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Maharana PK, Sharma N, Nagpal R, Jhanji V, Das S, Vajpayee RB. Recent advances in diagnosis and management of Mycotic Keratitis. Indian J Ophthalmol 2017; 64:346-57. [PMID: 27380973 PMCID: PMC4966371 DOI: 10.4103/0301-4738.185592] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mycotic keratitis is a major cause of corneal blindness, especially in tropical and subtropical countries. The prognosis is markedly worse compared to bacterial keratitis. Delayed diagnosis and scarcity of effective antifungal agents are the major factors for poor outcome. Over the last decade, considerable progress has been made to rapidly diagnose cases with mycotic keratitis and increase the efficacy of treatment. This review article discusses the recent advances in diagnosis and management of mycotic keratitis with a brief discussion on rare and emerging organisms. A MEDLINE search was carried out for articles in English language, with the keywords, mycotic keratitis, fungal keratitis, emerging or atypical fungal pathogens in mycotic keratitis, investigations in mycotic keratitis, polymerase chain reaction in mycotic keratitis, confocal microscopy, treatment of mycotic keratitis, newer therapy for mycotic keratitis. All relevant articles were included in this review. Considering the limited studies available on newer diagnostic and therapeutic modalities in mycotic keratitis, case series as well as case reports were also included if felt important.
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Affiliation(s)
- Prafulla K Maharana
- Department of Ophthalmology, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Namrata Sharma
- Cornea and Refractive Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Nagpal
- Department of Ophthalmology, L.V. Prasad Eye Institute, Hyderabad, India
| | - Vishal Jhanji
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Sujata Das
- Department of Ophthalmology, L.V. Prasad Eye Institute, Bhubaneswar, India
| | - Rasik B Vajpayee
- Department of Ophthalmology, Vision Eye Institute, Royal Victorian Eye and Ear Hospital, North West Academic Centre, University of Melbourne, Australia
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Shah R, Srinivasan M, Devi L, Das M, Ray KJ, O'Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J. Adjunctive Oral Voriconazole Treatment of Fusarium Keratitis: A Secondary Analysis From the Mycotic Ulcer Treatment Trial II. JAMA Ophthalmol 2017; 135:520-525. [PMID: 28426856 DOI: 10.1001/jamaophthalmol.2017.0616] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Fusarium keratitis is common and often results in poor outcomes. No new treatments since natamycin have become available. Objective To explore the role of adjuvant oral voriconazole on clinical outcomes in Fusarium keratitis. Design, Setting, and Participants In this prespecified subgroup analysis of a multicenter, double-masked, placebo-controlled randomized clinical trial, 240 patients from the Aravind Eye Care System in India, the Lumbini Eye Hospital and Bharatpur Eye Hospital in Nepal, and the University of California, San Francisco, who had culture-positive fungal ulcer and baseline visual acuity of 20/400 or worse were randomized to receive oral voriconazole vs placebo. Enrollment started May 24, 2010, and the last patient study visit was November 23, 2015. All patients received topical voriconazole, 1%, and after the results of the Mycotic Ulcer Treatment Trial (MUTT) II became available, topical natamycin, 5%, was added for all patients. Data analysis was performed from September 2 to October 28, 2016. Main Outcomes and Measures The primary outcome of the trial was the rate of corneal perforation or the need for therapeutic penetrating keratoplasty. Secondary outcomes included rate of reepithelialization, best spectacle-corrected visual acuity, and infiltrate or scar size at 3 months. Results Of the 240 study participants, 72 (30.4%) were culture positive for Fusarium species (41 [56.9%] male and 31 [43.1%] female; median [interquartile range] age, 50 [45-57] years). Of these, 33 (45.8%) were randomized to oral voriconazole and 39 (54.2%) to placebo. Fusarium ulcers randomized to oral voriconazole had a 0.43-fold decreased hazard of perforation or therapeutic penetrating keratoplasty compared with placebo after controlling for baseline infiltrate depth (95% CI, 0.22-fold to 0.84-fold; P = .01). Multiple linear regression revealed a 1.89-mm decreased infiltrate and/or scar size at 3 weeks (95% CI, -2.69 to -1.09 mm; P < .001) and a 0.83-mm decreased infiltrate and/or scar size at 3 months after correcting for baseline values (95% CI, -1.33 to -0.32 mm; P = .001) in eyes randomized to oral voriconazole vs placebo. Eyes treated with oral voriconazole also had a mean 0.29 decreased logMAR (improved) (Snellen equivalent 20/40) visual acuity at 3 months after controlling for baseline visual acuity, although this finding was not statistically significant (95% CI, -0.57 to 0.002; P = .052). Conclusions and Relevance Although MUTT II could not find a benefit for all corneal ulcers, Fusarium keratitis may benefit from the addition of oral voriconazole to topical natamycin, and physicians should consider prescribing oral voriconazole in these cases. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | | | | | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Lumbini Devi
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - 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
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco
| | | | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco
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153
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Al-Hatmi AMS, Bonifaz A, Ranque S, Sybren de Hoog G, Verweij PE, Meis JF. Current antifungal treatment of fusariosis. Int J Antimicrob Agents 2017; 51:326-332. [PMID: 28705676 DOI: 10.1016/j.ijantimicag.2017.06.017] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 04/28/2017] [Accepted: 06/24/2017] [Indexed: 12/12/2022]
Abstract
Fungi of the genus Fusarium are well known as major plant pathogens and soil inhabitants, but also cause a broad spectrum of human infections. Fusariosis is the second most common mould infection after aspergillosis, and keratitis is the most encountered implantation infection in immunocompetent individuals. Natamycin is active against Fusarium species both in vitro and in vivo, and is used along with voriconazole as the mainstay of treatment for Fusarium keratitis. Onychomycosis is treated with terbinafine, voriconazole and sometimes itraconazole. Cure is possible despite high in vitro minimum inhibitory concentrations (MICs). Recently, disseminated infections have increased dramatically, mainly affecting severely immunocompromised patients. The remarkable intrinsic resistance of Fusarium species to most antifungal agents results in high mortality rates in this patient population. Recovery of neutropenia is essential for patient survival and treatment should include voriconazole or amphotericin B as first-line and posaconazole as salvage therapy.
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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 Hospital, Ibri, Oman; Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands.
| | - Alexandro Bonifaz
- Hospital General de México, 'Dr. Eduardo Liceaga', Mexico City, Mexico
| | - Stephane Ranque
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-Méditerranée Infection, Marseille, France
| | - G Sybren de Hoog
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands; Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands; Basic Pathology Department, Federal University of Paraná State, Curitiba, Paraná, Brazil; Biological Sciences Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paul E Verweij
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jacques F Meis
- Centre of Expertise in Mycology Radboudumc/ Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University, Nijmegen Medical Centre, Nijmegen, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
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154
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Ray KJ, Lalitha P, Prajna NV, Rajaraman R, Krishnan T, Srinivasan M, Ryg P, McLeod S, Acharya NR, Lietman TM, Rose-Nussbaumer J. The Utility of Repeat Culture in Fungal Corneal Ulcer Management: A Secondary Analysis of the MUTT-I Randomized Clinical Trial. Am J Ophthalmol 2017; 178:157-162. [PMID: 28385473 DOI: 10.1016/j.ajo.2017.03.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine whether patients who had a positive repeated culture was predictive of worse clinical outcome than those who achieved microbiological cure at 6 days in the Mycotic Ulcer Treatment Trial I (MUTT-I). DESIGN Secondary analysis from a multicenter, double-masked, randomized clinical trial. METHODS setting: Multiple hospital sites of the Aravind Eye Care System, India. STUDY POPULATION Patients with culture-positive filamentous fungal ulcers and visual acuity of 20/40 to 20/400 reexamined 6 days after initiation of treatment. INTERVENTION Corneal scraping and cultures were obtained from study participants at day 6 after enrollment. MAIN OUTCOME MEASURES We assessed 3-month best spectacle-corrected visual acuity (BSCVA), 3-month infiltrate/scar size, corneal perforation, and re-epithelialization rates stratified by culture positivity at day 6. RESULTS Of the 323 patients with smear-positive ulcers enrolled in MUTT-I, 299 (92.6%) were scraped and cultured 6 days after enrollment. Repeat culture positivity was 31% (92/299). Among patients who tested positive at enrollment, those with positive 6-day cultures had significantly worse 3-month BSCVA (0.39 logMAR; 95% confidence interval [CI]: 0.24-0.44; P < .001), had larger 3-month scar size (0.39 mm; 95% CI: 0.06-0.73; P = .02), were more likely to perforate or require therapeutic penetrating keratoplasty (odds ratio: 6.27; 95% CI: 2.73-14.40; P < .001), and were slower to re-epithelialize (hazard ratio: 0.33; 95% CI: 0.21-0.50; P < .001) than those with a negative 6-day culture result. CONCLUSIONS Early microbiological cure on culture is a predictor of clinical response to treatment.
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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
| | | | | | - Peter Ryg
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Stephen McLeod
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Nisha R Acharya
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California.
