Corneal Cross-linking as an Adjuvant Therapy in the Management of Recalcitrant Deep Stromal Fungal Keratitis: A Randomized Trial

Uddaraju, Madhu; Mascarenhas, Jeena; Das, Mano Ranjan; Radhakrishnan, Nita; Keenan, Jeremy D.; Lalitha, Prajna; Prajna, Venkatesh

doi:10.1016/j.ajo.2015.03.024

Cited by 92 publications

(52 citation statements)

References 19 publications

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“…121 A third, small randomized clinical trial investigated cross-linking as adjuvant therapy for deep fungal ulcers at Aravind Eye Hospital in Madurai, India suggested that CXL could increase the rate of perforation in fungal ulcers. 122 …”

Section: Future Directionsmentioning

confidence: 99%

Update on the Management of Infectious Keratitis

2017

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Infectious keratitis is a major global cause of visual impairment and blindness, often affecting marginalized populations. Proper diagnosis of the causative organism is critical, and while culture remains the prevailing diagnostic tool, newer techniques such as in vivo confocal microscopy are helpful for diagnosing fungal keratitis and Acanthameoba. Next generation sequencing holds the potential for early and accurate diagnosis even for organisms that are difficult to culture by conventional methods. Topical antibiotics remain the best treatment for bacterial keratitis, and a recent review found all commonly prescribed topical antibiotics to be equally effective. However outcomes remain poor secondary to corneal melting, scarring and perforation. Adjuvant therapies aimed at reducing the immune response responsible for much of the morbidity associated with keratitis include topical corticosteroids. The large, randomized controlled Steroids for Corneal Ulcers trial found that while steroids provided no significant improvement overall, they did appear beneficial for ulcers that were central, deep or large, non-Nocardia or classically invasive P. aeruginosa, patients with low baseline vision, and when started early after the initiation of antibiotics. Fungal ulcers often have worse clinical outcomes than bacterial ulcers, with no new treatments since the 1960’s when topical natamycin was introduced. The randomized controlled Mycotic Ulcer Treatment Trial showed a benefit of topical natamycin over topical voriconazole for fungal keratitis, particularly among those caused by Fusarium. The second Mycotic Ulcer Treatment Trial showed that oral voriconazole did not improve outcomes overall although there may have been some effect among Fusarium ulcers. Given an increase in non-serious adverse events the authors concluded that they could not recommend oral voriconazole at this time. Viral keratitis differs from bacterial and fungal cases in that is often recurrent and is common in developed countries. The first Herpetic Eye Disease Study (HEDS) showed a significant benefit of topical corticosteroids and oral acyclovir for stromal keratitis. HEDS II showed that oral acyclovir decreased the recurrence of any type of HSV keratitis by approximately half. Future strategies to reduce the morbidity associated with infectious keratitis are likely to be multidimensional with adjuvant therapies aimed at modifying the immune response to infection holding the greatest potential to improve clinical outcomes.

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Section: Future Directionsmentioning

confidence: 99%

Update on the Management of Infectious Keratitis

2017

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“…16 Its application to deep stromal keratitis, however, is still under debate. 17,18 Future studies are warranted to investigate whether this novel technique could be used for treating A actinomycetemcomitans keratitis.…”

Section: Discussionmentioning

confidence: 99%

Actinobacillus actinomycetemcomitans Keratitis After Glaucoma Infiltration Surgery

Hong

Cao

et al. 2016

Medicine

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Actinobacillus actinomycetemcomitans infection is a rare and easily misdiagnosed ocular disease. In this article, the authors report a chronic, purulent, and difficult-to-treat case of A actinomycetemcomitans keratitis following a glaucoma infiltration surgery.A 56-year-old man with a long-standing history of open-angle glaucoma in both eyes presented with a 12-week history of ocular pain, redness, and blurred vision in his right eye. He underwent a glaucoma infiltration surgery in his right eye 6 months ago. Three months postoperatively, he developed peripheral corneal stromal opacities associated with a white, thin, cystic bleb, and conjunctival injection. These opacities grew despite topical treatment with topical tobramycin, levofloxacin, natamycin, amikacin, and metronidazole eye drops.Multiple corneal scrapings revealed no organisms, and no organisms grew on aerobic, anaerobic, fungal, or mycobacterial cultures. The patient's right eye developed a severe purulent corneal ulcer with a dense hypopyon and required a corneal transplantation. Histopathologic analysis and 16S ribosomalribonucleic acid polymerase chain reaction sequencing revealed A actinomycetemcomitans as the causative organism. Postoperatively, treatment was initiated with topical levofloxacin and cyclosporine, as well as oral levofloxacin and cyclosporine. Graft and host corneal transparency were maintained at the checkup 1 month after surgery.Although it is a rare cause of corneal disease, A actinomycetemcomitans should be suspected in patients with keratitis refractory to topical antibiotic therapy. Delay in diagnosis and appropriate treatment can result in vision loss.

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“…in a prospective randomized clinical trial found that CXL is not helpful in deep stromal fungal keratitis. [35] Five eyes in the CXL group and three eyes in the non-CXL group experienced treatment failure by 6 weeks ( P = 0.56). In a secondary analysis, the CXL group experienced more perforations than the non-CXL group (4 vs. 0, respectively; P = 0.02).…”

Section: What Is the Experience With Fungal And Parasitic Infections?mentioning

confidence: 99%