacán, Mexico
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132
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Sahay P, Asif MI, Maharana PK, Titiyal JS. Periocular contact dermatitis with use of topical voriconazole 1% in mycotic keratitis. BMJ Case Rep 2018; 2018:bcr-2018-226498. [PMID: 30219785 DOI: 10.1136/bcr-2018-226498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present two cases of culture-proven fungal keratitis on natamycin treatment which developed periocular erythema, oedema, burning sensation and pruritus within 48 hours of the addition of topical voriconazole. On clinical examination, periocular erythema with induration was noted. A diagnosis of orbital cellulitis was suspected, but the absence of pain and tenderness refuted the diagnosis on clinical grounds. A dermatology consultation was sought, and a diagnosis of periocular contact dermatitis with voriconazole was made. A skin patch test was performed with the same medication; however, it was negative. Topical voriconazole therapy was withdrawn, and the patient was prescribed cold compresses and oral antihistamine medication, to which they responded well.
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Affiliation(s)
- Pranita Sahay
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Mohamed Ibrahime Asif
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Prafulla Kumar Maharana
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Jeewan S Titiyal
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, New Delhi, India
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133
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Oldenburg CE, Prajna NV, Krishnan T, Rajaraman R, Srinivasan M, Ray KJ, O’Brien KS, Glymour MM, Porco TC, Acharya NR, Rose-Nussbaumer J, Lietman TM. Regression Discontinuity and Randomized Controlled Trial Estimates: An Application to The Mycotic Ulcer Treatment Trials. Ophthalmic Epidemiol 2018; 25:315-322. [PMID: 29718751 PMCID: PMC5980795 DOI: 10.1080/09286586.2018.1469156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/20/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE We compare results from regression discontinuity (RD) analysis to primary results of a randomized controlled trial (RCT) utilizing data from two contemporaneous RCTs for treatment of fungal corneal ulcers. METHODS Patients were enrolled in the Mycotic Ulcer Treatment Trials I and II (MUTT I & MUTT II) based on baseline visual acuity: patients with acuity ≤ 20/400 (logMAR 1.3) enrolled in MUTT I, and >20/400 in MUTT II. MUTT I investigated the effect of topical natamycin versus voriconazole on best spectacle-corrected visual acuity. MUTT II investigated the effect of topical voriconazole plus placebo versus topical voriconazole plus oral voriconazole. We compared the RD estimate (natamycin arm of MUTT I [N = 162] versus placebo arm of MUTT II [N = 54]) to the RCT estimate from MUTT I (topical natamycin [N = 162] versus topical voriconazole [N = 161]). RESULTS In the RD, patients receiving natamycin had mean improvement of 4-lines of visual acuity at 3 months (logMAR -0.39, 95% CI: -0.61, -0.17) compared to topical voriconazole plus placebo, and 2-lines in the RCT (logMAR -0.18, 95% CI: -0.30, -0.05) compared to topical voriconazole. CONCLUSIONS The RD and RCT estimates were similar, although the RD design overestimated effects compared to the RCT.
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Affiliation(s)
| | | | | | | | | | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
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134
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Mahmoudi S, Masoomi A, Ahmadikia K, Tabatabaei SA, Soleimani M, Rezaie S, Ghahvechian H, Banafsheafshan A. Fungal keratitis: An overview of clinical and laboratory aspects. Mycoses 2018; 61:916-930. [PMID: 29992633 DOI: 10.1111/myc.12822] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/28/2018] [Indexed: 12/22/2022]
Abstract
Mycotic keratitis or keratomycosis is a fungal infection with global distribution. The dominant aetiology of this disease varies based on geographical origin, socioeconomic status, and climatic condition. Generally, Aspergillus spp. and Fusarium spp. are common in tropical and subtropical regions and Candida spp. are dominant in temperate areas. Demonstration of fungal elements in microscopic examination besides the isolation of fungi in culture is the gold standard of laboratory diagnosis. As the culture is a time-consuming procedure, other approaches such as in vivo confocal microscopy which produces real-time imaging of corneal tissue and molecular techniques have been developed to facilitate rapid diagnosis of fungal keratitis. The first choice of treatment is topical natamycin, although topical amphotericin B is the best choice for Aspergillus and Candida keratitis. Regarding the diversity of fungal aetiology and the emergence of drug resistance in some genera and species, proper identification using molecular methods and antifungal susceptibility testing could provide useful data. Furthermore, as the better efficacy of combination therapy in comparison to monotherapy is reported, in vitro determination of interactions between various drugs seem informative. This review aims to provide a general and updated view on the aetiology, risk factors, epidemiology, clinical and laboratory diagnosis, and management of fungal keratitis.