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155
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Srinivasan M, Das M, Ray KJ, O'Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Porco TC, Acharya NR, Lietman TM, Rose-Nussbaumer J. Effect of Oral Voriconazole on Fungal Keratitis in the Mycotic Ulcer Treatment Trial II (MUTT II): A Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:1365-1372. [PMID: 27787540 DOI: 10.1001/jamaophthalmol.2016.4096] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective To compare oral voriconazole with placebo in addition to topical antifungals in the treatment of filamentous fungal keratitis. Design, Setting, and Participants The Mycotic Ulcer Treatment Trial II (MUTT II), a multicenter, double-masked, placebo-controlled, randomized clinical trial, was conducted in India and Nepal, with 2133 individuals screened for inclusion. Patients with smear-positive filamentous fungal ulcers and visual acuity of 20/400 (logMAR 1.3) or worse were randomized to receive oral voriconazole vs oral placebo; all participants received topical antifungal eyedrops. The study was conducted from May 24, 2010, to November 23, 2015. All trial end points were analyzed on an intent-to-treat basis. Interventions Study participants were randomized to receive oral voriconazole vs oral placebo; a voriconazole loading dose of 400 mg was administered twice daily for 24 hours, followed by a maintenance dose of 200 mg twice daily for 20 days, with dosing altered to weight based during the trial. All participants received topical voriconazole, 1%, and natamycin, 5%. Main Outcomes and Measures The primary outcome of the trial was rate of corneal perforation or the need for therapeutic penetrating keratoplasty (TPK) within 3 months. Secondary outcomes included microbiologic cure at 6 days, rate of re-epithelialization, best-corrected visual acuity and infiltrate and/or scar size at 3 weeks and 3 months, and complication rates associated with voriconazole use. Results A total of 2133 patients in India and Nepal with smear-positive ulcers were screened; of the 787 who were eligible, 240 (30.5%) were enrolled. Of the 119 patients (49.6%) in the oral voriconazole treatment group, 65 were male (54.6%), and the median age was 54 years (interquartile range, 42-62 years). Overall, no difference in the rate of corneal perforation or the need for TPK was determined for oral voriconazole vs placebo (hazard ratio, 0.82; 95% CI, 0.57-1.18; P = .29). In prespecified subgroup analyses comparing treatment effects among organism subgroups, there was some suggestion that Fusarium species might have a decreased rate of perforation or TPK in the oral voriconazole-treated arm; however, this was not a statistically significant finding after Holms-Šidák correction for multiple comparisons (effect coefficient, 0.49; 95% CI, 0.26-0.92; P = .03). Patients receiving oral voriconazole experienced a total of 58 adverse events (48.7%) compared with 28 adverse events (23.1%) in the placebo group (P < .001 after Holms-Šidák correction for multiple comparisons). Conclusions and Relevance There appears to be no benefit to adding oral voriconazole to topical antifungal agents in the treatment of severe filamentous fungal ulcers. All patients in this study were enrolled in India and Nepal; therefore, it is possible that organisms in this region may exhibit characteristics different from those in other regions of the world. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | | | - Muthiah Srinivasan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - 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
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | | | - Travis C Porco
- 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
| | - Nisha R Acharya
- 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 Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, 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
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156
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Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Raghavan A, Srinivasan M, O'Brien KS, Zegans M, McLeod SD, Acharya NR, Keenan JD, Lietman TM, Rose-Nussbaumer J. Changing Azole Resistance: A Secondary Analysis of the MUTT I Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:693-6. [PMID: 27054515 DOI: 10.1001/jamaophthalmol.2016.0530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The development of multiple triazole resistance in pathogenic filamentous fungi has become an increasing clinical concern and has been shown to increase the risk for treatment failure. OBJECTIVE To determine whether antifungal resistance increased during the Mycotic Ulcer Treatment Trial I (MUTT I), as measured by minimum inhibitory concentrations (MICs) in baseline cultures. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis of a double-masked, multicenter, randomized clinical trial included patients with culture- or smear-positive filamentous fungal corneal ulcer and a baseline visual acuity of 20/40 to 20/400. Culture-positive samples with susceptibility testing were included in this analysis. The patients were treated at multiple locations of the Aravind Eye Care Hospital system in South India. Data were collected from April 3, 2010, to December 31, 2011, and analyzed from July 15 to September 1, 2015. INTERVENTIONS Corneal smears and cultures were obtained from all study participants at baseline. Susceptibility testing was performed for each culture-positive specimen. MAIN OUTCOMES AND MEASURES Minimum inhibitory concentration of voriconazole and natamycin in baseline cultures. RESULTS Of 323 participants with smear-positive specimens (183 men [56.7%]; 140 women [43.3%]; median [interquartile range] age, 47 [38-56] years), fungal-positive cultures were obtained for 256 (79.3%). The MIC data were available for 221 of 323 participants (68.4%), because 35 samples had no growth during susceptibility testing. A 2.14-fold increase per year (95% CI, 1.13-4.56; P = .02) in voriconazole MICs after controlling for the infectious organism was found. This association was not found when looking at natamycin MICs of baseline cultures after controlling for the infectious organism (1.26; 95% CI, 0.13-12.55; P = .85). CONCLUSIONS AND RELEVANCE Susceptibility to voriconazole appeared to decrease during the relatively short enrollment period of the clinical trial. This decrease may be more related to increased resistance of environmental fungi rather than previous treatment with azoles, because presenting with azole treatment was not a risk factor for resistance. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
| | - Prajna Lalitha
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | | | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | | | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Michael Zegans
- Department of Ophthalmology, Dartmouth Medical School, Hanover, New Hampshire
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco6Department of Optometry, University of California, Berkeley
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157
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Fungal Keratitis Secondary to Trametes betulina: A Case Report and Review of Literature. Mycopathologia 2017; 182:755-759. [DOI: 10.1007/s11046-017-0128-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/21/2017] [Indexed: 11/27/2022]
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158
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Thanathanee O, Bhoomibunchoo C, Anutarapongpan O, Suwan-apichon O, Yospaiboon Y. Successful treatment of Chrysosporium keratitis with voriconazole. Int Med Case Rep J 2017; 10:93-95. [PMID: 28360537 PMCID: PMC5365330 DOI: 10.2147/imcrj.s131372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To report a patient with severe Chrysosporium keratitis successfully treated by voriconazole. METHOD Case report. RESULTS A 37-year-old healthy male presented with irritation, pain and reduced vision in his left eye after mud contamination. Examination demonstrated corneal stromal infiltration, endothelial plaque and hypopyon. Corneal scrapings demonstrated numerous septate hyphae, and specimen cultures were positive for Chrysosporium sp. The lesion did not respond to aggressive topical 5% natamycin, 0.15% topical amphotericin B and oral itraconazole. The patient was then treated by topical 1% voriconazole every hour. Intracameral and intrastromal voriconazole injections (50 μg/0.1 mL) were also undertaken. The keratitis was significantly improved after voriconazole. CONCLUSION To the best of the authors' knowledge, this is the first report on the use of voriconazole for Chrysosporium keratitis. Voriconazole may be an effective alternative to conventional antifungal agents in some cases of fungal keratitis. It should be considered before shifting to therapeutic keratoplasty.
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Affiliation(s)
- Onsiri Thanathanee
- KKU Eye Center, Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chavakij Bhoomibunchoo
- KKU Eye Center, Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Orapin Anutarapongpan
- KKU Eye Center, Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Olan Suwan-apichon
- KKU Eye Center, Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Yosanan Yospaiboon
- KKU Eye Center, Department of Ophthalmology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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159
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Davies EC, Daly MK, Siracuse-Lee D. A rare case of Phialemonium obovatum keratitis. Am J Ophthalmol Case Rep 2016; 5:81-84. [PMID: 29503953 PMCID: PMC5758013 DOI: 10.1016/j.ajoc.2016.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 12/01/2016] [Indexed: 11/13/2022] Open
Abstract
Purpose We report a rare case of Phialemonium obovatum fungal keratitis in a patient sustaining a corneal laceration from impact with a piece of moldy plaster. Observations The patient was treated with topical voriconazole with resolution of active keratitis and formation of a stromal scar. The patient's final visual acuity was 20/20 in the affected eye. Conclusions and importance There is only one other case of Phialemonium obovatum keratitis reported in the literature. The patient in the previous case required amniotic membrane transplantation for persistent stromal melting with resultant visual acuity of hand motions only. The present case demonstrates that the early use of topical antifungal medication with close follow-up can prevent corneal perforation and result in excellent visual acuity.
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Affiliation(s)
- Emma C Davies
- Department of Ophthalmology, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, USA.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, USA
| | - Mary K Daly
- Department of Ophthalmology, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, USA.,Department of Ophthalmology, Boston University School of Medicine, 85 East Concord Street, Boston, MA, USA.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA, USA
| | - Donna Siracuse-Lee
- Department of Ophthalmology, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, USA.,Department of Ophthalmology, Boston University School of Medicine, 85 East Concord Street, Boston, MA, USA
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160
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Wu J, Zhang WS, Zhao J, Zhou HY. Review of clinical and basic approaches of fungal keratitis. Int J Ophthalmol 2016; 9:1676-1683. [PMID: 27990375 DOI: 10.18240/ijo.2016.11.23] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 07/20/2016] [Indexed: 02/06/2023] Open
Abstract
Fungal keratitis (FK) is a serious disease which can cause blindness. This review has current information about the pathogenesis, limitations of traditional diagnosis and therapeutic strategies, immune recognition and the diagnosis and therapy of FK. The information of this summary was reviewed regularly and updated as what we need in the diagnosis and therapy of FK nowadays.
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Affiliation(s)
- Jie Wu
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Wen-Song Zhang
- Department of Ophthalmology, the Second Hospital of Jilin University, Changchun 130000, Jilin Province, China
| | - Jing Zhao
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
| | - Hong-Yan Zhou
- Department of Ophthalmology, China-Japan Union Hospital of Jilin University, Changchun 130033, Jilin Province, China
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161
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Cadena J, Thompson GR, Patterson TF. Invasive Aspergillosis: Current Strategies for Diagnosis and Management. Infect Dis Clin North Am 2016; 30:125-42. [PMID: 26897064 DOI: 10.1016/j.idc.2015.10.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Aspergillosis remains a significant cause of morbidity and mortality in the immunocompromised population. The spectrum of disease is broad, ranging from severe and rapidly fatal infection to noninvasive disease. The diversity of patients and risk factors complicates diagnostic and therapeutic decision-making. Invasive procedures are often precluded by host status; noninvasive diagnostic tests vary in their sensitivity and specificity. Advancements in understanding the pathophysiology of invasive aspergillosis and host genetics in differential risk have also occurred. Future work may assist in therapeutic decision-making and patient prognosis. Voriconazole remains the preferred agent for treatment. Additional alternatives have emerged.
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Affiliation(s)
- Jose Cadena
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center and South Texas Veterans Health Care System, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California - Davis, 1 Shields Avenue, Tupper Hall, Room 3146, Davis, CA, USA
| | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center and South Texas Veterans Health Care System, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA.
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162
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Kandhavelu J, Demonte NL, Namperumalsamy VP, Prajna L, Thangavel C, Jayapal JM, Kuppamuthu D. Aspergillus flavus induced alterations in tear protein profile reveal pathogen-induced host response to fungal infection. J Proteomics 2016; 152:13-21. [PMID: 27789337 DOI: 10.1016/j.jprot.2016.10.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/12/2016] [Accepted: 10/19/2016] [Indexed: 12/31/2022]
Abstract
Aspergillus flavus and Fusarium sp. are primary causative agents of keratitis that results in corneal tissue damage leading to vision loss particularly in individuals from the tropical parts of the world. Proteins in the tear film collected from control and keratitis patients was profiled and compared. A total of 1873 proteins from control and 1400 proteins from patient tear were identified by mass spectrometry. While 847 proteins were found to be glycosylated in the patient tear, only 726 were glycosylated in control tear. And, some of the tear proteins showed alterations in their glycosylation pattern after infection. Complement system proteins, proteins specific for neutrophil extracellular traps and proteins involved in would healing were found only in the patient tear. The presence of these innate immune system proteins in the tear film of patients supports the previous data indicating the involvement of neutrophil and complement pathways in antifungal defense. High levels of wound healing proteins in keratitis patient tear implied activation of tissue repair during infection. The early appearance of the host defense proteins and wound healing response indicates that tear proteins could be used as an early marker system for monitoring the progression of pathogenesis. Identification of negative regulators of the above defense pathways in keratitis tear indicates an intricate balance of pro and anti-defense mechanisms operating in fungal infection of the eye. SIGNIFICANCE Tear proteins from control and mycotic keratitis patients were separated into glycoproteins and non-glycosylated proteins and then identified by mass spectrometry. Tear proteins from keratitis patients showed alteration in the glycosylation pattern indicating the alteration of glycosylation machinery due to infection. Neutrophil extracellular traps specific proteins, complement pathway proteins, as well as wound healing proteins, were found only in patient tear showing the activation of antifungal defense in the patient tear. Negative regulators of these defense pathways were also found in patient tear indicating a fine balance between pathogen clearance and host tissue destruction during fungal infection depending upon the individual specific host - pathogen interaction. This understanding could be used to predict the progression and outcome of infection.
