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Prajna NV, Lalitha P, Sharma S, de Freitas D, Höfling-Lima A, Varnado N, Abdelrahman S, Cavallino V, Arnold BF, Lietman TM, Rose-Nussbaumer J. A double-masked, sham-controlled trial of rose bengal photodynamic therapy for the treatment of fungal and acanthamoeba keratitis: Rose Bengal Electromagnetic Activation with Green Light for Infection Reduction (REAGIR) study. Trials 2024; 25:566. [PMID: 39192339 DOI: 10.1186/s13063-024-08376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 08/06/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Infectious keratitis secondary to fungus or acanthamoeba often has a poor outcome despite receiving the best available medical therapy. In vitro rose bengal photodynamic therapy (RB-PDT) appears to be effective against fungal and acanthamoeba isolates (Atalay HT et al., Curr Eye Res 43:1322-5, 2018, Arboleda A et al. Am J Ophthalmol 158:64-70, 2014). In one published series, RB-PDT reduced the need for therapeutic penetrating keratoplasty in severe bacterial, fungal, and acanthamoeba keratitis not responsive to medical therapy. METHODS This international, randomized, sham and placebo controlled 2-arm clinical trial randomizes patients with smear positive fungal and acanthamoeba and smear negative corneal ulcers in a 1:1 fashion to one of two treatment arms: 1) topical antimicrobial plus sham RB-PDT or 2) topical antimicrobial plus RB-PDT. DISCUSSION We anticipate that RB-PDT will improve best spectacle-corrected visual acuity and also reduce complications such as corneal perforation and the need for therapeutic penetrating keratoplasty. This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. Our results will be disseminated via ClinicalTrials.gov website, meetings, and journal publications. Our data will also be available upon reasonable request. TRIAL REGISTRATION NCT, NCT05110001 , Registered on November 5, 2021.
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Affiliation(s)
| | - P Lalitha
- Aravind Eye Hospital, Madurai, India
| | - S Sharma
- Aravind Eye Hospital, Madurai, India
| | - D de Freitas
- Federal University of São Paulo, São Paulo, Brazil
| | | | - N Varnado
- Byers Eye Institute, Stanford University, 2452 Watson Ct, Palo Alto, CA, 94303, USA
| | - S Abdelrahman
- Francis I. Proctor Foundation, University of California, Sao Paulo, Brazil
| | - V Cavallino
- Francis I. Proctor Foundation, University of California, Sao Paulo, Brazil
| | - B F Arnold
- Francis I. Proctor Foundation, University of California, Sao Paulo, Brazil
- UCSF, Department of Ophthalmology, University of California, San Francisco, USA
| | - T M Lietman
- Francis I. Proctor Foundation, University of California, Sao Paulo, Brazil
- UCSF Epidemiology and Biostatistics, University of California, San Francisco, USA
- UCSF, Department of Ophthalmology, University of California, San Francisco, USA
| | - J Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, Sao Paulo, Brazil.
- UCSF, Department of Ophthalmology, University of California, San Francisco, USA.
- Byers Eye Institute, Stanford University, 2452 Watson Ct, Palo Alto, CA, 94303, USA.
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Prajna V, Prajna L, Sharma S, de Freitas D, Höfling-Lima AL, Varnado N, Abdelrahman S, Cavallino V, Arnold B, Lietman T, Rose-Nussbaumer J. A double-masked, sham-controlled trial of rose bengal photodynamic therapy for the treatment of fungal and acanthameoba keratitis: Rose Bengal Electromagnetic Activation with Green Light for Infection Reduction (REAGIR) Study. RESEARCH SQUARE 2024:rs.3.rs-4165312. [PMID: 39011096 PMCID: PMC11247944 DOI: 10.21203/rs.3.rs-4165312/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
Background Infectious keratitis secondary to fungus or acanthamoeba often has a poor outcome despite receiving the best available medical therapy. In vitro Rose Bengal Photodynamic therapy (RB-PDT) appears to be effective against fungal and acanthamoeba isolates.22,23 In one published series RB-PDT reduced the need for therapeutic penetrating keratoplasty in severe bacterial, fungal, and acanthameoba keratitis not responsive to medical therapy. Methods This international, randomized, sham and placebo controlled 2-arm clinical trial, randomizes patients with smear positive fungal and acanthameoba and smear negative corneal ulcers in a 1:1 fashion to one of two treatment arms: 1) Topical antimicrobial plus sham RB-PDT or 2) Topical antimicrobial plus RB-PDT. Discussion We anticipate that RB-PDT will improve best spectacle corrected visual acuity and also reduce complications such as corneal perforation and the need for therapeutic penetrating keratoplasty. This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. Our results will be disseminated via clinicaltrials.gov website, meetings, and journal publications. Our data will also be available upon reasonable request. Trial Registration NCT, NCT05110001, Registered November 5, 2021. https://www.clinicaltrials.gov/study/NCT05110001.
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Liu S, Fang S, Zhang L. Photoactivated chromophore-corneal cross-linking accelerates corneal healing in fungal keratitis: an updated meta-analysis. Syst Rev 2023; 12:208. [PMID: 37951953 PMCID: PMC10638714 DOI: 10.1186/s13643-023-02380-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/26/2023] [Indexed: 11/14/2023] Open
Abstract
AIM To determine the effectiveness and safety of photoactivated chromophore-corneal cross-linking (PACK-CXL) adjuvant in infectious keratitis by April 5, 2022. METHODS We searched randomized controlled trials (RCTs) comparing standard antibiotic treatment (SAT) plus PACK-CXL to SAT in infectious keratitis in Embase, MEDLINE with PubMed, Web of Science, and Cochrane Library. We independently screened and extracted data using predesigned tables. Cochrane's risk-of-bias tool was utilized to examine the quality of RCTs. A random-effects model was employed to determine the overall effect size of the meta-analyses. Grading of Recommendations, and Assessment, Development and Evaluations (GRADE) was also performed to examine the quality of evidence. RESULTS Seven eligible RCTs with 283 patients were acquired. Adjuvant PACK-CXL reduced the time needed to perform corneal healing in fungal keratitis (- 1.33 months; 95% CI, - 1.83 to - 0.42, I2 = 0%, P < 0.05) as compared to SAT alone. The risks of adverse events were not significantly different both in fungal and bacterial keratitis. Due to the substantial heterogeneity among studies, such as population, the type and severity of infectious keratitis, drug regimens of SAT, PACK-CXL protocol, and the judgment of subjective outcomes, the evidence grade was low. CONCLUSION Adjuvant PACK-CXL accelerates fungal keratitis healing as compared to SAT alone. But more rigorous RCTs are required to determine the clinical effectiveness and safety.
