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Deivarajan HR, Elamurugan V, Sivashanmugam P, Pandian J, Sevugamurthi K, Rameshkumar G, Ghosh S, Banerjee D, Venugopal A, Jose A, Rammohan R, Raghavan A, Rajaraman R, Kuppamuthu D, Prajna L, Prajna VN, Narendran S. Development and Clinical Evaluation of a CRISPR/Cas12a-Based Nucleic Acid Detection Platform for the Diagnosis of Keratomycoses. OPHTHALMOLOGY SCIENCE 2024; 4:100522. [PMID: 38881611 PMCID: PMC11179415 DOI: 10.1016/j.xops.2024.100522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 06/18/2024]
Abstract
Objective The objective of this study was to develop a rapid and accurate clustered regularly interspaced short palindromic repeats (CRISPR)/Cas12a-based molecular diagnostic assay (Rapid Identification of Mycoses using CRISPR, RID-MyC assay) to detect fungal nucleic acids and to compare it with existing conventional mycologic methods for the diagnosis of fungal keratitis (FK). Design This study was structured as a development and validation study focusing on the creation and assessment of the RID-MyC assay as a novel diagnostic modality for FK. Subjects Participants comprised 142 individuals presenting with suspected microbial keratitis at 3 tertiary care institutions in South India. Methods The RID-MyC assay utilized recombinase polymerase amplification targeting the 18S ribosomal RNA gene for isothermal amplification, followed by a CRISPR/Cas12a reaction. This was benchmarked against microscopy, culture, and polymerase chain reaction for the diagnosis of FK. Main Outcome Measures The primary outcome measures focused on the analytical sensitivity and specificity of the RID-MyC assay in detecting fungal nucleic acids. Secondary outcomes measured the assay's diagnostic sensitivity and specificity for FK, including its concordance with conventional diagnostic methods. Results The RID-MyC assay exhibited a detection limit ranging from 13.3 to 16.6 genomic copies across 4 common fungal species. In patients with microbial keratitis, the RID-MyC assay showed substantial agreement with microscopy (kappa = 0.714) and fair agreement with culture (kappa = 0.399). The assay demonstrated a sensitivity of 93.27% (95% confidence interval [CI], 86.62%-97.25%) and a specificity of 89.47% (95% CI, 66.86%-98.70%) for FK diagnosis, with a median diagnostic time of 50 minutes (range, 35-124 minutes). Conclusions The RID-MyC assay, utilizing CRISPR-Cas12a technology, offers high diagnostic accuracy for FK. Its potential for point-of-care use could expedite and enhance the precision of fungal diagnostics, presenting a promising solution to current diagnostic challenges. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Hanith Raj Deivarajan
- Department of Microbiology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Vignesh Elamurugan
- Department of Microbiology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
- Department of Retina & Vitreous Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Padmapriya Sivashanmugam
- Department of Microbiology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
- Aravind Medical Research Foundation Regional Centre, Coimbatore, Tamil Nadu, India
| | - Jaishree Pandian
- Aravind Medical Research Foundation Regional Centre, Coimbatore, Tamil Nadu, India
| | - Karvannan Sevugamurthi
- Department of Microbiology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | | | - Swagata Ghosh
- Department of Microbiology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Daipayan Banerjee
- Department of Proteomics, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Anitha Venugopal
- Department of Cornea & Refractive Surgery Services, Tirunelveli, Tamil Nadu, India
| | - Anju Jose
- Department of Retina & Vitreous Services, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
| | - Ram Rammohan
- Department of Microbiology, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
| | - Anita Raghavan
- Department of Microbiology, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
- Department of Cornea & Refractive Surgery Services, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
| | - Revathi Rajaraman
- Department of Microbiology, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