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Affiliation(s)
- Shahram Mahmoudi
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Masoomi
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Ahmadikia
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Ali Tabatabaei
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Soleimani
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sassan Rezaie
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ghahvechian
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Banafsheafshan
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
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135
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Dudeja L, Jeganathan L, Prajna NV, Prajna L. Fungal keratitis caused by Laetisaria arvalis. Indian J Med Microbiol 2018; 36:140-142. [PMID: 29735846 DOI: 10.4103/ijmm.ijmm_15_532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A 53-year-old female presented with keratitis (right eye) after fall of insect 10 days back. The ulcer worsened in spite of aggressive treatment with topical natamycin (5%) and amphotericin-B (0.15%) eye drops and finally perforated. Iris tissue sealed the perforation site, and ulcer healed with formation of adherent leucoma. This case represents first reported case of keratitis caused by Laetisaria arvalis and stresses on aggressive course of keratitis caused by this fungus. Importance of DNA sequencing in identification of unidentified fungal species is also highlighted.
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Affiliation(s)
- Lakshey Dudeja
- Department of Cornea and Refractive Surgeries, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | | | - N Venkatesh Prajna
- Department of Cornea and Refractive Surgeries, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Lalitha Prajna
- Department of Ocular Microbiology, Aravind Eye Care System, Madurai, Tamil Nadu, India
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136
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Ray KJ, Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Patel S, Das M, Shah R, Dhakhwa K, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J. The Significance of Repeat Cultures in the Treatment of Severe Fungal Keratitis. Am J Ophthalmol 2018; 189:41-46. [PMID: 29438654 DOI: 10.1016/j.ajo.2018.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 02/02/2018] [Accepted: 02/03/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE To identify fungal keratitis patients who are at risk of a poor outcome and may benefit from closer follow-up or more aggressive treatment. DESIGN Secondary analysis of randomized clinical trial data. METHODS We compared the clinical outcomes of patients who had positive 6-day fungal cultures with those who did not, using backward stepwise regression with covariates for all baseline clinical characteristics. SUBJECTS Patients presenting with a smear-positive filamentous fungal ulcer and visual acuity of 20/400 or worse, and who subsequently had a 6-day fungal culture performed at the Aravind Eye Care system (India), Lumbini Eye Hospital (Nepal), or Bharatpur Eye Hospital (Nepal). MAIN OUTCOME MEASURES The primary outcome is rate of corneal perforation and/or the need for therapeutic penetrating keratoplasty. Secondary outcomes include 3-month best spectacle-corrected visual acuity (BSCVA), 3-month infiltrate and/or scar size, and rate of re-epithelialization. RESULTS Patients who tested positive at their 6-day culture had twice the hazard of experiencing a corneal perforation or the need for therapeutic penetrating keratoplasty (P = .002) than those who tested negative, even after controlling for baseline ulcer characteristics. These patients also had on average 0.26 logMAR lines worse BSCVA at 3 months (P = .001). Culture positivity at day 6 was not a statistically significant predictor of 3-month infiltrate/scar-size (-0.24 mm1; P = .45) or time to re-epithelialization (hazard ratio = .81; P = .31). CONCLUSIONS Here we identify a uniquely valuable clinical tool, day 6 culture results, for the treatment of severe fungal keratitis. Risk stratification based on repeat culture positivity is an objective way to assess response to medical therapy and identify patients who are at high risk of a poor clinical outcome. This establishes a new standard of care for severe fungal keratitis management.