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Affiliation(s)
- Shuyi Liu
- Graduate School, Dalian Medical University, Dalian, Liaoning Province, 116044, China
- Department of Ophthalmology, The Third People's Hospital of Dalian, Non-Directly Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, 116033, China
| | - Shifeng Fang
- Department of Ophthalmology, The Third People's Hospital of Dalian, Non-Directly Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, 116033, China.
| | - Lijun Zhang
- Graduate School, Dalian Medical University, Dalian, Liaoning Province, 116044, China.
- Department of Ophthalmology, The Third People's Hospital of Dalian, Non-Directly Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, 116033, China.
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Al-Mahrouqi H, Cheung IMY, Angelo L, Yu TY, Gokul A, Ziaei M. Therapeutic non-ectasia applications of cornea cross-linking. Clin Exp Optom 2023; 106:580-590. [PMID: 36690333 DOI: 10.1080/08164622.2022.2159790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/28/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023] Open
Abstract
Corneal cross-linking is a photopolymerization technique traditionally used to strengthen corneal tissue. Corneal cross-linking utilizes riboflavin (vitamin B2) as a photosensitizer and ultraviolet-A light (UVA) to create strong covalent bonds within the corneal stroma, increasing tissue stiffness. Multiple studies have demonstrated corneal cross-linking's effectiveness in treating corneal ectasia, a progressive, degenerative, and non-inflammatory thinning disorder, as quantified by key tomographic, refractive, and visual parameters. Since its introduction two decades ago, corneal cross-linking has surpassed its original application in halting corneal ectatic disease and its application has expanded into several other areas. Corneal cross-linking also possesses antibacterial, antienzymolytic and antioedematous properties, and has since become a tool in treating microbial keratitis, correcting refractive error, preventing iatrogenic ectasia, stabilising bullous keratopathy and controlling post keratoplasty ametropia. This review provides an overview of the current evidence base for the therapeutic non-ectasia applications of cornea cross-linking and looks at future developments in the field.
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Affiliation(s)
| | | | - Lize Angelo
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | - Tzu-Ying Yu
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland District Health Board, Auckland, New Zealand
| | - Akilesh Gokul
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | - Mohammed Ziaei
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand
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Said DG, Rallis KI, Al-Aqaba MA, Ting DSJ, Dua HS. Surgical management of infectious keratitis. Ocul Surf 2023; 28:401-412. [PMID: 34592475 DOI: 10.1016/j.jtos.2021.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/18/2021] [Indexed: 12/27/2022]
Abstract
The successful management of infectious keratitis is usually achieved with a combination of tools for accurate diagnosis and targeted timely antimicrobial therapy. An armamentarium of surgical interventions is available in the acute stage which can be resorted to in a step wise manner or in combination guided by the response to treatment. Simple surgical modalities can facilitate accurate diagnosis e.g. corneal biopsy and alcohol delamination. Surgery to promote epithelial healing can vary from tarsorrhaphy, amniotic membrane transplantation or conjunctival flaps depending on the extent of infection, visual prognosis, availability of tissue and surgeon's experience. Collagen crosslinking has been increasingly utilized with successful results to strengthen the cornea and reduce the infective load consequently the need for further elaborate surgical interventions. It has shown encouraging results specially in superficial bacterial and fungal keratitis but for deeper infections, viral and acanthamoeba keratitis, its use remains questionable. When globe integrity is compromised, corneal gluing is the most commonly used procedure to seal small perforations. In larger perforations/fulminant infections a tectonic/therapeutic graft is advisable. Partial thickness grafts are increasingly popular to treat superficial infection or internally tamponade perforations. Peripheral therapeutic grafts face challenges with potential requirement for a manually fashioned graft, and increased risk of rejection due to proximity to the limbal vessels. Late stage visual rehabilitation is likely to require further surgical interventions after complete resolution of infection and inflammation. A preliminary assessment of corneal sensation and integrity of the ocular surface are key for any successful surgical intervention to restore vision.
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Affiliation(s)
- Dalia G Said
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK; Research Institute of Ophthalmology, Cairo, Egypt.
| | | | | | - Darren S J Ting
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK
| | - Harminder S Dua
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen's Medical Centre, Nottingham, UK
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Ung L, Chodosh J. Urgent unmet needs in the care of bacterial keratitis: An evidence-based synthesis. Ocul Surf 2023; 28:378-400. [PMID: 34461290 PMCID: PMC10721114 DOI: 10.1016/j.jtos.2021.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 11/21/2022]
Abstract
Bacterial corneal infections, or bacterial keratitis (BK), are ophthalmic emergencies that frequently lead to irreversible visual impairment. Though increasingly recognized as a major cause of global blindness, modern paradigms of evidence-based care in BK have remained at a diagnostic and therapeutic impasse for over half a century. Current standards of management - based on the collection of corneal cultures and the application of broad-spectrum topical antibiotics - are beset by important yet widely underrecognized limitations, including approximately 30% of all patients who will develop moderate to severe vision loss in the affected eye. Though recent advances have involved a more clearly defined role for adjunctive topical corticosteroids, and novel therapies such as corneal crosslinking, overall progress to improve patient and population-based outcomes remains incommensurate to the chronic morbidity caused by this disease. Recognizing that the care of BK is guided by the clinical axiom, "time equals vision", this chapter offers an evidence-based synthesis for the clinical management of these infections, underscoring critical unmet needs in disease prevention, diagnosis, and treatment.