- Department of Cornea & Refractive Surgery Services, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
| | | | - Lalitha Prajna
- Department of Microbiology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
- Department of Microbiology, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Venkatesh N Prajna
- Department of Microbiology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
- Department of Cornea & Refractive Surgery Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Siddharth Narendran
- Department of Microbiology, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
- Aravind Medical Research Foundation Regional Centre, Coimbatore, Tamil Nadu, India
- Department of Cataract Services, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
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Ferreira da Cunha Neto J, da Silva Rocha WP, Makris G, Sandoval-Denis M, Hagen F, Crous PW, Chaves GM. Fusarioid keratitis and other superficial infections: A 10-years prospective study from Northeastern Brazil. PLoS Negl Trop Dis 2024; 18:e0012247. [PMID: 38885283 DOI: 10.1371/journal.pntd.0012247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Fusarium and allied genera (fusarioid) species are common colonizers of roots and aerial plant parts, or act as phytopathogens in forestry and horticultural or grain crops. However, they can also cause a wide range of infections in humans, including onychomycosis, cutaneous and invasive infections. Fusarioid keratitis is characterized by an infection of the cornea with a suppurative and ulcerative appearance, which may cause damage to vision and permanent blindness. The aim of the present study was to investigate the prevalence of fusarioid species, biofilm formation and antifungal susceptibility profiling of clinical isolates recovered from patients with keratitis and dermatomycoses. METHODOLOGY/PRINCIPAL FINDINGS The study was performed between March, 2012-December, 2022. Demographic, clinical and epidemiological data of patients were also collected. In the present study, most of the patients with keratitis were male (74%), had a median age of 42 years old, worked with plant material or debris and 26% of them reported eye trauma. Regarding dermatomycosis, most of patients were female and exhibited toenail lesions. Forty-seven isolates belonged to the genus Neocosmospora (78.33%), nine to the Fusarium fujikuroi (15%) and four to the Fusarium oxysporum (6.66%) species complexes. Several strains were moderate biofilm producers, specifically among Fusarium annulatum. Most strains showed increased MICs to amphotericin B and ketoconazole and low MICs to itraconazole. MICs ranged from 0.25 to 16 μg/mL for amphotericin B, 0.0625 to >16 μg/mL for ketoconazole and 0.125 to 8 for itraconazole. CONCLUSIONS/SIGNIFICANCE It is possible to conclude that fusarioid keratitis in Northeastern Brazil is an important and neglected disease, given the high number of cases, increased need for keratoplasty and poor outcome of the disease.
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Affiliation(s)
- Jose Ferreira da Cunha Neto
- Laboratory of Medical and Molecular Mycology, Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | - Georgios Makris
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | | | - Ferry Hagen
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
| | | | - Guilherme Maranhão Chaves
- Laboratory of Medical and Molecular Mycology, Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
- Westerdijk Fungal Biodiversity Institute, Utrecht, the Netherlands