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Affiliation(s)
- Kathryn J Ray
- Francis I. Proctor Foundation, San Francisco, California
| | | | - Prajna Lalitha
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | | | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | | | - Stephen D McLeod
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | | | - Nisha R Acharya
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California; UCSF Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California; UCSF Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California.
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137
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Ramakrishnan S, Mandlik K, Sathe TS, Gubert J, Krishnan T, Baskaran P. Ocular infections caused by Scedosporium apiospermum: A case series. Indian J Ophthalmol 2018; 66:137-140. [PMID: 29283143 PMCID: PMC5778551 DOI: 10.4103/ijo.ijo_524_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The aim of our retrospective study is to report a case series of ocular infections caused by a rare fungus, Scedosporium apiospermum, in a South Indian population. Thirteen cases of culture-positive S. apiospermum infections diagnosed between January 2011 and March 2016 were included in this study. The parameters evaluated were predisposing factors, treatment and final clinical outcome. The most common mode of presentation was keratitis (84.6%) followed by sclerokeratitis (15.3%). The predisposing factors involved were unspecified foreign body injury (30.7%), organic matter injury (15.3%), uncontrolled diabetes (7.6%), and recent manual small-incision cataract surgery (7.6%). Five cases (38.46%) had no predisposing factor. Of the 11 keratitis cases, nine (69.2%) responded well to combination medical therapy while one case (7.6%) required therapeutic keratoplasty. One case was lost to follow-up. Both cases which presented with sclerokeratitis showed no response to medico-surgical treatment progressing to panophthalmitis and evisceration.
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Affiliation(s)
- Seema Ramakrishnan
- Department of Cornea and Refractive Surgery, Aravind Eye Hospital, Puducherry, India
| | - Kunal Mandlik
- Department of Cornea and Refractive Surgery, Aravind Eye Hospital, Puducherry, India
| | | | - Joseph Gubert
- Department of Microbiology, Aravind Eye Hospital, Puducherry, India
| | - Thiruvengada Krishnan
- Department of Cornea and Refractive Surgery, Aravind Eye Hospital, Puducherry, India
| | - Prabu Baskaran
- Department of Vitreo Retina Services, Aravind Eye Hospital, Puducherry, India
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138
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Hoarau G, Albrieux M, Martin-Phipps T, Zitte-Zehler K, Borry L, Peytral J, Garcia-Hermoso D, Picot S. [Fungal keratitis: A 5-year monocentric retrospective study on Reunion Island]. J Fr Ophtalmol 2018; 41:321-325. [PMID: 29681463 DOI: 10.1016/j.jfo.2017.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Fungal keratitis is rare in France, but could be a severe sight-threatening condition. Here, we aimed to describe the epidemiology of fungal keratitis in Réunion Island. METHODS In a retrospective study, we analyzed 13 culture-proven keratitis episodes, occurred between January 2013 and July 2017 in the ophthalmology ward of a University Hospital, Saint-Pierre. Twelve isolates were genotyped and antifungal susceptibility testing was performed. RESULTS Corneal abrasion caused by vegetable matter was the main predisposing factor. Stromal infiltration was observed in 12 patients. Six patients did not response to medical treatment, requiring surgical care, including two enucleations surgery. Fusarium solani (n = 6) and Fusarium dimerum (n = 4) were the main fungal species involved in fungal keratitis. Clinical failures were more prevalent with F. solani infections. The lowest minimal inhibitory concentrations for Fusarium sp. were observed with voriconazole and amphotericin B. CONCLUSION In Reunion Island, the epidemiology of fungal keratitis is characterized by the predominance of Fusarium species, potentially involved in visual loss. This pattern is consistent with the epidemiology usually observed in tropical areas.
