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Tawfeek MMM, Ahmed HMAH, Bor'i A, Rady AMNA. Repeated sessions of PACK-CXL WA for the treatment of resistant bacterial keratitis: a retrospective study. BMC Ophthalmol 2023; 23:333. [PMID: 37495952 PMCID: PMC10369738 DOI: 10.1186/s12886-023-03080-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVE The aim of this work is to evaluate the safety and efficacy of repeated sessions of photo-activated chromophore for keratitis-cross linking (PACK-CXL) window absorption (WA) for the treatment of resistant bacterial keratitis (BK). PATIENTS AND METHODS This is a retrospective clinical cohort study. Thirty eyes with clinically suspected and lab-confirmed bacterial keratitis, resistant to appropriate antibiotic therapy- which was modified by sensitivity reports- for 2 weeks with failure of epithelialization for 4 weeks after the standard anti-microbial therapy (SAT) together with one setting of PACK-CXL WA were included. If after the first session of PACK-CXL, there is a start of improvement in the form of reduction of the size of corneal ulcer and stromal infiltrates together with the start of epithelialization on clinical examination and AS-OCT, another session of PACK-CXL WA was performed after one week, and so on, till the complete healing and resolution of bacterial keratitis and confirmation by negative bacterial culture. Identification of the micro-organisms was done by lab study before and after treatment. Corneal healing was evaluated by corneal examination and anterior segment OCT (AS-OCT). RESULTS Thirty eyes of 30 patients were recruited in this study. They were 16 males and 14 females, their mean age was 44.3 ± 5.38 years. The mean ulcer size was 3.96 ± 1.87 (mm3), while the mean size of stromal infiltrates was 4.52 ± 2.24 (mm3). PACK-CXL WA treatment was performed an average of 2.87 times for the 30 eyes. Complete healing and resolution (Successful treatment) was observed in 27 eyes (90%) of cases and failure of epithelialization was observed only in 3 eyes (10%). Complete corneal healing was reported in the second month postoperatively in 90% of eyes. CONCLUSION AND RECOMMENDATION PACK-CXL WA may be a promising, non-invasive treatment option for resistant bacterial keratitis. It may have a synergistic effect with standard antimicrobial treatment (SAT). Also, it can overcome the antibiotics resistance that has become rapidly spreading worldwide. Repeated sessions of PACK-CXL WA may be more effective for the treatment of resistant bacterial keratitis till complete epithelialization and resolution of BK than a single session with few complications. However, further prospective and comparative studies to support the results are needed.
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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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Corneal cross-linking guards against infectious keratitis: an experimental model. Int Ophthalmol 2022; 43:1241-1248. [PMID: 36255611 PMCID: PMC10113293 DOI: 10.1007/s10792-022-02522-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 09/11/2022] [Indexed: 10/24/2022]
Abstract
BACKGROUND PACK-CXL (photo-activated chromophore for keratitis-corneal cross-linking) is an alternative option in treatment of corneal infections. It inhibits corneal melting by increasing the stromal resistance, besides the microbicidal effect of photo-activated riboflavin. METHODS Corneal infection with Pseudomonas aeruginosa and Staph aureus bacteria was induced in 20 eyes of 10 rabbits after 6 weeks of corneal cross-linking in half of the eyes, while the other acted as control group. Clinical and corneal histopathological examination was done to evaluate the extent of inflammation, ulceration, organism penetration, and depth of corneal stromal affection. RESULTS The control eyes developed severe inflammation compared to the cross-linked eyes. Corneal melting occurred in 6 eyes in the control versus none in cross-linked group. Histopathological examination showed that the inflammation was confined to the superficial part of the stroma with localization of the inflammation in the cross-linked eyes in contrast to the control eyes that showed deep infiltration. CONCLUSION PACK-CXL provides infection localization through increasing the corneal rigidity and resistance to enzymatic digestion, even in the absence of the riboflavin microbicidal role. So, early PACK-CXL is worth to be considered in the IK treatment algorithm.