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Nayel AA, Hamdy NA, Massoud TH, Mohamed NM. A comparison of antimicrobial regimen outcomes and antibiogram development in microbial keratitis: a prospective cohort study in Alexandria, Egypt. Graefes Arch Clin Exp Ophthalmol 2024; 262:1865-1882. [PMID: 38240778 PMCID: PMC11106157 DOI: 10.1007/s00417-023-06362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/12/2023] [Accepted: 12/23/2023] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Antimicrobial resistance in microbial keratitis has not been previously explored in Alexandria. We aim to recommend effective therapies through identification of etiological agents, determination of antimicrobial susceptibilities, and comparing outcomes of empiric topical antimicrobials. METHODS In this 2022 prospective cohort conducted in Alexandria Main University Hospital cornea clinic, antimicrobial susceptibilities of isolated microorganisms from corneal scrapings were detected and antibiograms were developed. Bacterial (BK), fungal (FK), or mixed fungal/bacterial keratitis (MFBK) patients on empiric regimens were compared for ulcer healing, time-to-epithelialization, best-corrected visual acuity, interventions, and complications. RESULTS The prevalent microorganisms in 93 positive-cultures were coagulase-negative staphylococci (CoNS, 30.1%), Pseudomonas aeruginosa (14%), and Aspergillus spp. (12.9%). CoNS were susceptible to vancomycin (VAN, 100%) and moxifloxacin (MOX, 90.9%). Gram-negative bacteria showed more susceptibility to gatifloxacin (90.9%) than MOX (57.1%), and to gentamicin (GEN, 44.4%) than ceftazidime (CAZ, 11.8%). Methicillin-resistance reached 23.9% among Gram-positive bacteria. Fungi exhibited 10% resistance to voriconazole (VRC). Percentages of healed ulcers in 49 BK patients using GEN + VAN, CAZ + VAN and MOX were 85.7%, 44.4%, and 64.5%, respectively (p = 0.259). Their median time-to-epithelialization reached 21, 30, and 30 days, respectively (log-rank p = 0.020). In 51 FK patients, more ulcers (88.9%) healed with natamycin (NT) + VRC combination compared to VRC (39.1%) or NT (52.6%) (p = 0.036). Their median time-to-epithelialization was 65, 60, and 22 days, respectively (log-rank p < 0.001). The VRC group required more interventions (60.9%) than NT + VRC-treated group (11.1%) (p = 0.018). In 23 MFBK patients, none healed using NT + CAZ + VAN, while 50% healed using VRC + CAZ + VAN (p = 0.052). Regimens had comparable visual outcomes and complications. CONCLUSION Based on the higher detected susceptibility, we recommend empiric MOX in suspected Gram-positive BK, gatifloxacin in Gram-negative BK, and GEN + VAN in severe BK. Due to better outcomes, we recommend NT + VRC in severe FK. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT05655689. Registered December 19, 2022- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05655689?cond=NCT05655689.&draw=2&rank=1.
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Affiliation(s)
- Amira A Nayel
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
- Clinical Pharmacy Department, Alexandria Ophthalmology Hospital, Ministry of Health and Population of Egypt, Alexandria, Egypt
| | - Noha A Hamdy
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt.
| | - Tamer H Massoud
- Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Nelly M Mohamed
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
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Novack GD, Robin AL. Ocular Pharmacology. J Clin Pharmacol 2024. [PMID: 38708561 DOI: 10.1002/jcph.2451] [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: 02/28/2024] [Accepted: 04/08/2024] [Indexed: 05/07/2024]
Abstract
Treatment of ocular diseases presents unique challenges and opportunities for the clinician and for the clinical pharmacologist. Ophthalmic pharmaceuticals, typically given as liquids, require consideration of solubility, physiological pH, and osmolarity, as well as sterility and stability, which in turn requires optimal pharmaceutics. Ocular tissue levels are challenging to obtain in humans, and the clinical pharmacokinetics is typically blood levels, which are primarily related to safety, rather than efficacy. The eye is a closed compartment with multiple physiological barriers with esterases and transporters, but relatively little cytochrome oxidases. Delivery routes include topical, intravitreal, and systemic. Patient dosing involves not only adherence issues common to all chronic diseases, but also performance requirements on eye drop instillation. Therapeutically, ocular diseases and their pharmacological treatments include both those analogous to systemic diseases (e.g., inflammation, infection, and neuronal degeneration) and those unique to the eye (e.g., cataract and myopia).