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Affiliation(s)
- G Hoarau
- Service de bactériologie-virologie-parasitologie, CHU de La Réunion, BP 350, 97448 Saint-Pierre, Réunion.
| | - M Albrieux
- Service d'ophtalmologie, CHU de La Réunion, BP 350, 97448 Saint-Pierre, Réunion
| | - T Martin-Phipps
- Service d'ophtalmologie, CHU de La Réunion, BP 350, 97448 Saint-Pierre, Réunion
| | - K Zitte-Zehler
- Service d'ophtalmologie, CHU de La Réunion, BP 350, 97448 Saint-Pierre, Réunion
| | - L Borry
- Service d'ophtalmologie, CHU de La Réunion, BP 350, 97448 Saint-Pierre, Réunion
| | - J Peytral
- Pharmacie, CHU de La Réunion, BP 350, 97448 Saint-Pierre, Réunion
| | - D Garcia-Hermoso
- Institut Pasteur, CNRS, unité de mycologie moléculaire, Centre national de référence mycoses invasives et antifongiques (CNRMA), URA3012, 75724 Paris, France
| | - S Picot
- Service de bactériologie-virologie-parasitologie, CHU de La Réunion, BP 350, 97448 Saint-Pierre, Réunion
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139
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Contact Lenses and Infectious Keratitis. CURRENT OPHTHALMOLOGY REPORTS 2018. [DOI: 10.1007/s40135-018-0172-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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140
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Comparison of Oral Voriconazole Versus Oral Ketoconazole as an Adjunct to Topical Natamycin in Severe Fungal Keratitis: A Randomized Controlled Trial. Cornea 2018; 36:1521-1527. [PMID: 28902012 DOI: 10.1097/ico.0000000000001365] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the efficacy of oral voriconazole (VCZ) with oral ketoconazole (KCZ) as an adjunct to topical natamycin in severe fungal keratitis. METHODS Fifty eyes of 50 patients with proven severe fungal keratitis, (>5 mm size, involving >4 mm central cornea and >50% stromal depth), smear, and/or culture positive were randomized to receive either oral VCZ (n = 25) or oral KCZ (n = 25) 200 mg twice a day. Both groups received topical natamycin along with oral medication. The primary outcome measure was best spectacle-corrected visual acuity (BSCVA) at 3 months of follow-up. Secondary outcomes were the percentage of healed cases and scar size. RESULTS The mean BSCVA after treatment was 1.3 ± 0.35 logarithm of minimum angle of resolution units in the VCZ group and 1.6 ± 0.39 logarithm of minimum angle of resolution units in the KCZ group [P = 0.004, 95% confidence interval (CI), -0.10 to 0.54]. The final mean scar size was smaller for oral VCZ than for oral KCZ (P = 0.04, 95% CI, -0.01 to 0.93 mm). The percentage of cases healed were 80% and 72% in VCZ and KCZ groups, respectively (P = 0.51, 95% CI, -0.15 to 0.31). The ratio of tear film to serum concentration of oral VCZ was better than oral KCZ at days 14 (P = 0.002) and 21 (P = 0.006). CONCLUSIONS Although the duration and percentage of healing was similar in both groups, oral VCZ attained a significantly better tear film concentration with a smaller scar size and better BSCVA compared with oral KCZ. Thus, oral VCZ may be preferred over oral KCZ in severe fungal keratitis.