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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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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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Gulias-Cañizo R, Benatti A, De Wit-Carter G, Hernández-Quintela E, Sánchez-Huerta V. Photoactivated Chromophore for Keratitis-Corneal Collagen Cross-Linking (PACK-CXL) Improves Outcomes of Treatment-Resistant Infectious Keratitis. Clin Ophthalmol 2020; 14:4451-4457. [PMID: 33376299 PMCID: PMC7762451 DOI: 10.2147/opth.s284306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 11/04/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the efficacy of photoactivated chromophore corneal collagen cross-linking (PACK)-CXL in the management of treatment-resistant infectious keratitis. Design Observational cohort study. Participants Forty-two eyes from 41 patients with treatment-resistant infectious keratitis. Methods Eyes underwent PACK-CXL treatment with the Dresden modified protocol in addition to standard antimicrobial therapy. The primary endpoint was the size of the corneal ulcer. Descriptive statistics, Wilcoxon rank test, McNemar test and Spearman correlation coefficient were used for statistical analysis, and p values lower than 0.05 were considered statistically significant. Results Success rate at third postoperative month was of 90.5%. Statistical analyses showed a significant effect of (PACK)‑CXL with standard antimicrobial therapy to reduce corneal ulcer size (p=0.031). Conclusion As adjuvant therapy to standard antimicrobial treatment, PACK-CXL improves the outcomes in patients with treatment-resistant corneal ulcers.
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Affiliation(s)
| | - Andres Benatti
- Cordoba Eye Clinic, Cornea and Refractive Surgery Department, Cordoba, Argentina
| | - Guillermo De Wit-Carter
- Asociación para Evitar la Ceguera en México, Hospital Dr. Luis Sanchez Bulnes, Cornea Department, Mexico City 04030, Mexico
| | - Everardo Hernández-Quintela
- Asociación para Evitar la Ceguera en México, Hospital Dr. Luis Sanchez Bulnes, Cornea Department, Mexico City 04030, Mexico
| | - Valeria Sánchez-Huerta
- Asociación para Evitar la Ceguera en México, Hospital Dr. Luis Sanchez Bulnes, Cornea Department, Mexico City 04030, Mexico
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Corneal Collagen Cross-Linking With Photoactivated Chromophore for Infectious Keratitis After Penetrating Keratoplasty. Cornea 2019; 39:283-289. [DOI: 10.1097/ico.0000000000002210] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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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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Mahmoudi S, Masoomi A, Ahmadikia K, Tabatabaei SA, Soleimani M, Rezaie S, Ghahvechian H, Banafsheafshan A. Fungal keratitis: An overview of clinical and laboratory aspects. Mycoses 2018; 61:916-930. [PMID: 29992633 DOI: 10.1111/myc.12822] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/28/2018] [Indexed: 12/22/2022]
Abstract
Mycotic keratitis or keratomycosis is a fungal infection with global distribution. The dominant aetiology of this disease varies based on geographical origin, socioeconomic status, and climatic condition. Generally, Aspergillus spp. and Fusarium spp. are common in tropical and subtropical regions and Candida spp. are dominant in temperate areas. Demonstration of fungal elements in microscopic examination besides the isolation of fungi in culture is the gold standard of laboratory diagnosis. As the culture is a time-consuming procedure, other approaches such as in vivo confocal microscopy which produces real-time imaging of corneal tissue and molecular techniques have been developed to facilitate rapid diagnosis of fungal keratitis. The first choice of treatment is topical natamycin, although topical amphotericin B is the best choice for Aspergillus and Candida keratitis. Regarding the diversity of fungal aetiology and the emergence of drug resistance in some genera and species, proper identification using molecular methods and antifungal susceptibility testing could provide useful data. Furthermore, as the better efficacy of combination therapy in comparison to monotherapy is reported, in vitro determination of interactions between various drugs seem informative. This review aims to provide a general and updated view on the aetiology, risk factors, epidemiology, clinical and laboratory diagnosis, and management of fungal keratitis.
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Affiliation(s)
- Shahram Mahmoudi
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Masoomi
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Ahmadikia
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Ali Tabatabaei
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Soleimani
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sassan Rezaie
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ghahvechian
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Banafsheafshan
- Department of Ocular Trauma and Emergency, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Lim L, Lim EWL. A Review of Corneal Collagen Cross-linking - Current Trends in Practice Applications. Open Ophthalmol J 2018; 12:181-213. [PMID: 30123383 PMCID: PMC6062907 DOI: 10.2174/1874364101812010181] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/05/2017] [Accepted: 01/22/2018] [Indexed: 01/02/2023] Open
Abstract
Objective: To review the literature on current applications of corneal Collagen Cross-Linking (CXL). Methods: A review of publications on corneal cross-linking was conducted. This included systemic reviews, randomized controlled clinical trials, cohort studies, case-controlled studies and case series. A summary of the publications is tabulated. Results: The original indication of riboflavin – Ultraviolet-A (UVA) induced corneal collagen cross-linking is to arrest the progression of keratoconus. Studies show that it is effective in arresting the progression of keratoconus and post-LASIK ectasia with the standard Dresden protocol (epithelium-off). There are also improvements in visual, keratometric and topographic measurements over time. Severe complications of cross-linking are rare. The epithelium-on techniques have less efficacy than the Dresden protocol. Accelerated protocols have variable results, with some studies reporting comparable outcomes to the Dresden protocol while other studies reporting less efficacious outcomes. Cross-linking combined with refractive procedures provide better visual outcome but long term studies are warranted. Cross-linking for the treatment of infective keratitis is a promising new treatment modality. Initial studies show that it is more effective for superficial rather than deep infections and for bacterial rather than fungal infections. Conclusions: Corneal cross-linking is a procedure with an expanding list of indications from the treatment of corneal ectasias to infective keratitis. While the standard Dresden protocol is established as the gold standard treatment for progressive keratoconus, the more recent protocols may require further refinements, investigative and long-term studies.