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Affiliation(s)
- Gary D Novack
- PharmaLogic Development, Inc., San Rafael, CA, USA
- Department of Ophthalmology and Vision Science, School of Medicine, University of California, Davis, CA, USA
| | - Alan L Robin
- Department of Ophthalmology, University of Michigan, Ann Arbor, MI, USA
- Department of Ophthalmology, School of Medicine Johns Hopkins University, Baltimore, MD, USA
- Department of International Health, Bloomberg School of International Health, Johns Hopkins University, Baltimore, MD, USA
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Anitha V, Madkaikar A, Patwardhan V, Ravindran M. Fulminant keratomycosis caused by Cylindrocarpon lichenicola- A case report. Eur J Ophthalmol 2024; 34:NP8-NP12. [PMID: 38178787 DOI: 10.1177/11206721231223542] [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] [Indexed: 01/06/2024]
Abstract
PURPOSE To report the clinical features, phylogenetic characteristics, microbiological characteristics, and the management of the rare emerging fungal species Cylindrocarpon lichenicola. METHODS A 55-year-old male farmer presented with a history of pain, redness, and defective vision. The corneal scrapings revealed septate hyphae macroconidia and multi-celled chlamydospores with lactophenol cotton blue mount. In addition, the culture revealed velvety to floccose, white growth with a pinkish-brown rim on the Sabouraud's dextrose agar. The growth was suggestive of the rare fungus Cylindrocarpon lichenicola. RESULTS The course of the infection was rapidly progressive, involving the entire cornea with descemetocele and impending perforation. Reinfection with the rapid spread of disease to the sclera was noted; finally, evisceration with scleral frill excision was done. CONCLUSION To our knowledge, this is the first case report of Fulminant Sclero Keratomycosis caused by Cylindrocarpon lichenicola.
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Affiliation(s)
- Venugopal Anitha
- Cornea and Refractive Services, Aravind Eye Hospital and Post graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
| | - Aditee Madkaikar
- Cornea and Refractive Services, Aravind Eye Hospital and Post graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
| | - Veena Patwardhan
- Cornea and Refractive Services, Aravind Eye Hospital and Post graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
| | - Meenakshi Ravindran
- Paediatric and Strabismus Services, Aravind Eye Hospital and Post graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
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Ling JYM, Yeung SN, Chan CC, Trinh T, Antaki F, Harissi-Dagher M, Sivachandran N, Fava M, Légaré MÈ, Iovieno A. Trends and Clinical Outcomes of Fungal Keratitis in Canada: A 20-year Retrospective Multicentre Study. Am J Ophthalmol 2024; 265:147-155. [PMID: 38642698 DOI: 10.1016/j.ajo.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE An increase in fungal and particularly filamentous keratitis has been observed in many geographic areas, mostly in contact lens wearers. This study seeks to characterize long-term trends in fungal keratitis in a continental climate area to provide guidance for diagnosis and treatment. DESIGN Retrospective multicentric case series. METHODS Cases of microbiology-confirmed fungal keratitis from 2003 to 2022 presenting to tertiary care centers across Canada were included. Charts were reviewed for patient demographics, risk factors, visual acuity, and treatments undertaken. RESULTS A total of 138 patients were identified: 75 had yeast keratitis while 63 had filamentous keratitis. Patients with yeast keratitis had more ocular surface disease (79% vs 28%) while patients with filamentous keratitis wore more refractive contact lenses (78% vs 19%). Candida species accounted for 96% of all yeast identified, while Aspergillus (32%) and Fusarium (26%) were the most common filamentous fungi species. The mean duration of treatment was 81 ± 96 days. Patients with yeast keratitis did not have significantly improved visual acuity with medical treatment (1.8 ± 1 LogMAR to 1.9 ± 1.5 LogMAR, P = .9980), in contrast to patients with filamentous keratitis (1.4 ± 1.2 LogMAR to 1.1 ± 1.3 LogMAR, P = .0093). CONCLUSIONS Fungal keratitis is increasing in incidence, with contact lenses emerging as one of the leading risk factors. Significant differences in the risk factors and visual outcomes exist between yeast keratitis and filamentous keratitis which may guide diagnosis and treatment.