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141
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Prajna VN, Prajna L, Muthiah S. Reply to Comment on: Fungal keratitis: The Aravind Experience. Indian J Ophthalmol 2018; 66:346-347. [PMID: 29380808 PMCID: PMC5819145 DOI: 10.4103/ijo.ijo_1163_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Venkatesh N Prajna
- Department of Cornea and Refractive Surgery, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Lalitha Prajna
- Department of Ocular Microbiology, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Srinivasan Muthiah
- Department of Cornea and Refractive Surgery, Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
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142
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Chang CC, Chen SCA. Fungal Eye Infections: New Hosts, Novel Emerging Pathogens but No New Treatments? CURRENT FUNGAL INFECTION REPORTS 2018. [DOI: 10.1007/s12281-018-0315-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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143
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Hsia YC, Moe CA, Lietman TM, Keenan JD, Rose-Nussbaumer J. Expert practice patterns and opinions on corneal cross-linking for infectious keratitis. BMJ Open Ophthalmol 2018; 3:e000112. [PMID: 29657977 PMCID: PMC5895970 DOI: 10.1136/bmjophth-2017-000112] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 01/05/2018] [Accepted: 01/15/2018] [Indexed: 11/11/2022] Open
Abstract
Objective To assess the current opinion and practice patterns from cornea experts regarding the benefit of corneal cross-linking (CXL) for infectious keratitis (IK). Methods and analysis An international survey was distributed to corneal specialists via an internet survey. The survey data collected were analysed with descriptive statistics. Results A survey was sent to 190 recipients, and 29 (15%) respondents completed the survey with an average of 7 years’ experience using CXL. A majority of respondents (66%) used CXL to treat IK due to bacterial, fungal, protozoan or unknown aetiology. Main indications to use CXL as adjuvant therapy were worsening infiltrate diameter or depth despite therapy (74%), followed by antibiotic resistance (68%), corneal thinning (53%), poor compliance with medication (26%) and other reasons (21%). Most respondents felt CXL would be at least moderately helpful as an adjuvant therapy for bacterial (96%) or fungal (75%) keratitis; about half (46%) thought it would be helpful for acanthamoeba keratitis. As sole therapy, fewer respondents believed CXL would be at least moderately helpful to treat bacterial (75%), fungal (58%) and acanthamoeba (43%) keratitis. Conclusion The survey offered insights into current expert practices and opinions of using CXL as therapy for IK. The results of this survey serve to guide in the design of future clinical studies.
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Affiliation(s)
- Yen C Hsia
- Department of Ophthalmology, University of California, San Francisco, California, USA
| | - Caitlin A Moe
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Thomas M Lietman
- Department of Ophthalmology, University of California, San Francisco, California, USA.,Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Jeremy D Keenan
- Department of Ophthalmology, University of California, San Francisco, California, USA.,Francis I Proctor Foundation, University of California, San Francisco, California, USA
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144
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Abstract
BACKGROUND Fungal keratitis is much less common in Europe than in Asia. Antifungal therapy can be applied topically as well as systemically and in advanced situations surgical intervention can become necessary. CASE REPORT We present the case of a 60-year-old woman who suffered from Fusarium keratitis that showed progression to endophthalmitis following contact lens wearing. Due to numerous resistances against antimycotic drugs the eye had to be enucleated to prevent the pathogens from spreading. Histologically, major inflammatory activity could be detected but no causative organism could be found. The failure to detect a pathogen was in clear contrast to the clinical findings and was interpreted as being an overreaction of the immune response even after the Fusarium had been destroyed. CONCLUSION If a fungal infection of the cornea is suspected, antimycotic therapy should be initiated as early as possible. In cases involving highly resistant pathogens the eye cannot always be saved.