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Affiliation(s)
- Lawson Ung
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Infectious Disease Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA; Infectious Disease Institute, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.
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Barac IR, Artamonov AR, Baltă G, Dinu V, Mehedințu C, Bobircă A, Baltă F, Barac DA. Photoactivated Chromophore Corneal Collagen Cross-Linking for Infectious Keratitis (PACK-CXL)-A Comprehensive Review of Diagnostic and Prognostic Factors Involved in Therapeutic Indications and Contraindications. J Pers Med 2022; 12:1907. [PMID: 36422083 PMCID: PMC9698237 DOI: 10.3390/jpm12111907] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 09/07/2023] Open
Abstract
Infectious keratitis is a severe infection of the eye, which requires urgent care in order to prevent permanent complications. Typical cases are usually diagnosed clinically, whereas severe cases also require additional tools, such as direct microscopy, corneal cultures, molecular techniques, or ophthalmic imaging. The initial treatment is empirical, based on the suspected etiology, and is later adjusted as needed. It ranges from topical administration of active substances to oral drugs, or to complex surgeries in advanced situations. A novel alternative is represented by Photoactivated Chromophore Corneal Collagen Cross-Linking (PACK-CXL), which is widely known as a minimally invasive therapy for corneal degenerations. The purpose of this review is to identify the main diagnostic and prognostic factors which further outline the indications and contraindications of PACK-CXL in infectious keratitis. Given the predominantly positive outcomes in the medical literature, we ponder whether this is a promising treatment modality, which should be further evaluated in a systematic, evidence-based manner in order to develop a clear treatment protocol for successful future results, especially in carefully selected cases.
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Affiliation(s)
- Ileana Ramona Barac
- Department of Ophthalmology/ENT, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | | | - George Baltă
- Department of Ophthalmology/ENT, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | - Valentin Dinu
- Department of Ophthalmology/ENT, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | - Claudia Mehedințu
- Department of Obstetrics and Gynecology, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
| | - Anca Bobircă
- Department of Rheumatology and Internal Medicine, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
| | - Florian Baltă
- Department of Ophthalmology/ENT, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
- Bucharest Emergency Eye Hospital, 030167 Bucharest, Romania
| | - Diana Andreea Barac
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050747 Bucharest, Romania
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Hamida Abdelkader SM, Rodríguez Calvo-de-Mora M, Gegúndez-Fernández JA, Soler-Ferrández FL, Rocha-de-Lossada C. Review of the literature on the currently available evidence for the management of infectious keratitis with PACK-CXL. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2022; 97:464-472. [PMID: 35752596 DOI: 10.1016/j.oftale.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 02/02/2022] [Indexed: 06/15/2023]
Abstract
Infectious keratitis (IK) is one of the most common causes of monocular blindness worldwide, especially in developing countries and may account for 5.1%-32.3% of all indications for penetrating keratoplasty (PK). However, performing a therapeutic PK on a "hot eye" is associated with a higher incidence of IK recurrence and graft rejection. Standard treatment includes antimicrobials (ATM) and, once the causative pathogen has been identified, must be continued with targeted treatment, depending on antibiogram sensitivity. However, appearance of multiresistant strains to ATM is progressively increasing at an alarming rate. Besides that, the diversity of the causative microorganisms (bacteria, fungi, parasites, viruses) may hinder the clinical diagnosis and secondarily the proper treatment from the beginning. It is estimated that only 50% of eyes will have a good visual result if the correct therapy is delayed. All these factors make the identification of alternatives to ATM treatment of paramount importance. Due to the ATM properties of photoactivated chromophore (riboflavin, RB) and ultraviolet (UV) light of wavelength (λ) 200-400 nanometers (nm), used in multiple medical and non-medical applications for disinfection, photoactivated chromophore for corneal cross-linking (CXL) of IK (PACK-CXL), as an addition to the therapeutic arsenal for the management of IK has been proposed. It must be differentiated from CXL used for the management of progressive keratoconus (KC). The objective of this review is to update the available evidence on the efficacy and safety of PACK-CXL in IKs.