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Affiliation(s)
- Li Lim
- MBBS (Singapore), MMed (Ophth), FRCS(Ed), FAMS (S'pore) Senior Consultant, Corneal and External Eye Disease Service, Singapore National Eye Centre, Singapore, Singapore
| | - Elizabeth Wen Ling Lim
- Undergraduate medical student, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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11
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Bonzano C, Di Zazzo A, Barabino S, Coco G, Traverso CE. Collagen Cross-Linking in the Management of Microbial Keratitis. Ocul Immunol Inflamm 2018; 27:507-512. [DOI: 10.1080/09273948.2017.1414856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Chiara Bonzano
- Clinica Oculistica, Di.N.O.G.M.I. University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Di Zazzo
- Department of Ophthalmology, IRCCS, GB Bietti Foundation, Rome, Italy
| | - Stefano Barabino
- Clinica Oculistica, Di.N.O.G.M.I. University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Giulia Coco
- Ophthalmology Department, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Enrico Traverso
- Clinica Oculistica, Di.N.O.G.M.I. University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
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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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13
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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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14
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Hao ZQ, Song JX, Pan SY, Zhang L, Cheng Y, Liu XN, Wu J, Xiao XH, Gao W, Zhu HF. Corneal collagen cross-linking and liposomal amphotericin B combination therapy for fungal keratitis in rabbits. Int J Ophthalmol 2016; 9:1549-1554. [PMID: 27990355 DOI: 10.18240/ijo.2016.11.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 06/12/2016] [Indexed: 11/23/2022] Open
Abstract
AIM To observe the therapeutic effect of corneal collagen cross-linking (CXL) in combination with liposomal amphotericin B in fungal corneal ulcers. METHODS New Zealand rabbits were induced fungal corneal ulcers by scratching and randomly divided into 3 groups, i.e. control, treated with CXL, and combined therapy of CXL with 0.25% liposomal amphotericin B (n=5 each). The corneal lesions were documented with slit-lamp and confocal microscopy on 3, 7, 14, 21 and 28d after treatment. The corneas were examined with transmission electron microscopy (TEM) at 4wk. RESULTS A rabbit corneal ulcer model of Fusarium was successfully established. The corneal epithelium defect areas in the two treatment groups were smaller than that in the control group on 3, 7, 14 and 21d (P<0.05). The corneal epithelium defect areas of the combined group was smaller than that of the CXL group (P<0.05) on 7 and 14d, but there were no statistical differences on 3, 21 and 28d. The corneal epithelium defects of the two treatment groups have been healed by day 21. The corneal epithelium defects of the control group were healed on 28d. The diameters of the corneal collagen fiber bundles (42.960±7.383 nm in the CXL group and 37.040±4.160 nm in the combined group) were thicker than that of the control group (24.900±1.868 nm), but there was no difference between the two treatment groups. Some corneal collagen fiber bundles were distorted and with irregular arrangement, a large number of fibroblasts could be seen among them but no inflammatory cells in both treatment groups. CONCLUSION CXL combined with liposomal amphotericin B have beneficial effects on fungal corneal ulcers. The combined therapy could alleviate corneal inflammattions, accelerate corneal repair, and shorten the course of disease.