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Affiliation(s)
- Jeyalakshmi Kandhavelu
- Department of Proteomics, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Naveen Luke Demonte
- Department of Proteomics, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | | | - Lalitha Prajna
- Department of Ocular Microbiology, Aravind Eye Hospital, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Chitra Thangavel
- Department of Proteomics, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Jeya Maheshwari Jayapal
- Department of Proteomics, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Dharmalingam Kuppamuthu
- Department of Proteomics, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India.
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RelA-Mediated BECN1 Expression Is Required for Reactive Oxygen Species-Induced Autophagy in Oral Cancer Cells Exposed to Low-Power Laser Irradiation. PLoS One 2016; 11:e0160586. [PMID: 27632526 PMCID: PMC5025201 DOI: 10.1371/journal.pone.0160586] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 07/21/2016] [Indexed: 12/22/2022] Open
Abstract
Low-power laser irradiation (LPLI) is a non-invasive and safe method for cancer treatment that alters a variety of physiological processes in the cells. Autophagy can play either a cytoprotective role or a detrimental role in cancer cells exposed to stress. The detailed mechanisms of autophagy and its role on cytotoxicity in oral cancer cells exposed to LPLI remain unclear. In this study, we showed that LPLI at 810 nm with energy density 60 J/cm2 increased the number of microtubule associated protein 1 light chain 3 (MAP1LC3) puncta and increased autophagic flux in oral cancer cells. Moreover, reactive oxygen species (ROS) production was induced, which increased RelA transcriptional activity and beclin 1 (BECN1) expression in oral cancer cells irradiated with LPLI. Furthermore, ROS scavenger or knockdown of RelA diminished LPLI-induced BECN1 expression and MAP1LC3-II conversion. In addition, pharmacological and genetic ablation of autophagy significantly enhanced the effects of LPLI-induced apoptosis in oral cancer cells. These results suggest that autophagy may be a resistant mechanism for LPLI-induced apoptosis in oral cancer cells.
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164
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Chidambaram JD, Prajna NV, Larke NL, Palepu S, Lanjewar S, Shah M, Elakkiya S, Lalitha P, Carnt N, Vesaluoma MH, Mason M, Hau S, Burton MJ. Prospective Study of the Diagnostic Accuracy of the In Vivo Laser Scanning Confocal Microscope for Severe Microbial Keratitis. Ophthalmology 2016; 123:2285-2293. [PMID: 27538797 PMCID: PMC5081072 DOI: 10.1016/j.ophtha.2016.07.009] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 07/09/2016] [Accepted: 07/10/2016] [Indexed: 11/26/2022] Open
Abstract
Purpose To determine the diagnostic accuracy of in vivo confocal microscopy (IVCM) for moderate to severe microbial keratitis (MK). Design Double-masked prospective cohort study. Participants Consecutive patients presenting to Aravind Eye Hospital, Madurai, India, between February 2012 and February 2013 with MK (diameter ≥3 mm, excluding descemetocele, perforation, or herpetic keratitis). Methods Following examination, the corneal ulcer was scanned by IVCM (HRT3/RCM, Heidelberg Engineering, Heidelberg, Germany). Images were graded for the presence or absence of fungal hyphae or Acanthamoeba cysts by the confocal microscopist who performed the scan (masked to microbial diagnosis) and 4 other experienced confocal graders (masked to clinical features and microbiology). The regrading of the shuffled image set was performed by 3 graders, 3 weeks later. Corneal-scrape samples were collected for microscopy and culture. Main Outcome Measures The main outcome measures were sensitivity, specificity, and positive and negative predictive values of IVCM compared with those of a reference standard of positive culture or light microscopy. Sensitivities and specificities for multiple graders were pooled and 95% confidence intervals calculated using a bivariate random-effects regression model. Results The study enrolled 239 patients with MK. Fungal infection was detected in 176 (74%) and Acanthamoeba in 17 (7%) by microbiological methods. IVCM had an overall pooled (5 graders) sensitivity of 85.7% (95% confidence interval [CI]: 82.2%–88.6%) and pooled specificity of 81.4% (95% CI: 76.0%–85.9%) for fungal filament detection. For Acanthamoeba, the pooled sensitivity was 88.2% (95% CI: 76.2%–94.6%) and pooled specificity was 98.2% (95% CI: 94.9%–99.3%). Intergrader agreement was good: κ was 0.88 for definite fungus; κ was 0.72 for definite Acanthamoeba. Intragrader repeatability was high for both definite fungus (κ: 0.88–0.95) and definite Acanthamoeba classification (κ: 0.63–0.90). IVCM images from 11 patients were considered by all 5 graders to have a specific organism present (10 fungus, 1 Acanthamoeba) but had negative results via culture and light microscopy. Conclusions Laser scanning IVCM performed with experienced confocal graders has high sensitivity, specificity, and test reproducibility for detecting fungal filaments and Acanthamoeba cysts in moderate to large corneal ulcers in India. This imaging modality was particularly useful for detecting organisms in deep ulcers in which culture and light microscopy results were negative.
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Affiliation(s)
| | - Namperumalsamy V Prajna
- Aravind Eye Hospital, Madurai, Tamil Nadu, India; Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Natasha L Larke
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Manisha Shah
- Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | | | - Prajna Lalitha
- Aravind Eye Hospital, Madurai, Tamil Nadu, India; Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | | | | | | | - Scott Hau
- Moorfields Eye Hospital, London, United Kingdom
| | - Matthew J Burton
- London School of Hygiene and Tropical Medicine, London, United Kingdom; Moorfields Eye Hospital, London, United Kingdom
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165
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Sara S, Sharpe K, Morris S. Multidrug-resistant Fusarium keratitis: diagnosis and treatment considerations. BMJ Case Rep 2016; 2016:bcr-2016-215401. [PMID: 27489066 DOI: 10.1136/bcr-2016-215401] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mycotic keratitis is an ocular infective process derived from any fungal species capable of corneal invasion. Despite its rarity in developed countries, its challenging and elusive diagnosis may result in keratoplasty or enucleation following failed medical management. Filamentous fungi such as Fusarium are often implicated in mycotic keratitis. Bearing greater morbidity than its bacterial counterpart, mycotic keratitis requires early clinical suspicion and initiation of antifungal therapy to prevent devastating consequences. We describe a case of multidrug-resistant mycotic keratitis in a 46-year-old man who continued to decline despite maximal therapy and therapeutic keratoplasty. Finally, enucleation was performed as a means of source control preventing dissemination of a likely untreatable fungal infection into the orbit. Multidrug-resistant Fusarium is rare, and may progress to endophthalmitis. We discuss potential management options which may enhance diagnosis and outcome in this condition.
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Affiliation(s)
- Sergio Sara
- Department of Ophthalmology, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Kendall Sharpe
- Department of Ophthalmology, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
| | - Sharon Morris
- Department of Ophthalmology, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
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166
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Jin X, Zhao Y, Zhang F, Wan T, Fan F, Xie X, Lin Z. Neutrophil extracellular traps involvement in corneal fungal infection. Mol Vis 2016; 22:944-52. [PMID: 27559290 PMCID: PMC4972034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 07/30/2016] [Indexed: 12/01/2022] Open
Abstract
PURPOSE Neutrophils release neutrophil extracellular traps (NETs) when defending against invading microorganisms. We investigated the existence of NETs in fungal keratitis. METHODS Fourteen patients with unilateral fungal keratitis were included. Detailed information about each patient was recorded, including (1) patient history (onset of symptoms and previous therapy), (2) ocular examination findings by slit-lamp biomicroscopy, (3) laboratory findings from direct smear examination and culture of corneal scrapings, (4) NET formation, and (5) treatment strategy and prognosis. Immunofluorescence staining was used to evaluate the existence of NETs on corneal scrapings. The relationship between the quantification of NETs and the clinical character of the fungal keratitis was identified. RESULTS NETs were identified in all 14 patients. Patients with a higher grade of NET formation and fewer fungal hyphae always showed a good treatment response and a short course of infection. NETs were consistently found mixed with fungal hyphae in the corneal scrapings from infected patients. No statistical significance was found between the grade of NETs formed and the course of infection before presentation, and no relationship between the quantification of NETs and the size of the ulcer was found. CONCLUSIONS The results suggest that NETs are involved in fungal keratitis. The number of NETs in infected corneas may provide a tool for evaluating the prognosis for fungal keratitis.
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Affiliation(s)
- Xiuming Jin
- Eye Center of the 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Yingying Zhao
- Eye Center of the 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Fan Zhang
- Zhejiang University School of Medicine, Hangzhou, China
| | - Ting Wan
- Eye Center of the 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Fangli Fan
- Eye Center of the 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xin Xie
- Eye Center of the 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Zhenyun Lin
- Department of Obstetrics and Gynecology, Hangzhou Maternity Hospital, Hangzhou, China
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167
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Ong HS, Fung SSM, Macleod D, Dart JKG, Tuft SJ, Burton MJ. Altered Patterns of Fungal Keratitis at a London Ophthalmic Referral Hospital: An Eight-Year Retrospective Observational Study. Am J Ophthalmol 2016; 168:227-236. [PMID: 27287820 DOI: 10.1016/j.ajo.2016.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/16/2016] [Accepted: 05/31/2016] [Indexed: 05/28/2023]
Abstract
PURPOSE In previous studies of fungal keratitis (FK) from temperate countries, yeasts were the predominant isolates, with ocular surface disease (OSD) being the leading risk factor. Since the 2005-2006 outbreak of contact lens (CL)-associated Fusarium keratitis, there may have been a rise in CL-associated filamentary FK in the United Kingdom. This retrospective case series investigated the patterns of FK from 2007 to 2014. We compared these to 1994-2006 data from the same hospital. DESIGN Retrospective observational study. METHODS All cases of FK presenting to Moorfields Eye Hospital between 2007 and 2014 were identified. The definition of FK was either a fungal organism isolated by culture or fungal structures identified by light microscopy (LM) of scrape material, histopathology, or in vivo corneal confocal microscopy (IVCM). Main outcome measure was cases of FK per year. RESULTS A total of 112 patients had confirmed FK. Median age was 47.2 years. Between 2007 and 2014, there was an increase in annual numbers of FK (Poisson regression, P = .0001). FK was confirmed using various modalities: 79 (70.5%) by positive culture, 16 (14.3%) by LM, and 61 (54.5%) by IVCM. Seventy-eight patients (69.6%) were diagnosed with filamentary fungus alone, 28 (25%) with yeast alone, and 6 (5.4%) with mixed filamentary and yeast infections. This represents an increase in the proportion of filamentary fungal infections from the pre-2007 data. Filamentary fungal and yeast infections were associated with CL use and OSD, respectively. CONCLUSIONS The number of FK cases has increased. This increase is due to CL-associated filamentary FK. Clinicians should be aware of these changes, which warrant epidemiologic investigations to identify modifiable risk factors.