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Affiliation(s)
| | | | | | | | - C Rocha-de-Lossada
- Departamento de Oftalmología (Qvision), Hospital Vithas Vírgen del Mar, Almería, Spain; Hospital Universitario Vírgen de las Nieves, Granada, Spain; Universidad de Sevilla, Departamento de Cirugía, Área de Oftalmología, Sevilla, Spain
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Bagga B, Sharma S, Ahirwar LK, Sheba E, Vaddavalli PK, Mishra DK. Clinical outcomes of Rose Bengal mediated Photodynamic Antimicrobial Therapy on Fungal Keratitis with their microbiological and pathological correlation. Curr Eye Res 2022; 47:987-994. [PMID: 35385332 DOI: 10.1080/02713683.2022.2058019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To report the clinical outcome of Photodynamic Antimicrobial Therapy (PDAT) with Rose Bengal (RB) used as an early adjuvant therapy in patients with fungal keratitis and their microbiological and pathological correlation. METHODS Patients with microbiologically confirmed fungal keratitis underwent PDAT-RB along with topical natamycin 5% drops hourly and oral ketoconazole 200 mg twice a day. This was performed by applying rose bengal (0.1%) to the de-epithelialized cornea for 30 minutes, followed by irradiation with a 6 mW/cm2 custom-made green LED source for 15 minutes (5.4 J/cm2). The corresponding fungal isolates were tested in vitro using PDAT-RB and corneal buttons were evaluated for correlation. RESULTS Following informed consent, seven patients (male-5, female-2, mean age 47.7 years) with fungal keratitis were recruited. There were 3 cases each of Fusarium and Aspergillus flavus and 1 case of Acremonium sp. The average vertical and horizontal diameters of the corneal infiltrate were 4.12+/- 0.55 and 3.99+/- 1.19 mm, respectively. The average depth of corneal involvement was 283 +/- 75.27μ as measured by anterior segment OCT. Clinical resolution was achieved in the cases with Fusarium keratitis with an average time of 39 days. Three cases of A. flavus and a single patient with Acremonium keratitis worsened and needed therapeutic keratoplasty (TPK) for resolution. Post-TPK, the corneal tissues grew Aspergillus flavus in one out of three cases and Acremonium sp. in one case. In vitro PDAT-RB experiment was performed on the corresponding fungal isolates grown from the corneal scraping. PDAT-RB produced clear inhibition of Fusarium and Acremonium sp. with no effect on the growth of A. flavus. Histopathologically, 2 out of 4 (50%) corneal buttons showed fungal filaments. CONCLUSION While the in vitro and in vivo results of PDAT-RB matched for Fusarium species and Aspergillus flavus keratitis being favourable in the former and non-favourable in the latter, these results were discrepant in Acremonium sp.
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Affiliation(s)
- Bhupesh Bagga
- The Cornea Institute, LV Prasad Eye Institute, Hyderabad, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Hyderabad, India
| | | | - Esther Sheba
- Jhaveri Microbiology Centre, LV Prasad Eye Institute, Hyderabad, India
| | | | - Dilip K Mishra
- Ophthalmic Pathology Laboratory, LV Prasad Eye Institute, Hyderabad, India
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Hafezi F, Hosny M, Shetty R, Knyazer B, Chen S, Wang Q, Hashemi H, Torres-Netto EA. PACK-CXL vs. antimicrobial therapy for bacterial, fungal, and mixed infectious keratitis: a prospective randomized phase 3 trial. EYE AND VISION (LONDON, ENGLAND) 2022; 9:2. [PMID: 34996516 PMCID: PMC8742313 DOI: 10.1186/s40662-021-00272-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/27/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Infectious keratitis is a major cause of global blindness. We tested whether standalone photoactivated chromophore corneal cross-linking (PACK-CXL) may be an effective first-line treatment in early to moderate infectious keratitis, compared with standard antimicrobial treatment. METHODS This is a randomized, controlled, multinational phase 3 clinical trial. Participants in five centers in Egypt, India, Iran, Israel, and China, aged ≥ 18 years, with infectious keratitis of presumed bacterial, fungal, or mixed origin, were randomly assigned (1:1) to PACK-CXL, or antimicrobial therapy. Outcomes measures included healing, defined as time to re-epithelialization of the corneal epithelial defect in the absence of inflammatory activity in the anterior chamber and clearance of stromal infiltrates. Treatment success was defined as the complete resolution of signs of infection. RESULTS Between July 21, 2016, and March 4, 2020, participants were randomly assigned to receive PACK-CXL (n = 18) or antimicrobial therapy per American Academy of Ophthalmology (AAO) guidelines (n = 21). No participants were lost to follow-up. Four eyes were excluded from the epithelialization time analysis due to treatment failure: two in the antimicrobial therapy group, and two in the PACK-CXL group. Success rates were 88.9% (16/18 patients) in the PACK-CXL group and 90.5% (19/21 patients) in the medication group. There was no significant difference in time to complete corneal re-epithelialization (P = 0.828) between both treatment groups. CONCLUSIONS PACK-CXL may be an alternative to antimicrobial drugs for first-line and standalone treatment of early to moderate infectious keratitis of bacterial or fungal origin. Trial registration This trial is registered at ClinicalTrials.gov, trial registration number: NCT02717871.
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Affiliation(s)
- Farhad Hafezi
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland.
- ELZA Institute, Dietikon, Switzerland.
- Faculty of Medicine, University of Geneva, Geneva, Switzerland.
- Department of Ophthalmology, Medical University of Wenzhou, Wenzhou, China.
- USC Roski Eye Institute, University of Southern California Los Angeles, Los Angeles, USA.
| | - Mohammed Hosny
- Department of Ophthalmology, University of Cairo, Cairo, Egypt
| | - Rohit Shetty
- Narayana Nethralaya Eye Hospital and the Postgraduate Institute of Ophthalmology, Bangalore, India
| | - Boris Knyazer
- Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Shihao Chen
- Department of Ophthalmology, Medical University of Wenzhou, Wenzhou, China
| | - Qinmei Wang
- Department of Ophthalmology, Medical University of Wenzhou, Wenzhou, China
| | - Hassan Hashemi
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Emilio A Torres-Netto
- Center for Applied Biotechnology and Molecular Medicine (CABMM), University of Zurich, Zurich, Switzerland
- ELZA Institute, Dietikon, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- University Hospital Zurich, Zurich, Switzerland
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Crosslinking in Microbial Keratitis: Where Are We Today? Eye Contact Lens 2022; 48:1-2. [PMID: 34860722 DOI: 10.1097/icl.0000000000000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Recent Advances in Photodynamic Therapy against Fungal Keratitis. Pharmaceutics 2021; 13:pharmaceutics13122011. [PMID: 34959293 PMCID: PMC8709008 DOI: 10.3390/pharmaceutics13122011] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/14/2021] [Accepted: 11/20/2021] [Indexed: 01/08/2023] Open
Abstract
Fungal keratitis is a serious clinical infection on the cornea caused by fungi and is one of the leading causes of blindness in Asian countries. The treatment options are currently limited to a few antifungal agents. With the increasing incidence of drug-resistant infections, many patients fail to respond to antibiotics. Riboflavin-mediated corneal crosslinking (similar to photodynamic therapy (PDT)) for corneal ectasia was approved in the US in the early 2000s. Current evidence suggests that PDT could have the potential to inhibit fungal biofilm formation and overcome drug resistance by using riboflavin and rose bengal as photosensitizers. However, only a few clinical trials have been initiated in anti-fungal keratitis PDT treatment. Moreover, the removal of the corneal epithelium and repeated application of riboflavin and rose bengal are required to improve drug penetration before and during PDT. Thus, an improvement in trans-corneal drug delivery is mandatory for a successful and efficient treatment. In this article, we review the studies published to date using PDT against fungal keratitis and aim to enhance the understanding and awareness of this research area. The potential of modifying photosensitizers using nanotechnology to improve the efficacy of PDT on fungal keratitis is also briefly reviewed.