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Affiliation(s)
- Zhao-Qin Hao
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
| | - Jin-Xin Song
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
| | - Shi-Yin Pan
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
| | - Lin Zhang
- Department of Ophthalmology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, Shaanxi Province, China
| | - Yan Cheng
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
| | - Xian-Ning Liu
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
| | - Jie Wu
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
| | - Xiang-Hua Xiao
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
| | - Wei Gao
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
| | - Hai-Feng Zhu
- Department of Ophthalmology, the First Hospital of Xi'an, Shaanxi Ophthalmological Institute, Xi'an 710002, Shaanxi Province, China
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Yagci A, Palamar M, Polat Hilmioglu S, Irkec M. Cross-Linking Treatment and Corneal Transplant in Refractory Acremonium Keratitis: Case Report. EXP CLIN TRANSPLANT 2016; 14:580-583. [PMID: 27452505 DOI: 10.6002/ect.2014.0187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To report a case of Acremonium keratitis treated with voriconazole, corneal collagen cross-linking, and corneal transplant. MATERIALS AND METHODS Case report. RESULTS A 42-year-old woman who wore contact lenses daily was referred for refractory keratitis. Her main complaints were gritty sensation and pain. At slit lamp biomicroscopy, an infiltrate on the inferior paracentral cornea and an arcuate conjunctival ulceration were evident. The rest of the cornea was clear with no anterior chamber reaction. Scrapings from the corneal ulcer showed Candida parapsilosis and Acremonium species, which were sensitive to voriconazole. Despite the administration of topical, systemic, and intrastromal voriconazole for 1 month, repeat corneal scraping was positive for Acremonium, and clinical appearance and pain did not resolve. Therefore, corneal collagen cross-linking was applied. Although the pain resolved immediately after the procedure, the lesion showed no improvement. After a month of cross-linking, corneal transplant was performed for visual rehabilitation and treatment of the refractory lesion. The excised corneal button was negative for any microorganisms. CONCLUSIONS Although corneal collagen cross-linking may be an effective treatment for Acremonium keratitis refractory to medical therapy, corneal transplant was required for visual gain and recovery.
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Affiliation(s)
- Ayse Yagci
- From the Department of , Ophthalmology, Ege University Faculty of Medicine, Izmir, Turkey
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Tabibian D, Mazzotta C, Hafezi F. PACK-CXL: Corneal cross-linking in infectious keratitis. EYE AND VISION 2016; 3:11. [PMID: 27096139 PMCID: PMC4836155 DOI: 10.1186/s40662-016-0042-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 03/24/2016] [Indexed: 11/24/2022]
Abstract
Background Corneal cross-linking (CXL) using ultraviolet light-A (UV-A) and riboflavin is a technique developed in the 1990’s to treat corneal ectatic disorders such as keratoconus. It soon became the new gold standard in multiple countries around the world to halt the progression of this disorder, with good long-term outcomes in keratometry reading and visual acuity. The original Dresden treatment protocol was also later on used to stabilize iatrogenic corneal ectasia appearing after laser-assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). CXL efficiently strengthened the cornea but was also shown to kill most of the keratocytes within the corneal stroma, later on repopulated by those cells. Review Ultraviolet-light has long been known for its microbicidal effect, and thus CXL postulated to be able to sterilize the cornea from infectious pathogens. This cytotoxic effect led to the first clinical trials using CXL to treat advanced infectious melting corneal keratitis. Patients treated with this technique showed, in the majority of cases, a stabilization of the melting process and were able to avoid emergent à chaud keratoplasty. Following those primary favorable results, CXL was used to treat beginning bacterial keratitis as a first-line treatment without any adjunctive antibiotics with positive results for most patients. In order to distinguish the use of CXL for infectious keratitis treatment from its use for corneal ectatic disorders, a new term was proposed at the 9th CXL congress in Dublin to rename its use in infections as photoactivated chromophore for infectious keratitis -corneal collagen cross-linking (PACK-CXL). Conclusion PACK-CXL is now more frequently used to treat infections from various infectious origins. The original Dresden protocol is still used for this purpose. Careful modifications of this protocol could improve the efficiency of this technique in specific clinical situations regarding certain types of pathogens.
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Affiliation(s)
- David Tabibian
- Laboratory for Ocular Cell Biology, University of Geneva, Geneva, Switzerland ; Department of Ophthalmology, Northampton General Hospital, Northampton, United Kingdom
| | - Cosimo Mazzotta
- Siena Crosslinking Center, Siena University Hospital, Siena, Italy
| | - Farhad Hafezi
- Laboratory for Ocular Cell Biology, University of Geneva, Geneva, Switzerland ; Department of Ophthalmology, University of Southern California, Los Angeles, CA USA ; EyeCare Laboratory Research Zurich Associates (ELZA) Institute, Webereistrasse 2, 8953 Dietikon, Switzerland
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Chan TCY, Lau TWS, Lee JWY, Wong IYH, Jhanji V, Wong RLM. Corneal collagen cross-linking for infectious keratitis: an update of clinical studies. Acta Ophthalmol 2015; 93:689-96. [PMID: 25990098 DOI: 10.1111/aos.12754] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 03/30/2015] [Indexed: 11/30/2022]
Abstract
Collagen cross-linking (CXL) with ultraviolet light-activated riboflavin is a corneal surface procedure developed for the treatment of keratoconus and corneal ectasia. With the known microbicidal and corneal stiffening effects of ultraviolet irradiation and photoactivated riboflavin, it has recently been introduced for the management of infectious keratitis, especially for ulcers resistant to antimicrobial therapy or associated with corneal melting. Various authors have attempted to use CXL as an adjunctive, salvage or even as the sole treatment for infectious corneal ulcers. The aim of this review was to provide a summary of the clinical studies in the literature. It is worth noting that there is still no consensus on the treatment protocol of CXL against infectious keratitis. The disparities in outcome measures, treatment protocol and study design can confound the interpretation and hamper the generalization of the study results. Based on current evidence, the role of CXL in infectious keratitis remained unclear despite the reported success in some clinical cases. Further investigations are warranted concerning the efficacy and safety of treating infectious keratitis with CXL.