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145
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Galvis V, Tello A, Gomez AJ, Castillo CA, Carreño NI. Comment on: Fungal keratitis: The Aravind Experience. Indian J Ophthalmol 2018; 66:345-346. [PMID: 29380807 PMCID: PMC5819144 DOI: 10.4103/ijo.ijo_1114_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Virgilio Galvis
- Department of Ophthalmology, Fundación Oftalmológica de Santander FOSCAL; Centro Oftalmológico Virgilio Galvis; Faculty of Health Sciences, Department of Ophthalmology, Universidad Autónoma de Bucaramanga UNAB, Floridablanca, Colombia
| | - Alejandro Tello
- Department of Ophthalmology, Fundación Oftalmológica de Santander FOSCAL; Centro Oftalmológico Virgilio Galvis; Faculty of Health Sciences, Department of Ophthalmology, Universidad Autónoma de Bucaramanga UNAB, Floridablanca, Colombia
| | - Augusto J Gomez
- Department of Ophthalmology, Fundación Oftalmológica de Santander FOSCAL, Floridablanca; Faculty of Health Sciences, Department of Ophthalmology, Universidad Industrial de Santander UIS, Bucaramanga, Colombia
| | - Carmen A Castillo
- Department of Ophthalmology, Fundación Oftalmológica de Santander FOSCAL, Floridablanca; Faculty of Health Sciences, Department of Ophthalmology, Universidad Industrial de Santander UIS, Bucaramanga, Colombia
| | - Néstor I Carreño
- Department of Ophthalmology, Fundación Oftalmológica de Santander FOSCAL; Centro Oftalmológico Virgilio Galvis; Faculty of Health Sciences, Department of Ophthalmology, Universidad Autónoma de Bucaramanga UNAB, Floridablanca, Colombia
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146
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Zhong J, Wang B, Li S, Deng Y, Huang H, Chen L, Yuan J. Full-thickness conjunctival flap covering surgery combined with amniotic membrane transplantation for severe fungal keratitis. Exp Ther Med 2018; 15:2711-2718. [PMID: 29456673 PMCID: PMC5795562 DOI: 10.3892/etm.2018.5765] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 06/08/2017] [Indexed: 11/05/2022] Open
Abstract
Fungal keratitis is a severe and common ocular infectious disease. The present study evaluated the efficiency of full-thickness conjunctival flap covering surgery with amniotic membrane transplantation (FCCS + AMT) as a transitional surgery for severe fungal keratitis. A total of 17 patients with severe fungal keratitis without corneal perforation underwent FCCS + AMT between January 2010 and December 2015. The pathogenic factors, preoperative diagnosis and postoperative prognosis of FCCS + AMT at 3 months were evaluated. Subsequently, 7 patients received sclerokeratoplasty, and the best-corrected visual acuity (BCVA) and recurrence ratio were analyzed at 1 month postoperatively. The primary risk factor was agricultural trauma (7 cases), followed by a non-agricultural object entering the eye (3 cases). Preoperatively, there were 10 cases of fungal keratitis positively identified using confocal microscopy and 9 cases positively identified by corneal scrapings. A total of 3 months following FCCS + AMT, the percentage of cases resulting in preservation of the eyeball was 88.24%, with 15/17 patients demonstrating complete conjunctival re-epithelization and a smooth conjunctival surface without any complications. A total of 2 (11.76%) patients experienced melting of the conjunctival flap and development of endophthalmitis, and subsequently underwent ocular evisceration surgery. A total of 7 patients underwent sclerokeratoplasty and the mean logarithm of the minimum angle of resolution BCVA at 1 month was significantly improved (0.689±0.121; P<0.001) compared with preoperative values (2.459±0.037) and BCVA values following FCCS + AMT (2.529±0.066). No recurrence was observed in any of the cases during the follow-up period. Conclusively, FCCS + AMT may be a preferable treatment for severe fungal keratitis of the entire corneal ulcer without perforation, and may save the eyeball and provide a greater opportunity for corneal transplantation.