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Altamirano D, Martinez J, Leviste KD, Parel JM, Amescua G. Photodynamic Therapy for Infectious Keratitis. CURRENT OPHTHALMOLOGY REPORTS 2021; 8:245-251. [PMID: 34540359 DOI: 10.1007/s40135-020-00252-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Infectious keratitis is a sight-threatening microbial infection. The prevalence of antimicrobial resistance in cases of infectious keratitis has increased the demand for fortified compounded antimicrobial drops. Even with proper medical management, severe cases of infectious keratitis can further evolve into corneal perforation, requiring surgical intervention in the form of keratoplasty to control the infectious process. Due to the invasive nature of the procedure and the shortage of available donor tissue around the world, alternative treatments are needed for the management of progressive infectious keratitis. In ophthalmology, photodynamic therapy (PDT) has been used for numerous applications. PDT with Rose Bengal as a photosensitizer combined with green light optical irradiation (RB-PDAT) is a novel treatment with dual purpose: to arrest the infection from progressing and strengthen the collagen of the cornea. RB-PDAT may be considered as an adjunct therapy in severe cases of infectious keratitis to minimize the need for a therapeutic keratoplasty.
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Affiliation(s)
- Diego Altamirano
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jaime Martinez
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Katherine D Leviste
- Ocular Microbiology Laboratory, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jean Marie Parel
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ophthalmic Biophysics Center, McKnight Vision Research Center, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Guillermo Amescua
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
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Feizi S, Karimian F, Esfandiari H. Corneal crosslinking for the treatment of infectious keratitis: a review. EXPERT REVIEW OF OPHTHALMOLOGY 2021. [DOI: 10.1080/17469899.2021.1933440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Sepehr Feizi
- Ophthalmic Research Center, Department of Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Karimian
- Ophthalmic Research Center, Department of Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamed Esfandiari
- Department of Ophthalmology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
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Alternative Indications for Corneal Crosslinking. J Cataract Refract Surg 2021; 47:1360-1366. [PMID: 33929804 DOI: 10.1097/j.jcrs.0000000000000663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Corneal crosslinking (CXL) is the current mainstay treatment for progressive keratoconus. In the past 15 years, a variety of other indications have been tested. A systematic review was conducted to examine these alternative indications for CXL. In total, of 143 papers on crosslinking as a treatment for infectious keratitis, bullous keratopathy, pellucid marginal degeneration, post- laser in situ keratomileusis (LASIK) ectasia, and as a way to improve vision either on its own or in combination with other interventions were included. Post-LASIK ectasia is a definite indication for crosslinking. Surprisingly, only limited research has been performed on pellucid marginal degeneration, with no randomized trials available to date. Other interesting applications are the combined use of refractive lasers and crosslinking for suspicious or ectatic corneas and crosslinking as a standalone intervention for minor refractive errors. CXL might offer a solution for refractory bacterial keratitis. In bullous keratopathy, it seems to offer only a transient benefit.
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Marasini S, Zhang AC, Dean SJ, Swift S, Craig JP. Safety and efficacy of UV application for superficial infections in humans: A systematic review and meta-analysis. Ocul Surf 2021; 21:331-344. [PMID: 33812086 DOI: 10.1016/j.jtos.2021.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Ultraviolet (UV) light is naturally antimicrobial, but risks associated with UV overexposure have limited its clinical application. This systematic review evaluates the safety and efficacy of UV light treatment of superficial human infections. METHODS MEDLINE, Embase, Cochrane CENTRAL, ANZCTR and US National Library of Medicine were searched (March 25, 2020). Clinical studies applying UV light (200-400 nm) for superficial infections and non-clinical studies evaluating the antimicrobial effects of UV light on human samples were included. Randomised controlled trials (RCTs) and non- RCTs were appraised using the Cochrane risk of bias and the ROBINS-I tools, respectively. RESULTS Eleven RCTs, seven non-RCTs, 24 case studies, and 11 in vitro studies were included. Most clinical studies (34/42) evaluated UVA treatment for microbial keratitis (MK) using cross-linking (UVA-CXL) methods. Six clinical studies assessed UVC; one, UVB; and one, broadband UV for chronic skin infections. Pooled data analysis showed no difference in the time to wound resolution with UVA-CXL relative to standard treatment (mean difference [MD]: -18.20 [95% CI: -39.04 to 2.65] days; p = 0.09). Adverse event incidence was similar to control for UVA-CXL in MK (RR: 0.70 [95%CI: 0.32-1.79]; 5 RCTs) and UVC in skin infections (RR: 0.63 [95%CI: 0.25-1.54]; 2 RCTs). CONCLUSION Alone or as an adjunct to standard therapy, UV light shows promise as a safe and effective treatment for a wide range of infections. Applications of UV light as an anti-infective agent are deserving of further evaluation, especially in the context of growing antibiotic resistance. REGISTRATION PROSPERO registration number CRD42020176510.