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Affiliation(s)
- Tommy C. Y. Chan
- Hong Kong Eye Hospital; Hong Kong SAR China
- Department of Ophthalmology and Visual Sciences; The Chinese University of Hong Kong; Hong Kong SAR China
| | - Tiffany W. S. Lau
- Hong Kong Eye Hospital; Hong Kong SAR China
- Department of Ophthalmology and Visual Sciences; The Chinese University of Hong Kong; Hong Kong SAR China
| | - Jacky W. Y. Lee
- Department of Ophthalmology; The University of Hong Kong; Hong Kong SAR China
| | - Ian Y. H. Wong
- Department of Ophthalmology; The University of Hong Kong; Hong Kong SAR China
| | - Vishal Jhanji
- Hong Kong Eye Hospital; Hong Kong SAR China
- Department of Ophthalmology and Visual Sciences; The Chinese University of Hong Kong; Hong Kong SAR China
| | - Raymond L. M. Wong
- Hong Kong Eye Hospital; Hong Kong SAR China
- Department of Ophthalmology and Visual Sciences; The Chinese University of Hong Kong; Hong Kong SAR China
- Department of Ophthalmology; The University of Hong Kong; Hong Kong SAR China
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Tabibian D, Richoz O, Hafezi F. PACK-CXL: Corneal Cross-linking for Treatment of Infectious Keratitis. J Ophthalmic Vis Res 2015; 10:77-80. [PMID: 26005557 PMCID: PMC4424723 DOI: 10.4103/2008-322x.156122] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/04/2014] [Indexed: 11/04/2022] Open
Abstract
This article discusses corneal cross-linking (CXL) and how it transitioned from a modality for treating corneal ectatic disorders to an inventive means of treating infectious keratitis. Initially, CXL was successfully developed to halt the progression of ectatic diseases such as keratoconus, using the standard Dresden protocol. Later, indications were extended to treat iatrogenic ectasia developing after laser-assisted in situ keratomileusis (LASIK) and photo-refractive keratectomy (PRK). At the time, it had been postulated that the combination of ultraviolet light with riboflavin could not only biomechanically strengthen the cornea but also was capable of destroying living cells and organisms including keratocytes and pathogens. Thus a new and innovative concept of treatment for infectious keratitis emerged through the use of CXL technology. Initially only advanced infectious melting ulcers resisting standard microbicidal therapy were treated with CXL in addition to standard therapy. In subsequent studies CXL was also used to treat bacterial keratitis as first line therapy without the use of concomitant antibiotic therapy. With the increasing interest in CXL technology to treat infectious keratitis and to clearly separate its use from the treatment of ectatic disorders, a new term was adopted at the 9(th) CXL congress in Dublin for this specific indication: PACK-CXL (photoactivated chromophore for infectious keratitis). PACK-CXL has the potential to eventually become an interesting alternative to standard antibiotic therapy in treating infectious corneal disorders, and may help reduce the global burden of microbial resistance to antibiotics and other therapeutic agents.
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Affiliation(s)
- David Tabibian
- Laboratory for Ocular Cell Biology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Olivier Richoz
- Laboratory for Ocular Cell Biology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Farhad Hafezi
- Laboratory for Ocular Cell Biology, Faculty of Medicine, University of Geneva, Geneva, Switzerland ; Department of Ophthalmology, University of Southern California, Los Angeles, California, USA ; The ELZA Institute, Dietikon/Zurich, Switzerland
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Ultraviolet A/Riboflavin Collagen Cross-Linking for Treatment of Moderate Bacterial Corneal Ulcers. Cornea 2015; 34:402-6. [DOI: 10.1097/ico.0000000000000375] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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