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Affiliation(s)
- Jing Zhong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong 510060, P.R. China
| | - Bowen Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong 510060, P.R. China
| | - Saiqun Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong 510060, P.R. China
| | - Yuqing Deng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong 510060, P.R. China
| | - Haixiang Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong 510060, P.R. China
| | - Ling Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong 510060, P.R. China
| | - Jin Yuan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong 510060, P.R. China
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147
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Oldenburg CE, Prajna NV, Amza A, Loh A, Acharya NR, Mannis MJ, Lietman TM. Evolution of Practice Patterns for the Treatment of Fungal Keratitis. JAMA Ophthalmol 2017; 135:1448-1449. [PMID: 29121153 DOI: 10.1001/jamaophthalmol.2017.4763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco,Department of Ophthalmology, University of California, San Francisco,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Abdou Amza
- Programme FSS, Université Abdou Moumouni de Niamey, Programme National de Santé Oculaire, Niamey, Niger
| | - Allison Loh
- Department of Ophthalmology, Oregon Health Sciences University, Portland
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco,Department of Ophthalmology, University of California, San Francisco,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Mark J Mannis
- Department of Ophthalmology & Vision Science, Eye Center, University of California, Davis
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco,Department of Ophthalmology, University of California, San Francisco,Department of Epidemiology and Biostatistics, University of California, San Francisco
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148
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Ruban VV, Archana PT, Sundararajan M, Geraldine P, Thomas PA. Inflammation and oxidative stress in corneal tissue in experimental keratitis due to Fusarium solani: Amelioration following topical therapy with voriconazole and epigallocatechin gallate. Mycoses 2017; 61:159-171. [PMID: 29064157 DOI: 10.1111/myc.12718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 10/15/2017] [Accepted: 10/17/2017] [Indexed: 01/14/2023]
Abstract
Combined antifungal and antioxidant therapy may help to reduce oxidative stress in fungal keratitis. Experimental Fusarium solani keratitis was induced by application of F. solani conidia to scarified cornea (right eye) of 16 rabbits (another four rabbits were negative controls [Group I]). Five days later, F. solani-infected animals began receiving hourly topical saline alone (Group II), voriconazole (10 mg/mL) alone (Group III), epigallocatechin gallate (EGCG, 10 mg/mL) alone (Group IV) or voriconazole and EGCG (Group V). Twenty days post-inoculation, corneal lesions were graded. After animal sacrifice, excised corneas underwent histopathological and microbiological investigations. Corneal tissue levels/activities of interleukin 1 beta (IL-1β) and tumour necrosis factor alpha (TNF-α) gene mRNA transcripts, matrix metalloproteinase (MMP) 2 and 9 proteins, malondialdehyde (MDA) and reduced glutathione (GSH), and superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx), were also measured. Clinical and histopathological scores (severity of corneal lesions; [P < .05]) and mean levels (P < .05) of IL-1β and TNF-α mRNA transcripts, MMP 2, MMP 9 and MDA were Group II > Groups IV and III > Groups V and I. Mean SOD, CAT, GPx and GSH levels (P < .05) were Group II < Groups IV and III < Groups V and I. Topical voriconazole with EGCG apparently reduces inflammation in experimental F. solani keratitis, as manifested by improved clinical, histological, microbiological and molecular parameters.
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Affiliation(s)
- Vasanthakumar V Ruban
- Department of Animal Science, School of Life Sciences, Bharathidasan University, Tiruchirappalli, Tamil Nadu, India
| | - Philip T Archana
- Thomas Diagnostic and Research Centre, Tiruchirapalli, Tamil Nadu, India
| | - Mahalingam Sundararajan
- Department of Animal Science, School of Life Sciences, Bharathidasan University, Tiruchirappalli, Tamil Nadu, India
| | - Pitchairaj Geraldine
- Department of Animal Science, School of Life Sciences, Bharathidasan University, Tiruchirappalli, Tamil Nadu, India
| | - Philip A Thomas
- Thomas Diagnostic and Research Centre, Tiruchirapalli, Tamil Nadu, India
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149
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Austin A, Lietman T, Rose-Nussbaumer J. Update on the Management of Infectious Keratitis. Ophthalmology 2017; 124:1678-1689. [PMID: 28942073 PMCID: PMC5710829 DOI: 10.1016/j.ophtha.2017.05.012] [Citation(s) in RCA: 314] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 05/12/2017] [Accepted: 05/15/2017] [Indexed: 11/29/2022] Open