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Affiliation(s)
- Sanjay Marasini
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand
| | - Alexis Ceecee Zhang
- Department of Optometry and Vision Sciences, University of Melbourne, Parkville, Australia
| | - Simon J Dean
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand
| | - Simon Swift
- Department of Molecular Medicine and Pathology, The University of Auckland, Auckland, New Zealand
| | - Jennifer P Craig
- Department of Ophthalmology, New Zealand National Eye Centre, The University of Auckland, Auckland, New Zealand.
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Cross-Linking Assisted Infection Reduction (CLAIR): A Randomized Clinical Trial Evaluating the Effect of Adjuvant Cross-Linking on Bacterial Keratitis. Cornea 2020; 40:837-841. [PMID: 33079921 DOI: 10.1097/ico.0000000000002510] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/20/2020] [Indexed: 01/10/2023]
Abstract
PURPOSE To determine whether there is a benefit to adjuvant corneal cross-linking (CXL) for bacterial keratitis. METHODS This is an outcome-masked, randomized controlled clinical trial. Consecutive patients presenting with a smear-positive bacterial ulcer at Aravind Eye Hospitals at Madurai, Pondicherry, and Coimbatore in India were enrolled. Study eyes were randomized to topical moxifloxacin 0.5% or topical moxifloxacin 0.5% plus CXL. The primary outcome of the trial was microbiological cure at 24 hours on repeat culture. Secondary outcomes included best spectacle corrected visual acuity at 3 weeks and 3 months, percentage of study participants with epithelial healing at 3 weeks and 3 months, infiltrate and/or scar size at 3 weeks and 3 months, 3-day smear and culture, and adverse events. RESULTS Those randomized to CXL had 0.60 decreased odds of culture positivity at 24 hours (95% confidence interval [CI]: 0.10-3.50; P = 0.65), 0.9 logarithm of the minimum angle of resolution lines worse visual acuity (95% CI: -2.8 to 4.6; P = 0.63), and 0.41-mm larger scar size (95% CI: -0.48 to 1.30; P = 0.38) at 3 months. We note fewer corneal perforations or need for therapeutic penetrating keratoplasty in the CXL group. CONCLUSIONS We were unable to confirm a benefit to adjuvant CXL in the primary treatment of moderate bacterial keratitis. However, CXL may reduce culture positivity and complication rates; therefore, a larger trial to fully evaluate this is warranted. TRIAL REGISTRATION NCT02570321.
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Abstract
BACKGROUND Infectious keratitis is an infection of the cornea that can be caused by bacteria, viruses, fungi, protozoa, or parasites. It may be associated with ocular surgery, trauma, contact lens wear, or conditions that cause deficiency or loss of corneal sensation, or suppression of the immune system, such as diabetes, chronic use of topical steroids, or immunomodulatory therapies. Photoactivated chromophore for collagen cross-linking (PACK-CXL) of the cornea is a therapy that has been successful in treating eye conditions such as keratoconus and corneal ectasia. More recently, PACK-CXL has been explored as a treatment option for infectious keratitis. OBJECTIVES To determine the comparative effectiveness and safety of PACK-CXL with standard therapy versus standard therapy alone for the treatment of bacterial keratitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2019, Issue 7); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Science Information database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 8 July 2019. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs, and controlled clinical trials (CCTs) of PACK-CXL for bacterial keratitis. We included quasi-RCTs and CCTs as we anticipated that there would not be many RCTs eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors working independently selected studies for inclusion in the review, assessed trials for risk of bias, and extracted data. The primary outcome was proportion of participants with complete healing at four to eight weeks. Secondary outcomes included visual acuity, morphology, adverse events, and treatment failure at four to eight weeks. MAIN RESULTS We included three trials (two RCTs and one quasi-RCT) in this review for a total of 59 participants (59 eyes) with bacterial keratitis. Trials were all single-center and were conducted in Egypt, Iran, and Thailand between 2010 and 2014. It is very uncertain whether PACK-CXL with standard antibiotic therapy is more effective than standard antibiotic therapy alone for re-epithelialization and complete healing (risk ratio (RR) 1.53, 95% confidence interval (CI) 0.88 to 2.66; participants = 15). We judged the certainty of the evidence to be very low due to the small sample size and high risk of selection and performance bias. The high risk of selection bias reflects the overall review. Masking of participants was not possible for the surgical arm. No participant had a best-corrected visual acuity of 20/100 or better at eight weeks (very low certainty evidence). There is also no evidence that use of PACK-CXL with standard therapy results in fewer instances of treatment failure than standard therapy alone (RR 0.50, 95% CI 0.05 to 4.98; participants = 32). We judged the certainty of evidence to be low due to the small sample size and high risk of selection bias. There were no adverse events reported at 14 days (low certainty evidence). Data on other outcomes, such as visual acuity and morphological characteristics, could not be compared because of variable time points and specific metrics. AUTHORS' CONCLUSIONS The current evidence on the effectiveness of PACK-CXL for bacterial keratitis is of low certainty and clinically heterogenous in regard to outcomes. There are five ongoing RCTs enrolling 1136 participants that may provide better answers in the next update of this review. Any future research should include subgroup analyses based on etiology. A core outcomes set would benefit healthcare decision-makers in comparing and understanding study data.