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Affiliation(s)
- Hon Shing Ong
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom.
| | - Simon S M Fung
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John K G Dart
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom
| | - Stephen J Tuft
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom
| | - Matthew J Burton
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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168
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Ong HS, Fung SSM, Macleod D, Dart JKG, Tuft SJ, Burton MJ. Altered Patterns of Fungal Keratitis at a London Ophthalmic Referral Hospital: An Eight-Year Retrospective Observational Study. Am J Ophthalmol 2016; 168:227-236. [PMID: 27287820 PMCID: PMC4977014 DOI: 10.1016/j.ajo.2016.05.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/16/2016] [Accepted: 05/31/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE In previous studies of fungal keratitis (FK) from temperate countries, yeasts were the predominant isolates, with ocular surface disease (OSD) being the leading risk factor. Since the 2005-2006 outbreak of contact lens (CL)-associated Fusarium keratitis, there may have been a rise in CL-associated filamentary FK in the United Kingdom. This retrospective case series investigated the patterns of FK from 2007 to 2014. We compared these to 1994-2006 data from the same hospital. DESIGN Retrospective observational study. METHODS All cases of FK presenting to Moorfields Eye Hospital between 2007 and 2014 were identified. The definition of FK was either a fungal organism isolated by culture or fungal structures identified by light microscopy (LM) of scrape material, histopathology, or in vivo corneal confocal microscopy (IVCM). Main outcome measure was cases of FK per year. RESULTS A total of 112 patients had confirmed FK. Median age was 47.2 years. Between 2007 and 2014, there was an increase in annual numbers of FK (Poisson regression, P = .0001). FK was confirmed using various modalities: 79 (70.5%) by positive culture, 16 (14.3%) by LM, and 61 (54.5%) by IVCM. Seventy-eight patients (69.6%) were diagnosed with filamentary fungus alone, 28 (25%) with yeast alone, and 6 (5.4%) with mixed filamentary and yeast infections. This represents an increase in the proportion of filamentary fungal infections from the pre-2007 data. Filamentary fungal and yeast infections were associated with CL use and OSD, respectively. CONCLUSIONS The number of FK cases has increased. This increase is due to CL-associated filamentary FK. Clinicians should be aware of these changes, which warrant epidemiologic investigations to identify modifiable risk factors.
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Affiliation(s)
- Hon Shing Ong
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom.
| | - Simon S M Fung
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John K G Dart
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom
| | - Stephen J Tuft
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom
| | - Matthew J Burton
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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169
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Sun CQ, Prajna NV, Krishnan T, Rajaraman R, Srinivasan M, Raghavan A, O'Brien KS, McLeod SD, Acharya NR, Rose-Nussbaumer J. Effect of pretreatment with antifungal agents on clinical outcomes in fungal keratitis. Clin Exp Ophthalmol 2016; 44:763-767. [PMID: 27329780 DOI: 10.1111/ceo.12794] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/12/2016] [Accepted: 06/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND To determine if pretreatment with antifungal agents is predictive of worse clinical outcome in a fungal keratitis clinical trial. DESIGN Non-pre-specified subgroup analysis of a randomized controlled trial in a tertiary hospital. PARTICIPANTS Three hundred twenty-three fungal ulcer cases with an enrolment visual acuity of 20/40 to 20/400. METHODS The Mycotic Ulcer Treatment Trial I was a randomized, double-masked trial to determine the optimal treatment for filamentous fungal keratitis at the Aravind Eye Care System, India. Enrolled cases were randomized to receive topical natamycin or voriconazole. Prior antifungal medication use, dose and duration were collected at enrolment. A subgroup analysis was performed to determine if patients using natamycin or azoles at presentation have worse clinical outcomes compared with those who were not pretreated. MAIN OUTCOME MEASURES Three-month visual acuity (primary), 3-month infiltrate or scar size, corneal perforation and/or transplant and re-epithelialization time. RESULTS Of the 323 patients enrolled, 44% presented on an antifungal agent. Pretreated patients had larger mean baseline infiltrate size (P < 0.001) and epithelial defect size (P = 0.02). Multivariate regression analysis demonstrated that pretreatment was associated with significantly worse 3-month visual acuity (P = 0.006), larger 3-month scar size (P < 0.001) and increased odds of corneal perforation and/or transplant (P = 0.001). CONCLUSIONS Fungal keratitis that is smear-positive despite being pretreated with appropriate antifungal agents appears to be a risk factor for worse outcomes, likely a result of initial ulcer severity and treatment failure. These patients may benefit from more aggressive multimodal therapy at a tertiary centre.
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Affiliation(s)
- Catherine Q Sun
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - N Venkatesh Prajna
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | | | - Revathi Rajaraman
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Muthiah Srinivasan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Stephen D McLeod
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Nisha R Acharya
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Rose-Nussbaumer
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Optometry, University of California Berkeley, Berkeley, California, USA
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171
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Patterson TF, Thompson GR, Denning DW, Fishman JA, Hadley S, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ, Stevens DA, Walsh TJ, Wingard JR, Young JAH, Bennett JE. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 63:e1-e60. [PMID: 27365388 DOI: 10.1093/cid/ciw326] [Citation(s) in RCA: 1593] [Impact Index Per Article: 199.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 12/12/2022] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- Thomas F Patterson
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System
| | | | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, University of Manchester, United Kingdom
| | - Jay A Fishman
- Massachusetts General Hospital and Harvard Medical School
| | | | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine and the Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Vicki A Morrison
- Hennepin County Medical Center and University of Minnesota, Minneapolis
| | | | - Brahm H Segal
- University at Buffalo Jacobs School of Medicine and Biomedical Sciences, and Roswell Park Cancer Institute, New York
| | | | | | - Thomas J Walsh
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York
| | | | | | - John E Bennett
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, Maryland
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172
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Therapeutic Effect of Intrastromal Voriconazole, Topical Voriconazole, and Topical Natamycin on Fusarium Keratitis in Rabbit. J Ophthalmol 2016; 2016:8692830. [PMID: 27298734 PMCID: PMC4889827 DOI: 10.1155/2016/8692830] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/27/2016] [Accepted: 04/18/2016] [Indexed: 11/24/2022] Open
Abstract
Purpose. Evaluating the therapeutic effect of topical and intrastromal voriconazole and topical natamycin on Fusarium keratitis. Methods. 24 rabbits were selected. The stroma of their corneas was inoculated with suspension of Fusarium solani species complex. Seven days after injection they were divided into 4 groups randomly: the first group was treated with topical voriconazole (TV) 1% for one week, the second one with one-time intrastromal injection of voriconazole (ISV) 50 microgram/0.1 mL, and the third group with topical gel of natamycin (TN) for one week, and the last one did not receive any antifungal treatment. Finally the eyes were enucleated and sclerocorneal buttons were sent for histological and microbiological examinations. Results. After treatment the ISV group and TN group showed significantly lower clinical score and colony forming units than the control group (P = 0.040 and P = 0.026, resp.), but there was statistically no significant difference between control and TV groups (P = 0.249) or between ISV and TN groups (P = 0.665). In pathological evaluation, fewer chronic inflammations were reported in 2 of the 3 buttons from TV group and 3 of the 3 buttons from ISV and TN groups in comparison with the control group. Conclusion. Intrastromal injection of voriconazole seems to be effective in treatment of Fusarium keratitis as much as topical natamycin and these are more effective than topical voriconazole.
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173
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Sav H, Ozdemir HG, Altınbas R, Kiraz N, Ilkit M, Seyedmousavi S. Virulence Attributes and Antifungal Susceptibility Profile of Opportunistic Fungi Isolated from Ophthalmic Infections. Mycopathologia 2016; 181:653-61. [PMID: 27193295 DOI: 10.1007/s11046-016-0018-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 05/07/2016] [Indexed: 02/04/2023]
Abstract
Investigations of both virulence factors and antifungal susceptibility profiles are crucial for understanding the pathogenesis and prognosis of ophthalmic mycoses. In this study, we investigated the in vitro antifungal susceptibility of amphotericin B (AMB), voriconazole (VRC), and natamycin (NAT) against a set of 50 fungal isolates obtained from patients with ocular mycoses using the Clinical and Laboratory Standards Institute broth microdilution method. In addition, putative virulence factor, such as secretory phospholipases and proteinases, and biofilm formation activity were analyzed. The geometric means (GMs) of the minimum inhibitory concentrations (MICs) of the antifungals across all isolates were the following (in increasing order): VRC (0.70 μg/mL), AMB (0.81 μg/mL), and NAT (1.05 μg/mL). The highest activity against 14 Aspergillus strains was exhibited by VRC (GM MIC: 0.10 μg/mL), followed by AMB and NAT (GM MICs: 0.21 and 0.27 μg/mL), respectively. However, for 12 Fusarium spp., the GM MIC of VRC (2.66) was higher than those of NAT and AMB (GM MICs 1.3 and 0.8 μg/mL, respectively). Proteinase and phospholipase activity were observed in 30 % and 42 % of the isolates, respectively, whereas only 8 % of the isolates were able to produce biofilms. Phospholipase activity was observed in all Fusarium isolates, but not in any of the Aspergillus isolates. In contrast, biofilm-forming capability was detected in 25 % of the Fusarium isolates, but none of the Aspergillus isolates. The differences in the MICs of AMB, VRC, and NAT, biofilm-forming ability and proteinase and phospholipase activities among the isolates were not significant (p > 0.05). Overall, our study suggests no significant correlation between the antifungal susceptibility profiles and virulence attributes of ocular fungal isolates.
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Affiliation(s)
- Hafize Sav
- Division of Mycology, Department of Microbiology, Cerrahpaşa Faculty of Medicine, Istanbul University, 34098, Istanbul, Turkey.
| | - Havva Gül Ozdemir
- Division of Ophthalmology, Medicosocial Health Center, University of Çukurova, Adana, Turkey
| | - Rabiye Altınbas
- Division of Mycology, Department of Microbiology, Cerrahpaşa Faculty of Medicine, Istanbul University, 34098, Istanbul, Turkey
| | - Nuri Kiraz
- Division of Mycology, Department of Microbiology, Cerrahpaşa Faculty of Medicine, Istanbul University, 34098, Istanbul, Turkey
| | - Macit Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Çukurova, Adana, Turkey
| | - Seyedmojtaba Seyedmousavi
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
- Department of Medical Microbiology, Radboud UMC, Nijmegen, The Netherlands
- Invasive Fungi Research Center, Mazandaran University of Medical Sciences, Sari, Iran
- Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institute of Health (NIH), Bethesda, MD, USA
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174
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Aruljyothi L, Radhakrishnan N, Prajna VN, Lalitha P. Clinical and microbiological study of paediatric infectious keratitis in South India: a 3-year study (2011–2013). Br J Ophthalmol 2016; 100:1719-1723. [DOI: 10.1136/bjophthalmol-2015-307631] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 12/12/2015] [Accepted: 02/07/2016] [Indexed: 11/03/2022]
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175
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Warner DB, WrightIII HE, Rosenbaum ER. Rhizopus Keratitis Associated with Poor Contact Lens Hygiene. Case Rep Ophthalmol 2016; 7:21-4. [PMID: 26889155 PMCID: PMC4748783 DOI: 10.1159/000443325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We report a case of Rhizopus keratitis in a young woman with poor contact lens hygiene. The mold was highly sensitive to treatment with amphotericin 0.15% drops, after a relatively prompt diagnosis. Obtaining cultures of both corneal infiltrates and presumably infected contact lenses may help to avoid a delay in proper treatment.