Abstract
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 although culture remains the prevailing diagnostic tool, newer techniques such as in vivo confocal microscopy are helpful for diagnosing fungus and Acanthamoeba. 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 associated with keratitis include topical corticosteroids. The large, randomized, controlled Steroids for Corneal Ulcers Trial found that although steroids provided no significant improvement overall, they did seem beneficial for ulcers that were central, deep or large, non-Nocardia, or classically invasive Pseudomonas aeruginosa; for 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 1960s when topical natamycin was introduced. The randomized controlled Mycotic Ulcer Treatment Trial (MUTT) I showed a benefit of topical natamycin over topical voriconazole for fungal ulcers, particularly among those caused by Fusarium. MUTT II showed that oral voriconazole did not improve outcomes overall, although there may have been some effect among Fusarium ulcers. Given an increase in nonserious adverse events, the authors concluded that they could not recommend oral voriconazole. Viral keratitis differs from bacterial and fungal cases in that it is often recurrent and is common in developed countries. The Herpetic Eye Disease Study (HEDS) I 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 herpes simplex virus 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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MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Antifungal Agents/therapeutic use
- Antiviral Agents/therapeutic use
- Corneal Ulcer/diagnosis
- Corneal Ulcer/drug therapy
- Corneal Ulcer/microbiology
- Diagnostic Techniques, Ophthalmological
- Eye Infections, Bacterial/diagnosis
- Eye Infections, Bacterial/drug therapy
- Eye Infections, Bacterial/microbiology
- Eye Infections, Fungal/diagnosis
- Eye Infections, Fungal/drug therapy
- Eye Infections, Fungal/microbiology
- Female
- Glucocorticoids/therapeutic use
- Humans
- Keratitis, Herpetic/diagnosis
- Keratitis, Herpetic/drug therapy
- Keratitis, Herpetic/virology
- Male
- Randomized Controlled Trials as Topic
- Visual Acuity/physiology
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Affiliation(s)
- Ariana Austin
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Tom Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, California.
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150
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Kalkanci A, Bilgihan K, Ozdemir HB, Yar Saglam AS, Karakurt F, Erdogan M. Corneal Cross-Linking Has No Effect on Matrix Metalloproteinase 9 and 13 Levels During Fungal Keratitis on the Early Stage. Mycopathologia 2017; 183:329-336. [PMID: 29043533 DOI: 10.1007/s11046-017-0207-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 10/02/2017] [Indexed: 11/26/2022]
Abstract
The aim of our study was to investigate matrix metalloproteinases, MMP-9 and MMP-13 levels, in the rabbit model of Fusarium and Candida keratitis treated by corneal cross-linking (PACK-CXL). Rabbit corneas were inoculated with fungal inoculum for keratitis. Each group divided into four subgroups, including un-treated group, PACK-CXL group, voriconazole group and PACK-CXL plus voriconazole group. PACK-CXL was applied with 0.25% riboflavin in accelerated Dresden protocol, and 0.1% voriconazole drops were administered. All corneal buttons excised at tenth day after ophthalmological examination. Fungal cell counts and Scheiber scores were determined in all groups. Corneal tissue MMP mRNA levels were evaluated quantitative reverse transcriptase PCR. The difference in MMP-9 and MMP-13 levels at all groups was not statistically significant (p > 0.05). PACK-CXL with 0.25% riboflavin either alone or combined with antifungal drops was unable to provide decline in inflammatory findings in both macroscopic and microscopic levels similar to medical antifungal treatment.
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Affiliation(s)
- Ayse Kalkanci
- Department of Medical Microbiology, Gazi University School of Medicine, Dekanlik 2.Kat, Besevler, 06500, Ankara, Turkey.
| | - Kamil Bilgihan
- Department of Ophthalmology, Gazi University School of Medicine, Ankara, Turkey
| | | | - Atiye Seda Yar Saglam
- Department of Medical Biology and Genetics, Gazi University School of Medicine, Ankara, Turkey
| | - Funda Karakurt
- Department of Medical Microbiology, Gazi University School of Medicine, Dekanlik 2.Kat, Besevler, 06500, Ankara, Turkey
| | - Merve Erdogan
- Department of Medical Microbiology, Gazi University School of Medicine, Dekanlik 2.Kat, Besevler, 06500, Ankara, Turkey
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