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Affiliation(s)
- Shadi A Davis
- Ophthalmology and Ocuplastics Surgery, Cheyenne VA Hospital, Cheyenne, Wyoming, USA
| | - Renee Bovelle
- Department of Ophthalmology, Howard University, Washington, DC, USA
| | - Genie Han
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John Kwagyan
- General Clinical Research Center, Howard University, Washington, DC, USA
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Ting DSJ, Henein C, Said DG, Dua HS. Effectiveness of adjuvant photoactivated chromophore corneal collagen cross-linking versus standard antimicrobial treatment for infectious keratitis: a systematic review protocol. JBI Evid Synth 2020; 18:194-199. [PMID: 31567558 DOI: 10.11124/jbisrir-d-19-00148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The objective of this review is to systematically examine the effectiveness of adjuvant photoactivated chromophore for keratitis - corneal collagen cross-linking (PACK-CXL) versus standard antimicrobial treatment alone for corneal healing in patients with infectious keratitis. INTRODUCTION Infectious keratitis is a major cause for corneal blindness globally. Broad-spectrum antimicrobial therapy is currently the standard treatment, but there is a growing need for alternative or adjuvant antimicrobial treatment, due to the emerging antimicrobial resistance, long treatment duration and cost of treatment. Photoactivated chromophore for keratitis - corneal collagen cross-linking has been increasingly used as an adjuvant treatment for infectious keratitis but high-quality evidence is limited. INCLUSION CRITERIA This review will consider studies that include patients with infectious keratitis, encompassing bacterial, fungal, acanthamoeba, viral, mixed or culture-negative presumed infectious keratitis cases. Patients who have a previous history of infectious keratitis before the study or those that had less than seven days' follow-up from the start of the treatment will be excluded. METHODS The electronic databases to be searched will include MEDLINE, Embase and Cochrane Central Register of Controlled Trials. Only English articles will be included. Titles, abstracts and full text of the relevant studies will be assessed by two independent reviewers. The extracted data will include specific details about the study, including authors and study title, year of publication, sample size, populations, and study methods. A meta-analysis will be performed for the included randomized controlled trials when there are sufficient similarities in the reporting of outcome measures. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019131290.
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Affiliation(s)
- Darren Shu Jeng Ting
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Ophthalmology, Queen Medical Centre, Nottingham, UK
| | - Christin Henein
- Newcastle University, Newcastle upon Tyne, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Dalia G Said
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Ophthalmology, Queen Medical Centre, Nottingham, UK
| | - Harminder S Dua
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Ophthalmology, Queen Medical Centre, Nottingham, UK
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Mikropoulos DG, Kymionis GD, Voulgari N, Kaisari E, Nikolakopoulos KA, Katsanos A, Konstas AG. Intraoperative Photoactivated Chromophore for Infectious Keratitis-Corneal Cross-Linking (PACK-CXL) During Penetrating Keratoplasty for the Management of Fungal Keratitis in an Immunocompromised Patient. Ophthalmol Ther 2019; 8:491-495. [PMID: 31278588 PMCID: PMC6692791 DOI: 10.1007/s40123-019-0196-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION To present a novel intraoperative application of photoactivated chromophore for infectious keratitis-corneal cross-linking (PACK-CXL) in the management of post-penetrating keratoplasty (PKP) multiresistant fungal keratitis in a patient with irradiation-related local immunosuppression. CASE REPORT A 62-year-old female underwent uneventful PKP for the management of post-irradiation actinic keratopathy. Three months postoperatively, she presented with a diffuse corneal melting abscess that was infiltrating the donor-recipient junction. Despite intensive antibiotic and antifungal therapy, corneal melting progressed to graft perforation. A repeat PKP combined with intraoperative PACK-CXL was performed. PACK-CXL was applied initially on the infected graft, involving the corneoscleral rim and then following placement of the donor button. No intra- or postoperative graft-related complications were encountered. No signs of infection were noted, and the graft remained clear during the 9-month follow-up period. CONCLUSION Intraoperative PACK-CXL combined with PKP appears to be a safe and effective technique for the management of post-PKP resistant fungal keratitis.
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Affiliation(s)
- Dimitrios G Mikropoulos
- 3rd University Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George D Kymionis
- Ophthalmology Department, Jules Gonin Eye Hospital, University of Lausanne, Lausanne, Switzerland
| | - Nafsika Voulgari
- Ophthalmology Department, Jules Gonin Eye Hospital, University of Lausanne, Lausanne, Switzerland
| | - Eirini Kaisari
- Ophthalmology Department, Jules Gonin Eye Hospital, University of Lausanne, Lausanne, Switzerland
| | | | - Andreas Katsanos
- Department of Ophthalmology, University of Ioannina, Ioannina, Greece
| | - Anastasios G Konstas
- 1st and 3rd University, Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Ting DSJ, Henein C, Said DG, Dua HS. Photoactivated chromophore for infectious keratitis - Corneal cross-linking (PACK-CXL): A systematic review and meta-analysis. Ocul Surf 2019; 17:624-634. [PMID: 31401338 DOI: 10.1016/j.jtos.2019.08.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/29/2019] [Accepted: 08/07/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE To examine the efficacy of adjuvant photoactivated chromophore for infectious keratitis-corneal cross-linking (PACK-CXL) for the treatment of infectious keratitis (IK). METHODS Electronic databases, including MEDLINE, EMBASE and Cochrane Central, were searched for articles related to PACK-CXL. All clinical studies, including randomized controlled trials (RCTs), non-randomized controlled studies, case series and case reports, were included. A meta-analysis was further performed when there were sufficient similarities in the included RCTs. Primary outcome measure was time to complete corneal healing and secondary outcome measures included size of epithelial defect and infiltrate, corrected-distance-visual-acuity (CDVA), and adverse events. RESULTS Forty-six eligible studies (including four RCTs) with 435 patients were included. When compared to standard antimicrobial treatment (SAT) alone, adjuvant PACK-CXL resulted in shorter mean time to complete corneal healing (-7.44 days; 95% CI, -10.71 to -4.16) and quicker resolution of the infiltrate at 7 days (-5.49 mm2; 95% CI, -7.44 to -3.54) and at 14-30 days (-5.27 mm2; 95% CI, -9.12 to -1.41). There was no significant difference in the size of epithelial defect, CDVA and risk of adverse events. Evidence on the use of PACK-CXL in acanthamoeba and mixed IK was insufficient. CONCLUSIONS Our study demonstrates that adjuvant PACK-CXL expedites the healing of IK when compared to SAT alone (low-quality evidence). Further adequately powered, high-quality RCTs are required to fully ascertain the therapeutic effect of PACK-CXL.