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Affiliation(s)
- David B Warner
- Department of Ophthalmology, University of Arkansas for Medical Sciences, Little Rock, Ark., USA
| | - Hugh E WrightIII
- Department of Ophthalmology, University of Arkansas for Medical Sciences, Little Rock, Ark., USA
| | - Eric R Rosenbaum
- Department of Microbiology, University of Arkansas for Medical Sciences, Little Rock, Ark., USA
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176
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Zimmerman AB, Nixon AD, Rueff EM. Contact lens associated microbial keratitis: practical considerations for the optometrist. CLINICAL OPTOMETRY 2016; 8:1-12. [PMID: 30214344 PMCID: PMC6095396 DOI: 10.2147/opto.s66424] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Microbial keratitis (MK) is a corneal condition that encompasses several different pathogens and etiologies. While contact lens associated MK is most often associated with bacterial infections, other pathogens (fungi, Acanthamoeba species, etc) may be responsible. This review summarizes the risk factors, microbiology, diagnostic characteristics, and treatment options for all forms of contact lens-related MK.
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Affiliation(s)
| | - Alex D Nixon
- College of Optometry, The Ohio State University, Columbus, OH, USA,
| | - Erin M Rueff
- College of Optometry, The Ohio State University, Columbus, OH, USA,
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177
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Al-Hatmi AMS, Meletiadis J, Curfs-Breuker I, Bonifaz A, Meis JF, De Hoog GS. In vitro combinations of natamycin with voriconazole, itraconazole and micafungin against clinical Fusarium strains causing keratitis. J Antimicrob Chemother 2015; 71:953-5. [PMID: 26702918 DOI: 10.1093/jac/dkv421] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 11/09/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Fusarium species cause a broad spectrum of infections, from superficial to disseminated disease. Because Fusarium species are intrinsically resistant to most antifungal drugs, new approaches are needed. The aim of the present study was to evaluate the in vitro combination of natamycin with currently used antifungal drugs. METHODS The in vitro interactions of combinations between natamycin and voriconazole, itraconazole and micafungin applied to 20 clinical Fusarium strains (members of Fusarium falciforme, Fusarium napiforme, Fusarium petroliphilum, Fusarium proliferatum, Fusarium pseudensiforme and Fusarium sacchari) were evaluated using a chequerboard microdilution method. The MICs of all drugs alone and in combination were determined visually after 48 h and interactions were assessed using fractional inhibitory concentration index (FICI) analysis. RESULTS MICs of voriconazole and natamycin alone were 4 to >16 and 4-8 mg/L, respectively. Values were reduced 3.5-10-fold to 0.02-0.5 mg/L and 0.5-5-fold to 0.13-2 mg/L in combination, for the currently used antifungals and natamycin, respectively, demonstrating additive to synergistic interactions. The combinations natamycin/voriconazole, natamycin/itraconazole and natamycin/micafungin were synergistic (FICI ≤0.5) for 70%, 15% and 5% of the strains, respectively. No antagonism was found. CONCLUSIONS The combination of natamycin with voriconazole was strongly synergistic at clinically achievable serum concentrations.
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Affiliation(s)
- Abdullah M S Al-Hatmi
- CBS-KNAW Fungal Biodiversity Centre, PO Box 85167, 3508 AD Utrecht, The Netherlands Institutes of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands Directorate General of Health Services, Ibri Hospital, Ministry of Health, Muscat, Oman
| | - Joseph Meletiadis
- Clinical Microbiology Laboratory, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ilse Curfs-Breuker
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Jacques F Meis
- Department of Medical Microbiology and Infectious Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - G Sybren De Hoog
- CBS-KNAW Fungal Biodiversity Centre, PO Box 85167, 3508 AD Utrecht, The Netherlands Institutes of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands Basic Pathology Department, Federal University of Paraná State, Curitiba, Paraná, Brazil Biology Department, Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
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178
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Rose-Nussbaumer J, Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Srinivasan M, Raghavan A, Oldenburg CE, O'Brien KS, Ray KJ, Porco TC, McLeod SD, Acharya NR, Keenan JD, Lietman TM. Risk factors for low vision related functioning in the Mycotic Ulcer Treatment Trial: a randomised trial comparing natamycin with voriconazole. Br J Ophthalmol 2015; 100:929-932. [PMID: 26531051 DOI: 10.1136/bjophthalmol-2015-306828] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 09/04/2015] [Accepted: 10/03/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS The Mycotic Ulcer Treatment Trial I (MUTT I) was a double-masked, multicentre, randomised controlled trial, which found that topical natamycin is superior to voriconazole for the treatment of filamentous fungal corneal ulcers. In this study, we determine risk factors for low vision-related quality of life in patients with fungal keratitis. METHODS The Indian visual function questionnaire (IND-VFQ) was administered to MUTT I study participants at 3 months. Associations between patient and ulcer characteristics and IND-VFQ subscale score were assessed using generalised estimating equations. RESULTS 323 patients were enrolled in the trial, and 292 (90.4%) completed the IND-VFQ at 3 months. Out of a total possible score of 100, the average VFQ score for all participants was 81.3 (range 0-100, SD 23.6). After correcting for treatment arm, each logMAR line of worse baseline visual acuity in the affected eye resulted in an average 1.2 points decrease on VFQ at 3 months (95% CI -1.8 to 0.6, p<0.001). Those who required therapeutic penetrating keratoplasty had an average of 25.2 points decrease on VFQ after correcting for treatment arm (95% CI -31.8 to -18.5, p<0.001). Study participants who were unemployed had on average 28.5 points decrease on VFQ (95% CI -46.9 to -10.2, p=0.002) after correcting for treatment arm. CONCLUSIONS Monocular vision loss from corneal opacity due to fungal keratitis reduced vision-related quality of life. Given the relatively high worldwide burden of corneal opacity, improving treatment outcomes of corneal infections should be a public health priority. TRIAL REGISTRATION NUMBER Clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Department of Optometry, University of California Berkeley
| | | | | | | | | | | | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Travis C Porco
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Stephen D McLeod
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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179
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Spierer O, Dugar J, Miller D, OʼBrien TP. Comparative antifungal susceptibility analysis of Candida albicans versus non-albicans Candida corneal isolates. Cornea 2015; 34:576-9. [PMID: 25826327 DOI: 10.1097/ico.0000000000000380] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the in vitro activity of topical amphotericin B (AMB), natamycin, voriconazole, and fluconazole against human corneal isolates of Candida sp. for guidance in the treatment of Candida keratitis. METHODS Sixty-eight Candida isolates (37 albicans and 31 non-albicans isolates) recovered from corneal scrapings submitted to rule out microbial keratitis, during the years 2005 to 2011, at the Bascom Palmer Eye Institute, were examined in this study. Corneal isolates were cultured on fungal agars for 48 hours. Each yeast isolate was dispensed into 4 microtiter wells, each containing 100 mL of commercial (natamycin 5%) or compounded (AMB 0.15%, voriconazole 1%, and fluconazole 0.2%) antifungal medications. A comparison of growth patterns was conducted. RESULTS One hundred percent of the samples showed growth inhibition after treatment exposure with AMB or natamycin. The isolates treated with voriconazole demonstrated an 85% inhibition rate overall, with the Candida albicans samples showing a 77% inhibition rate and the non-albicans sp. a 93% inhibition rate. In the fluconazole group, there was only a 19.6% inhibition rate noted, with a 7.7% inhibition rate observed in the C. albicans group versus a 30% inhibition rate in the non-albicans group. CONCLUSIONS AMB 0.2% and natamycin 5% have equal effectiveness and full inhibition against Candida keratitis isolates. Fluconazole 0.2% is not the drug of choice in both C. albicans and non-albicans keratitis. Voriconazole 1% may need a stronger concentration for higher effectiveness, but potentially may be helpful as a second agent in the treatment of Candida keratitis.
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Affiliation(s)
- Oriel Spierer
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
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180
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Rose-Nussbaumer J, Prajna NV, Krishnan KT, Mascarenhas J, Rajaraman R, Srinivasan M, Raghavan A, Oldenburg CE, O'Brien KS, Ray KJ, McLeod SD, Porco TC, Lietman TM, Acharya NR, Keenan JD. Vision-Related Quality-of-Life Outcomes in the Mycotic Ulcer Treatment Trial I: A Randomized Clinical Trial. JAMA Ophthalmol 2015; 133:642-6. [PMID: 25764482 DOI: 10.1001/jamaophthalmol.2015.0319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Given the limitations in health care resources, quality-of-life measures for interventions have gained importance. OBJECTIVE To determine whether vision-related quality-of-life outcomes were different between the natamycin and voriconazole treatment arms in the Mycotic Ulcer Treatment Trial I, as measured by an Indian Vision Function Questionnaire. DESIGN, SETTING, AND PARTICIPANTS Secondary analysis (performed October 11-25, 2014) of a double-masked, multicenter, randomized, active comparator-controlled, clinical trial at multiple locations of the Aravind Eye Care System in South India that enrolled patients with culture- or smear-positive filamentous fungal corneal ulcers who had a baseline visual acuity of 20/40 to 20/400 (logMAR of 0.3-1.3). INTERVENTIONS Study participants were randomly assigned to topical voriconazole, 1%, or topical natamycin, 5%. MAIN OUTCOMES AND MEASURES Subscale score on the Indian Vision Function Questionnaire from each of the 4 subscales (mobility, activity limitation, psychosocial impact, and visual function) at 3 months. RESULTS A total of 323 patients were enrolled in the trial, and 292 (90.4%) completed the Indian Vision Function Questionnaire at 3 months. The majority of study participants had subscale scores consistent with excellent function. After adjusting for baseline visual acuity and organism, we found that study participants in the natamycin-treated group scored, on average, 4.3 points (95% CI, 0.1-8.5) higher than study participants in the voriconazole-treated group (P = .046). In subgroup analyses looking at ulcers caused by Fusarium species and adjusting for baseline best spectacle-corrected visual acuity, the natamycin-treated group scored 8.4 points (95% CI, 1.9-14.9) higher than the voriconazole-treated group (P = .01). Differences in quality of life were not detected for patients with Aspergillus or other non-Fusarium species as the causative organism (1.5 points [95% CI, -3.9 to 6.9]; P = .52). CONCLUSIONS AND RELEVANCE We found evidence of improvement in vision-related quality of life among patients with fungal ulcers who were randomly assigned to natamycin compared with those randomly assigned to voriconazole, and especially among patients with Fusarium species as the causative organism. Incorporation of quality-of-life measures in clinical trials is important to fully evaluate the effect of the studied interventions. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT00996736.
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Affiliation(s)
- Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco3Department of Optometry, University of California, Berkeley
| | - N Venkatesh Prajna
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - K Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - Jeena Mascarenhas
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - Anita Raghavan
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | | | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco
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181
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Ong HS, Corbett MC. Corneal infections in the 21st century. Postgrad Med J 2015; 91:565-71. [PMID: 26354125 DOI: 10.1136/postgradmedj-2015-133323] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/14/2015] [Indexed: 11/04/2022]
Abstract
Ninety years ago, the first issue of the Postgraduate Medical Journal published a review of an article written by Mr Robert Lindsay-Rea, a consultant ophthalmic surgeon in the Western Ophthalmic Hospital and an oculist in the West End Hospital for Nervous Diseases, entitled "A preliminary report on the treatment of keratitis". Today, microbial keratitis remains an important cause of avoidable visual impairment in the world. The aetiology of microbial keratitis has changed greatly over the past century due to the discovery of antibiotics, improvement in sanitation and education, the rising trend of contact lens wear and increased air travel. Significant advances have also been made in our understanding and management of this important disorder. This article highlights some of these changes and discusses the current management and research.
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Affiliation(s)
- Hon Shing Ong
- Department of Corneal and Ocular Surface Disease, The Western Eye Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Melanie C Corbett
- Department of Corneal and Ocular Surface Disease, The Western Eye Hospital, Imperial College Healthcare NHS Trust, London, UK
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182
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Seasonal, geographic, and antimicrobial resistance patterns in microbial keratitis: 4-year experience in eastern Pennsylvania. Cornea 2015; 34:296-302. [PMID: 25603231 DOI: 10.1097/ico.0000000000000352] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to review the demographics, causative organisms, seasonal and geographic variation, and antimicrobial resistance patterns of microbial keratitis at our institution over a 4-year period. METHODS Electronic medical records of all patients with microbial keratitis who underwent corneal culturing at a single institution in eastern Pennsylvania between January 1, 2009 and December 31, 2012 were reviewed. RESULTS A total of 311 patients representing 323 instances of infectious keratitis were analyzed. The most frequently implicated organisms in contact lens-related infections were Pseudomonas aeruginosa for bacteria and Fusarium species for fungus, compared with Staphylococcus aureus and Candida species in non-contact lens-associated bacterial infections. Bacterial keratitis occurred most frequently in spring and least frequently in winter (P = 0.024). Patients who live in large fringe metro (suburban) areas accounted for the highest proportion of infectious keratitis cases. P. aeruginosa and methicillin-sensitive S. aureus isolates were highly susceptible to fluoroquinolones, whereas 32% of coagulase-negative staphylococcus isolates tested were resistant to moxifloxacin and gatifloxacin, and all methicillin-resistant S. aureus organisms tested were resistant to these 2 fluoroquinolones. No organisms tested were resistant to tobramycin, gentamicin, or vancomycin. No fungal infections tested were resistant to voriconazole. CONCLUSIONS Most infectious keratitis occurred in nonwinter months and in patients from suburban counties. Although fluoroquinolones were effective against the most common bacteria, staphylococcal species exhibited a high rate of resistance, representing a therapeutic challenge given the increasing use of fluoroquinolones as first-line monotherapy. No organisms tested were resistant to tobramycin, gentamicin, vancomycin, or voriconazole.
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183
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Wang L, Wang L, Han L, Yin W. Study of Pathogens of Fungal Keratitis and the Sensitivity of Pathogenic Fungi to Therapeutic Agents with the Disk Diffusion Method. Curr Eye Res 2015; 40:1095-101. [PMID: 26268399 DOI: 10.3109/02713683.2015.1056802] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE/AIM OF THE STUDY To identify the causative fungi of fungal keratitis, test their susceptibility to antifungal agents with the disk diffusion method and study the relationship between the organisms, the inhibition zones and the clinical outcomes. MATERIALS AND METHODS 535 patients with fungal keratitis in one eye were included in this study. Pathogenic fungi were isolated by corneal scraping, identified by fungal cultivation and subjected to drug sensitivity tests conducted with the disk diffusion method. The patients were treated initially with voriconazole, terbinafine and natamycin eye drops for one week. Further treatment continued using the most effective drug according to the drug sensitivity results. The patients were followed up every week until three months after cured. The inhibition zones of fungi cultured with voriconazole, terbinafine and natamycin were compared. The relationship between inhibition zones and organism, organism and treatment results measure, and each treatment results measure and inhibition zones were evaluated. RESULTS Of 535 patients, 53.84%, 19.25% and 26.91% were infected with Aspergillus, Fusarium and other fungi, respectively. Keratitis patients infected with Aspergillus keratitis had the worst outcome. The size of the inhibition zones of Aspergillus spp., Fusarium spp. and other fungal genera differed significantly in response to voriconazole, terbinafine and natamycin. The inhibition zone associated with natamycin correlated significantly with the clinical outcome of fungal keratitis (OR = 0.925), but no other such correlations were found for the other drugs tested. CONCLUSIONS Aspergillus and Fusarium were the predominant pathogenic genera causing fungal keratitis in our patients. Among the causative fungi, infections due to Aspergillus spp. were associated with the worst outcomes. The inhibition zones of fungal isolates in response to natamycin significantly correlated with the treatment outcomes of keratitis. Specifically, the smaller the natamycin inhibition zone, the lower the probability that the fungal keratitis had been eliminated.
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Affiliation(s)
- Lulu Wang
- a Department of Ophthalmology , Zhengzhou University People's Hospital , Zhengzhou , P.R. China
| | - Liya Wang
- a Department of Ophthalmology , Zhengzhou University People's Hospital , Zhengzhou , P.R. China
| | - Lei Han
- a Department of Ophthalmology , Zhengzhou University People's Hospital , Zhengzhou , P.R. China
| | - Weijing Yin
- a Department of Ophthalmology , Zhengzhou University People's Hospital , Zhengzhou , P.R. China
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Uddaraju M, Mascarenhas J, Das MR, Radhakrishnan N, Keenan JD, Prajna L, Prajna VN. Corneal Cross-linking as an Adjuvant Therapy in the Management of Recalcitrant Deep Stromal Fungal Keratitis: A Randomized Trial. Am J Ophthalmol 2015; 160:131-4.e5. [PMID: 25841317 DOI: 10.1016/j.ajo.2015.03.024] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 03/27/2015] [Accepted: 03/29/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the efficacy of corneal cross-linking (CXL) as an adjuvant to appropriate antifungal therapy in nonresolving deep stromal fungal keratitis. DESIGN Randomized clinical trial. METHODS Eyes with culture-positive deep stromal fungal keratitis not responding to appropriate medical therapy for a period of 2 weeks were randomized to receive either adjuvant CXL or no additional treatment. Antifungal medical therapy was continued in both groups. The prespecified primary outcome was treatment failure at 6 weeks after enrollment, defined as perforation and/or increase in ulcer size by ≥2 mm. RESULTS The trial was stopped before full enrollment because of a marked difference in the rate of perforation between the 2 groups. Of the 13 cases enrolled in the study, 6 were randomized to the CXL group and 7 to the non-CXL group. Five eyes in the CXL group and 3 eyes in the non-CXL group experienced treatment failure by 6 weeks (P = .56). In a secondary analysis, the CXL group experienced more perforations than the non-CXL group (4 vs 0, respectively; P = .02). CONCLUSION CXL used as adjuvant therapy for recalcitrant deep stromal fungal keratitis did not improve outcomes.
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185
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First Human Case of Fungal Keratitis Caused by a Putatively Novel Species of Lophotrichus. J Clin Microbiol 2015; 53:3063-7. [PMID: 26109445 DOI: 10.1128/jcm.00471-15] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/17/2015] [Indexed: 11/20/2022] Open
Abstract
We report an aggressive fungal keratitis caused by a putatively novel species of Lophotrichus in a patient with traumatic injury to the cornea from a dog paw. The organism was isolated from the patient's necrotic cornea, which perforated despite coverage with hourly fortified broad-spectrum topical antibiotic therapy. This report represents the first case of human infection caused by this species.
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Prajna NV, Prajna L, O'Brien KS, Sun CQ, Acharya N, Lietman TM, Rose-Nussbaumer J. Association of pretreatment with antifungal medication and fungal resistance in the mycotic ulcer treatment trial I. JAMA Ophthalmol 2015; 133:1210-1. [PMID: 26110254 DOI: 10.1001/jamaophthalmol.2015.2040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
| | | | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Catherine Q Sun
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Nisha Acharya
- Francis I. Proctor Foundation, University of California, San Francisco3Department of Epidemiology and Biostatistics, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco3Department of Epidemiology and Biostatistics, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Optometry, University of California, Berkeley
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Qiu S, Zhao GQ, Lin J, Wang X, Hu LT, Du ZD, Wang Q, Zhu CC. Natamycin in the treatment of fungal keratitis: a systematic review and Meta-analysis. Int J Ophthalmol 2015; 8:597-602. [PMID: 26086015 DOI: 10.3980/j.issn.2222-3959.2015.03.29] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/09/2015] [Indexed: 11/02/2022] Open
Abstract
AIM To review published clinical studies examining the effect of natamycin in the treatment of fungal keratitis. METHODS We selected the publications in CENTRAL, MEDLINE, EMBASE, CNKI, and CBM. This study systematically reviewed published randomized controlled trials (RCTs) that compared natamycin to other antifungal agents, and conducted feasible Meta-analysis of efficacy results using Revman 5.2 software. RESULTS We included seven trials which were mainly carried out in developing countries of Asia, with five trials conducted in India, one each in China and Bangladesh. A total of 804 participants were randomized to following comparisons: 2% econazole versus 5% natamycin showed little difference in the effects of treatment of fungal keratitis [RR=0.99, 95% confidence interval (CI), 0.8 to 1.21]; chlorhexidine gluconate versus 5% natamycin indicated that the results on healing of the ulcer at 21d was less conclusive (RR=0.77, 95% CI, 0.55 to 1.08; I (2)=0%); 1% voriconazole versus 5% natamycin suggested that natamycin treatment appeared to be significantly better outcomes than voriconazole (regression coefficient =-0.18 logMAR; 95% CI, -0.30 to -0.05; P=0.006), especially in Fusarium cases (regression coefficient=-0.41 logMAR; 95% CI, -0.61 to -0.20; P<0.001); natamycin versus fluconazole showed a significant difference in cure rate (χ(2)=5.048, P<0.05) and natamycin group was more effective than fluconazole in average period of therapy (t=7.94, P<0.01). CONCLUSION Natamycin was a preferable choice in the treatment of fungal keratitis, especially in the early period of Fusarium cases.
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Affiliation(s)
- Sheng Qiu
- Department of Ophthalmology, Medical College, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Gui-Qiu Zhao
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Jing Lin
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Xue Wang
- Department of Ophthalmology, Medical College, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Li-Ting Hu
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Zhao-Dong Du
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Qian Wang
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Cheng-Cheng Zhu
- Department of Ophthalmology, Medical College, Qingdao University, Qingdao 266071, Shandong Province, China
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Sobolewska B, Guerel G, Hofmann J, Tarek B, Bartz-Schmidt KU, Yoeruek E. Cytotoxic Effect of Voriconazole on Human Corneal Epithelial Cells. Ophthalmic Res 2015; 54:41-7. [DOI: 10.1159/000371712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 12/18/2014] [Indexed: 11/19/2022]
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Solanki S, Rathi M, Khanduja S, Dhull C, Sachdeva S, Phogat J. Recent trends: Medical management of infectious keratitis. Oman J Ophthalmol 2015; 8:83-5. [PMID: 26622133 PMCID: PMC4640046 DOI: 10.4103/0974-620x.159104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This review article highlights the newer diagnostic modalities and approaches in the medical management of infectious keratitis. A Medline literature search conducted to March 2014 has been included. Recent studies or publications were selected from international indexed journals using suitable key words. Development of specular microscopy and polymerase chain reaction (PCR) has a promising role as diagnostic modalities in infectious keratitis, especially in refractory cases. Previously fortified antibiotics have been the mainstay of treatment for bacterial keratitis. Recently, the advent of fourth-generation fluoroquinolones monotherapy has shown promising results in the management of bacterial keratitis. Corneal collagen cross-linking is being considered in the refractory cases. Topical natamycin and amphotericin B should be considered as the first choice anti-fungal agents in suspected filamentous or yeast infection respectively. Voriconazole and newer routes of administration such as intrastromal and intracameral injection of conventional anti-fungal agents have demonstrated a positive clinical response. Ganciclovir is a newer anti-viral agent with promising results in herpes simplex keratitis. Thus, introduction of newer diagnostic modalities and collagen cross-linking along with fourth-generation fluoroquinolones and newer azoles have a promising role in the management of infectious keratitis.