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Affiliation(s)
- Darren Shu Jeng Ting
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen Medical Centre, Nottingham, UK.
| | - Christin Henein
- Newcastle University, Newcastle Upon Tyne, UK; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Dalia G Said
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen Medical Centre, Nottingham, UK
| | - Harminder S Dua
- Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK; Department of Ophthalmology, Queen Medical Centre, Nottingham, UK
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Martinez JD, Arboleda A, Naranjo A, Aguilar MC, Durkee H, Monsalve P, Dubovy SR, Donaldson KE, Miller D, Amescua G, Parel JM. Long-term outcomes of riboflavin photodynamic antimicrobial therapy as a treatment for infectious keratitis. Am J Ophthalmol Case Rep 2019; 15:100481. [PMID: 31198886 PMCID: PMC6556526 DOI: 10.1016/j.ajoc.2019.100481] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 01/25/2019] [Accepted: 05/29/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose To report the long-term outcomes of three patients with infectious keratitis treated with riboflavin photodynamic antimicrobial therapy (PDAT). Observations Case series reporting three patients with infectious keratitis unresponsive to standard medical treatment who underwent riboflavin photodynamic antimicrobial therapy (PDAT) as an adjunct therapy. One male and two female patients were treated, the median age of presentation was 58 years (range, 29-79 years). The organisms isolated and treated were Pseudomonas aeruginosa, Mycobacterium chenolae, and Curvularia spp. Different risk factors to develop corneal infection ulcers were identified, including corneal abrasion in a contact lens user, history of penetrating keratoplasty with chronic use of topical corticosteroids, and organic trauma. The median follow-up was 47 months (range 37-54 months), and there were no complications secondary to riboflavin PDAT treatment. Two cases underwent optical penetrating keratoplasty after infection was resolved and ocular surface was quiet for at least 3 years. Conclusions and importance Riboflavin PDAT can be used as an adjunct treatment in infectious keratitis to strengthen the corneal collagen fibers, delay keratolysis, and allow more time for antimicrobials to work and this way prevent a corneal perforation.
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Affiliation(s)
- Jaime D Martinez
- Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alejandro Arboleda
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Andrea Naranjo
- Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mariela C Aguilar
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Heather Durkee
- Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Pedro Monsalve
- Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Pathology, University of Miami, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sander R Dubovy
- Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Florida Lions Ocular Pathology Laboratory, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL, USA.,Department of Pathology, University of Miami, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kendall E Donaldson
- Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Darlene Miller
- Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Ocular Microbiology Laboratory, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Guillermo Amescua
- Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jean-Marie Parel
- Anne Bates Leach Eye Hospital, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Ophthalmic Biophysics Center, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,University of Liege Sart-Tillman CHU Dept. of Ophthalmology, Liege, Belgium
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Atia R, Jouve L, Knoeri J, Georgeon C, Laroche L, Borderie V, Bouheraoua N. [Corneal collagen cross-linking to treat infectious keratitis]. J Fr Ophtalmol 2018; 41:560-568. [PMID: 29903589 DOI: 10.1016/j.jfo.2017.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 11/24/2022]
Abstract
Infectious keratitis are a frequent cause of ocular morbidity. Today, new treatments are necessary to combat the emergence of antibiotic resistant germs. Corneal collagen cross-linking has been suggested to treat corneal infectious (PACK-CXL). Its action would be both antimicrobial and protective for the cornea, increasing its biochemical resistence to proteolytic enzymes. In vivo, PACK-CXL might demonstrate good efficacy against bacterial keratitis, contrary to herpetic keratitis for which it is contraindicated. For fungal or amoebic keratitis, results are uncertain regarding its safety and efficacy. The purpose of this paper is to clarify the use of corneal collagen cross-linking to treat infectious keratitis.
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Affiliation(s)
- R Atia
- Service d'ophtalmologie 5, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75012 Paris, France
| | - L Jouve
- Service d'ophtalmologie 5, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75012 Paris, France
| | - J Knoeri
- Service d'ophtalmologie 5, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75012 Paris, France
| | - C Georgeon
- Service d'ophtalmologie 5, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75012 Paris, France
| | - L Laroche
- Service d'ophtalmologie 5, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75012 Paris, France; Inserm UMR S 968, université Pierre-et-Marie-Curie-Paris-VI, institut de la vision, 75012 Paris, France
| | - V Borderie
- Service d'ophtalmologie 5, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75012 Paris, France; Inserm UMR S 968, université Pierre-et-Marie-Curie-Paris-VI, institut de la vision, 75012 Paris, France
| | - N Bouheraoua
- Service d'ophtalmologie 5, centre hospitalier national d'ophtalmologie des Quinze-Vingts, 28, rue de Charenton, 75012 Paris, France; Inserm UMR S 968, université Pierre-et-Marie-Curie-Paris-VI, institut de la vision, 75012 Paris, France.
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Cold atmospheric pressure plasma jet for the treatment of Aspergillus keratitis. CLINICAL PLASMA MEDICINE 2018. [DOI: 10.1016/j.cpme.2017.12.075] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Reply. Am J Ophthalmol 2016; 168:294-295. [PMID: 27292530 DOI: 10.1016/j.ajo.2016.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/18/2016] [Indexed: 11/22/2022]
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Hafezi F, Kling S. Photoactivated Chromophore for Moderate to Severe Infectious Keratitis as an Adjunct Therapy: A Randomized Controlled Trial. Am J Ophthalmol 2016; 168:293-294. [PMID: 27292531 DOI: 10.1016/j.ajo.2016.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
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