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Affiliation(s)
- Sneha Solanki
- Department of Ophthalmology, Regional Institute of Ophthalmology, Pt.B.D. Sharma, PGIMS, Rohtak, Haryana, India
| | - Manisha Rathi
- Department of Ophthalmology, Regional Institute of Ophthalmology, Pt.B.D. Sharma, PGIMS, Rohtak, Haryana, India
| | - Sumeet Khanduja
- Department of Ophthalmology, Regional Institute of Ophthalmology, Pt.B.D. Sharma, PGIMS, Rohtak, Haryana, India
| | - C.S. Dhull
- Department of Ophthalmology, Regional Institute of Ophthalmology, Pt.B.D. Sharma, PGIMS, Rohtak, Haryana, India
| | - Sumit Sachdeva
- Department of Ophthalmology, Regional Institute of Ophthalmology, Pt.B.D. Sharma, PGIMS, Rohtak, Haryana, India
| | - Jitender Phogat
- Department of Ophthalmology, Regional Institute of Ophthalmology, Pt.B.D. Sharma, PGIMS, Rohtak, Haryana, India
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Abstract
BACKGROUND Fungal keratitis is a fungal infection of the cornea. It is common in lower income countries, particularly in agricultural areas but relatively uncommon in higher income countries. Although there are medications available, their effectiveness is unclear. OBJECTIVES To assess the effects of different antifungal drugs in the management of fungal keratitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 2), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to March 2015), EMBASE (January 1980 to March 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to March 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 16 March 2015. SELECTION CRITERIA We included randomised controlled trials of medical therapy for fungal keratitis. DATA COLLECTION AND ANALYSIS Two review authors selected studies for inclusion in the review, assessed trials for risk of bias and extracted data. The primary outcome was clinical cure at two to three months. Secondary outcomes included best-corrected visual acuity, time to clinical cure, compliance with treatment, adverse outcomes and quality of life. MAIN RESULTS We included 12 trials in this review; 10 trials were conducted in India, one in Bangladesh and one in Egypt. Seven of these trials were at high risk of bias in one or more domains, two of these studies were at low risk of bias in all domains. Participants were randomised to the following comparisons: topical 5% natamycin compared to topical 1% voriconazole; topical 5% natamycin compared to topical 2% econazole; topical 5% natamycin compared to topical chlorhexidine gluconate (0.05%, 0.1% and 0.2%); topical 1% voriconazole compared to intrastromal voriconazole 50 g/0.1 mL (both treatments combined with topical 5% natamycin); topical 1% voriconazole combined with oral voriconazole compared to both oral voriconazole and oral itraconazole (both combined with topical 5% natamycin); topical 1% itraconazole compared to topical 1% itraconazole combined with oral itraconazole; topical amphotericin B compared to topical amphotericin B combined with subconjunctival injection of fluconazole; intracameral injection of amphotericin B with conventional treatment compared to conventional treatment alone (severe fungal ulcers); topical 0.5% and 1% silver sulphadiazine compared to topical 1% miconazole. Overall the results were inconclusive because for most comparisons only one small trial was available. The exception was the comparison of topical natamycin and topical voriconazole for which three trials were available. In one of these trials clinical cure (healed ulcer) was reported in all 15 people allocated to natamycin and in 14/15 people allocated to voriconazole (risk ratio (RR) 1.07; 95% confidence interval (CI) 0.89 to 1.28, low quality evidence). In one trial people randomised to natamycin were more likely to have a microbiological cure at six days (RR 1.64; 95% CI 1.38 to 1.94, 299 participants). On average, people randomised to natamycin had better spectacle-corrected visual acuity at two to three months compared to people randomised to voriconazole but the estimate was uncertain and the 95% confidence intervals included 0 (no difference) (mean difference -0.12 logMAR, 95% CI -0.31 to 0.06, 434 participants; 3 studies, low quality evidence) and a decreased risk of corneal perforation or therapeutic penetrating keratoplasty, or both (RR 0.61; 95% CI 0.40 to 0.94, 434 participants, high quality evidence). There was inconclusive evidence on time to clinical cure. Compliance with treatment and quality of life were not reported. One trial comparing natamycin and voriconazole found the effect of treatment greater in Fusarium species, but this subgroup analysis was not prespecified by this review. AUTHORS' CONCLUSIONS The trials included in this review were of variable quality and were generally underpowered. There is evidence that natamycin is more effective than voriconazole in the treatment of fungal ulcers. Future research should evaluate treatment effects according to fungus species.
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Affiliation(s)
- Nilo Vincent FlorCruz
- University of the Phillipines‐Philippine General HospitalDepartment of Ophthalmology and Visual SciencesTaft AvenueManilaPhilippines1000
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision Group, ICEHKeppel StreetLondonUKWC1E 7HT
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191
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Kawakami H, Inuzuka H, Hori N, Takahashi N, Ishida K, Mochizuki K, Ohkusu K, Muraosa Y, Watanabe A, Kamei K. Inhibitory effects of antimicrobial agents againstFusariumspecies. Med Mycol 2015; 53:603-11. [DOI: 10.1093/mmy/myv016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/10/2015] [Indexed: 11/12/2022] Open
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192
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Sharma S, Das S, Virdi A, Fernandes M, Sahu SK, Kumar Koday N, Ali MH, Garg P, Motukupally SR. Re-appraisal of topical 1% voriconazole and 5% natamycin in the treatment of fungal keratitis in a randomised trial. Br J Ophthalmol 2015; 99:1190-5. [PMID: 25740805 DOI: 10.1136/bjophthalmol-2014-306485] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 02/15/2015] [Indexed: 11/04/2022]
Abstract
PURPOSE To compare the efficacy of topical 1% voriconazole vs 5% natamycin for the treatment of fungal keratitis. METHODS In a prospective, double-masked, randomised, controlled, registered clinical trial, 118 patients with fungal keratitis were treated using identical dosage schedule with either voriconazole (58) or natamycin (60) as inpatients for 7 days and followed up weekly. The outcome measures were percentage of patients with healed or resolving ulcer and final visual acuity at last follow-up (primary) and on day 7 (secondary) in each group. RESULTS More patients (p=0.005) on natamycin (50/56, 89.2%) had healed or resolving ulcer compared with voriconazole (34/51, 66.6%) at last follow-up. The improvement in vision was marginally greater in patients in the natamycin group compared with the voriconazole group at day 7 (p=0.04) and significantly greater at final visit (p=0.01). In univariate analysis, drug, age and mean size of corneal infiltrate and epithelial defect had a significant effect on the final visual outcome. In multivariate analysis, the effect of drug (voriconazole vs natamycin, adjusted coefficient 0.27 (-0.04 to 0.57), p=0.09) was marginal while the effect of age and epithelial defect was significant (p<0.001 for both). In the group treated with natamycin, the final visual acuity was significantly better (p=0.005, Wilcoxon signed-rank test) in patients with Fusarium keratitis but not with Aspergillus keratitis (p=0.714, paired t test). CONCLUSIONS When compared with voriconazole, natamycin was more effective in the treatment of fungal keratitis, especially Fusarium keratitis. TRIAL REGISTRATION NUMBER Clinical Trial Registry India (2010/091/003041).
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Affiliation(s)
- Savitri Sharma
- L V Prasad Eye Institute, Bhubaneswar, Odisha, India L V Prasad Eye Institute, Brien Holden Eye Research Center, Hyderabad, Andhra Pradesh, India
| | - Sujata Das
- L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Ajoy Virdi
- L V Prasad Eye Institute, Bhubaneswar, Odisha, India
| | - Merle Fernandes
- L V Prasad Eye Institute, Visakhapatnam, Andhra Pradesh, India
| | | | | | - Md Hasnat Ali
- L V Prasad Eye Institute, Brien Holden Eye Research Center, Hyderabad, Andhra Pradesh, India
| | - Prashant Garg
- L V Prasad Eye Institute, Brien Holden Eye Research Center, Hyderabad, Andhra Pradesh, India
| | - Swapna R Motukupally
- L V Prasad Eye Institute, Brien Holden Eye Research Center, Hyderabad, Andhra Pradesh, India
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193
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Ali TK, Amescua G, Miller D, Suh LH, Delmonte DW, Gibbons A, Alfonso EC, Forster RK. Contact-Lens-Associated Purpureocillium Keratitis: Risk Factors, Microbiologic Characteristics, Clinical Course, and Outcomes. Semin Ophthalmol 2015; 32:157-162. [DOI: 10.3109/08820538.2015.1011342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Tayyeba K. Ali
- Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Guillermo Amescua
- Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Darlene Miller
- Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Leejee H. Suh
- Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Derek W. Delmonte
- Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Allister Gibbons
- Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Eduardo C. Alfonso
- Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Richard K. Forster
- Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
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194
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Vélez M, Balparda K, Díaz AM. A rare pigmented keratitis caused by Aspergillus fumigatus. Int J Ophthalmol 2015; 8:208-10. [PMID: 25709935 PMCID: PMC4325269 DOI: 10.3980/j.issn.2222-3959.2015.01.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 03/13/2014] [Indexed: 01/23/2023] Open
Affiliation(s)
| | - Kepa Balparda
- Universidad Pontificia Bolivariana, Medellín, Colombia
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195
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Vasantha Ruban V, Geraldine P, Kaliamurthy J, Jesudasan CAN, Thomas PA. Keratitis due to Fusarium langsethiae: clinical profile, molecular identification, and susceptibility to antifungals. Mycopathologia 2015; 179:453-8. [PMID: 25645251 DOI: 10.1007/s11046-015-9866-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 01/21/2015] [Indexed: 11/24/2022]
Abstract
We report a case of keratitis due to Fusarium langsethiae in a 56-year-old man. The patient presented with pain and tearing of 10 days duration in the right eye, which had sustained a paddy stalk injury. On examination, a hypopyon corneal ulcer was noted in the right eye. Multiple scrapings were obtained from the affected part of the cornea. A lactophenol cotton blue wet mount and a Gram-stained smear of scrapings were made. Scrapings were also inoculated on various culture media, including Sabouraud dextrose agar (SDA). A fungal etiology was sought by conventional microbiological techniques and polymerase chain reaction. In vitro susceptibility testing was performed by an agar dilution method. Direct microscopy of corneal scrapings revealed septate hyphae, leading to initiation of intensive topical therapy with natamycin (5 %). However, the keratitis progressed, necessitating therapeutic penetrating keratoplasty. White, powdery-like colonies, with abundant aerial mycelium, were recovered on SDA from corneal scrape material. Based on macroscopic and microscopic morphological features, the isolated fungus was initially identified as a Fusarium species. Sequence analysis of the 28S rRNA region of the fungal genome led to a specific identification of F. langsethiae. Antifungal susceptibility testing results suggested that the strain isolated was susceptible to voriconazole, ketoconazole, and itraconazole. To our knowledge, this is the first reported case of keratitis due to F. langsethiae; attention is drawn to the unique characteristics of the fungal isolate, difficulties in identification and non-responsiveness to medical therapy.
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Affiliation(s)
- Vasanthakumar Vasantha Ruban
- Department of Animal Science, School of Life Sciences, Bharathidasan University, Tiruchirappalli, 620 024, Tamil Nadu, India
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Lekhanont K, Nonpassopon M, Nimvorapun N, Santanirand P. Treatment with intrastromal and intracameral voriconazole in 2 eyes with Lasiodiplodia theobromae keratitis: case reports. Medicine (Baltimore) 2015; 94:e541. [PMID: 25674759 PMCID: PMC4602755 DOI: 10.1097/md.0000000000000541] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To report the clinical presentation and the role of intrastromal and intracameral voriconazole injection in the management of rare cases of fungal keratitis caused by Lasiodiplodia theobromae.Two eyes of 2 patients with Lasiodiplodia keratitis unresponsive to topical and oral antifungal medications were included in this study. Diagnosis of Lasiodiplodia keratitis was confirmed by microbiological analysis, including culture-based (case 1 and 2) and DNA sequencing techniques (case 2 only).The first patient presented with multiple satellite lesions and one of these infiltrates spread deeply into the cornea, forming a stromal abscess. Another patient had a large full-thickness corneal infiltrates with several fungal balls in the anterior chamber, requiring a limbus-to-limbus therapeutic penetrating keratoplasty. Despite aggressive topical therapy, the stromal abscess continued to worsen in the first case and recurrent keratitis was observed postoperatively in the second case. Voriconazole 50 μg/0.1 mL was administered intracamerally and intrastromally around the fungal abscess as adjuncts to topical antimycotics in the first case. The second patient who needed therapeutic keratoplasty was treated with an intracameral injection of 50 μg/0.1 mL voriconazole at the end of surgery. Postoperatively, 100 μg/0.1 mL voriconazole was also injected intracamerally after the recurrence of infection was noted in the graft. Reinjections were given 48 hours apart in both cases. After the injections, all corneal and anterior chamber lesions were reduced in size and density and completely resolved within 4 weeks.Intrastromal and intracameral voriconazole injections may offer safe and effective treatment options for L theobromae keratitis.
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Affiliation(s)
- Kaevalin Lekhanont
- From the Department of Ophthalmology (KL, MN, NN); and Department of Pathology (PS), Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Arbelaez JG, Feng MT, Pena TJ, Price MO, Price FW. A year of cornea in review: 2013. Asia Pac J Ophthalmol (Phila) 2015; 4:40-50. [PMID: 26068612 DOI: 10.1097/apo.0000000000000110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The goal of this study was to provide an update of significant corneal literature published in 2013. DESIGN This study is a systematic literature review. METHODS We conducted a systematic review of the English-language literature published from January 1, 2013, to December 31, 2013, using the following PubMed search and Medical Subject Headings terms: cornea transplantation, keratoplasty, Descemet membrane endothelial keratoplasty, Descemet stripping endothelial keratoplasty, cross linking, pre-Descemet's layer, Rho-associated kinase, keratoprosthesis, infectious keratitis, corneal dystrophy, corneal astigmatism, and keratoconus. RESULTS This review summarizes relevant and innovative original articles, review articles, and novel techniques from the following journals: American Journal of Ophthalmology, British Journal of Ophthalmology, Cornea, Graefe's Archive for Clinical and Experimental Ophthalmology, Investigative Ophthalmology & Visual Science, JAMA Ophthalmology, Journal of Cataract and Refractive Surgery, Journal of Refractive Surgery, and Ophthalmology. Case reports, abstracts, letters to the Editor, and unpublished work were excluded, as well as articles e-published ahead of print in 2012 that were discussed in the previous review. One hundred twenty-seven articles met the criteria for this review. CONCLUSIONS This review summarizes significant cornea-related literature from 2013.
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Affiliation(s)
- Juan G Arbelaez
- From the *Price Vision Group; and †Cornea Research Foundation of America, Indianapolis, IN
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198
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In vitro susceptibility of filamentous fungi from mycotic keratitis to azole drugs. J Mycol Med 2014; 25:44-9. [PMID: 25541256 DOI: 10.1016/j.mycmed.2014.10.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 09/29/2014] [Accepted: 10/20/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The in vitro antifungal activities of azole drugs viz., itraconazole, voriconazole, ketoconazole, econazole and clotrimazole were investigated in order to evaluate their efficacy against filamentous fungi isolated from mycotic keratitis. METHODS The specimen collection was carried out from fungal keratitis patients attending Aravind eye hospital and Post-graduate institute of ophthalmology, Coimbatore, India and was subsequently processed for the isolation of fungi. The dilutions of antifungal drugs were prepared in RPMI 1640 medium. Minimum inhibitory concentrations (MICs) were determined and MIC50 and MIC90 were calculated for each drug tested. RESULTS A total of 60 fungal isolates were identified as Fusarium spp. (n=30), non-sporulating moulds (n=9), Aspergillus flavus (n=6), Bipolaris spp. (n=6), Exserohilum spp. (n=4), Curvularia spp. (n=3), Alternaria spp. (n=1) and Exophiala spp. (n=1). The MICs of ketoconazole, clotrimazole, voriconazole, econazole and itraconazole for all the fungal isolates ranged between 16 μg/mL and 0.03 μg/mL, 4 μg/mL and 0.015 μg/mL, 8 μg/mL and 0.015 μg/mL, 8 μg/mL and 0.015 μg/mL and 32 μg/mL and 0.06 μg/mL respectively. From the MIC50 and MIC90 values, it could be deciphered that in the present study, clotrimazole was more active against the test isolates at lower concentrations (0.12-5 μg/mL) when compared to other drugs tested. CONCLUSION The results suggest that amongst the tested azole drugs, clotrimazole followed by voriconazole and econazole had lower MICs against moulds isolated from mycotic keratitis.
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199
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Selvam RM, Nithya R, Devi PN, Shree RSB, Nila MV, Demonte NL, Thangavel C, Maheshwari JJ, Lalitha P, Prajna NV, Dharmalingam K. Exoproteome of Aspergillus flavus corneal isolates and saprophytes: identification of proteoforms of an oversecreted alkaline protease. J Proteomics 2014; 115:23-35. [PMID: 25497218 DOI: 10.1016/j.jprot.2014.11.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/19/2014] [Accepted: 11/28/2014] [Indexed: 01/14/2023]
Abstract
UNLABELLED Aspergillus flavus infects the human eye leading to keratitis. Extracellular proteins, the earliest proteins that come in contact with the host and virulence related exoproteins, were identified in the fungus isolated from infected cornea. Virulence of the corneal isolates was tested in the Galleria mellonella larvae model and those isolates showing higher virulence were taken for subsequent exoproteome analysis. High resolution two-dimensional electrophoresis and mass spectrometry were used to generate A. flavus exoproteome reference map as well as to profile most of the exoproteins. Analysis of the identified proteins clearly shows the major biological processes that they are involved in. Nearly 50% of the exoproteins possess catalytic activity and one of these, an alkaline serine protease (Alp1) is present in high abundance as well as multiple proteoforms. Many proteins in the A. flavus exoproteome have been shown to be virulence factors in other pathogens indicating the probable role for these proteins in the corneal infection as well. Interestingly, the majority of the exoproteins do not have secretory signal indicating that they are secreted through the non-classical pathway. Thus, this study provides a clue to the early strategies employed by the pathogen to establish an infection in an immunocompetent host. BIOLOGICAL SIGNIFICANCE The outcome of a fungal infection in an immunocompetent human eye depends on the ability of the fungus to overcome the host defense and propagate itself. In this process, the earliest events with respect to the fungal proteins involved include the secretory proteins of the invading organism. As a first step towards understanding the role of the extracellular proteins, exoproteome profile of the fungal isolates was generated. The fungal isolates from cornea showed a distinct pattern of the exoproteome when compared to the saprophyte. Since corneal isolates also showed higher virulence in the insect larval model, presumably the proteins elaborated by the corneal isolates are virulence related. One of the abundant proteins is an alkaline serine protease and this protein exists as multiple proteoforms. This study reports the comprehensive profile of exoproteome and reveals proteins that are potential virulence factors.
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Affiliation(s)
- Ramu Muthu Selvam
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Rathnavel Nithya
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Palraj Narmatha Devi
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - R S Bhuvana Shree
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Murugesan Valar Nila
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Naveen Luke Demonte
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Chitra Thangavel
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Jayapal Jeya Maheshwari
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Prajna Lalitha
- Department Of Ocular Microbiology, Aravind Eye Hospital, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | | | - Kuppamuthu Dharmalingam
- Proteomics Department, Aravind Medical Research Foundation, Dr. G. Venkataswamy Eye Research Institute, Aravind Eye Care System, Madurai, Tamil Nadu, India.
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Spadea L, Abbouda A, Abicca I, Paroli MP. Aspergillus flavus endophthalmitis after penetrating keratoplasty combined with cataract phacoemulsification and IOL implantation. Int Ophthalmol 2014; 35:145-8. [PMID: 25488017 DOI: 10.1007/s10792-014-0030-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/04/2014] [Indexed: 11/29/2022]
Abstract
To report the clinical findings and management of a case of Aspergillus flavus endophthalmitis following penetrating keratoplasty (PKP) and combined cataract extraction. Clinical cornea appearance was evaluated by slit-lamp examination. Ocular ultrasonography was performed to evaluate the anterior chamber and vitreous cavity. The cornea was scraped. The corneal-scleral donor rim and media were cultured. The diagnosis of A. flavus infection was made. The patient received fortified antifungal drops (voriconazole 1 % solution) plus systemic voriconazole 400 mg/die. A second corneal transplant was performed, and the anterior chamber was cleaned and washed with a solution of voriconazole 1 %. At the end of follow-up, CDVA was 20/20 and slit-lamp examination showed a clear cornea graft. This case illustrates a severe A. flavus endophthalmitis after PKP and demonstrates the possibilities of visual function restoration. Furthermore, this case describes the different sources of fungal infection after PKP and the different clinical appearances.
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Affiliation(s)
- Leopoldo Spadea
- Department of Medical-Surgical Sciences and Biotechnology, "Sapienza" University of Rome, Latina, Italy. .,, Via Benozzo Gozzoli 34, 00142, Rome, Italy.
| | | | - Irene Abicca
- Department of Ophthalmology, "Sapienza" University of Rome, Rome, Italy
| | - Maria Pia Paroli
- Department of Ophthalmology, "Sapienza" University of Rome, Rome, Italy
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