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Affiliation(s)
- Jennifer Y M Ling
- From the Department of Ophthalmology and Visual Sciences (J.Y.M.L., S.N.Y., A.I.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Sonia N Yeung
- From the Department of Ophthalmology and Visual Sciences (J.Y.M.L., S.N.Y., A.I.), University of British Columbia, Vancouver, British Columbia, Canada
| | - Clara C Chan
- Department of Ophthalmology and Vision Sciences (C.C., T.T.), University of Toronto, Toronto, Ontario, Canada
| | - Tanya Trinh
- Department of Ophthalmology and Vision Sciences (C.C., T.T.), University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology (T.T.), Sydney Eye Hospital, Sydney, Australia
| | - Fares Antaki
- Department of Ophthalmology (F.A., M.H.), Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Mona Harissi-Dagher
- Department of Ophthalmology (F.A., M.H.), Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Nirojini Sivachandran
- Division of Ophthalmology (N.S., M.F.), McMaster University, Hamilton, Ontario, Canada
| | - Mark Fava
- Division of Ophthalmology (N.S., M.F.), McMaster University, Hamilton, Ontario, Canada
| | - Marie-Ève Légaré
- Centre Universitaire d'Ophtalmologie - CHU de Québec (M.L.), Université Laval, Québec City, Québec, Canada
| | - Alfonso Iovieno
- From the Department of Ophthalmology and Visual Sciences (J.Y.M.L., S.N.Y., A.I.), University of British Columbia, Vancouver, British Columbia, Canada.
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Rudhra O, Gnanam H, Sivaperumal S, Namperumalsamy V, Prajna L, Kuppamuthu D. Melanin depletion affects Aspergillus flavus conidial surface proteins, architecture, and virulence. Appl Microbiol Biotechnol 2024; 108:291. [PMID: 38592509 PMCID: PMC11004046 DOI: 10.1007/s00253-024-13107-4] [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: 08/17/2023] [Revised: 03/06/2024] [Accepted: 03/10/2024] [Indexed: 04/10/2024]
Abstract
Melanin is an Aspergillus flavus cell wall component that provides chemical and physical protection to the organism. However, the molecular and biological mechanisms modulating melanin-mediated host-pathogen interaction in A. flavus keratitis are not well understood. This work aimed to compare the morphology, surface proteome profile, and virulence of melanized conidia (MC) and non-melanized conidia (NMC) of A. flavus. Kojic acid treatment inhibited melanin synthesis in A. flavus, and the conidial surface protein profile was significantly different in kojic acid-treated non-melanized conidia. Several cell wall-associated proteins and proteins responsible for oxidative stress, carbohydrate, and chitin metabolic pathways were found only in the formic acid extracts of NMC. Scanning electron microscopy (SEM) analysis showed the conidial surface morphology difference between the NMC and MC, indicating the role of melanin in the structural integrity of the conidial cell wall. The levels of calcofluor white staining efficiency were different, but there was no microscopic morphology difference in lactophenol cotton blue staining between MC and NMC. Evaluation of the virulence of MC and NMC in the Galleria mellonella model showed NMC was less virulent compared to MC. Our findings showed that the integrity of the conidial surface is controlled by the melanin layer. The alteration in the surface protein profile indicated that many surface proteins are masked by the melanin layer, and hence, melanin can modulate the host response by preventing the exposure of fungal proteins to the host immune defense system. The G. mellonella virulence assay also confirmed that the NMC were susceptible to host defense as in other Aspergillus pathogens. KEY POINTS: • l-DOPA melanin production was inhibited in A. flavus isolates by kojic acid, and for the first time, scanning electron microscopy (SEM) analysis revealed morphological differences between MC and NMC of A. flavus strains • Proteome profile of non-melanized conidia showed more conidial surface proteins and these proteins were mainly involved in the virulence, oxidative stress, and metabolism pathways • Non-melanized conidia of A. flavus strains were shown to be less virulent than melanised conidia in an in vivo virulence experiment with the G. melonella model.
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Affiliation(s)
- Ondippili Rudhra
- Department of Proteomics, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Hariharan Gnanam
- Department of Proteomics, Aravind Medical Research Foundation, Madurai, Tamil Nadu, India
| | - Sivaramakrishnan Sivaperumal
- Department of Biotechnology and Genetic Engineering, Bharathidasan University, Tiruchirappalli, Tamil Nadu, India
| | | | - Lalitha Prajna
- Department of Ocular Microbiology, Aravind Eye Hospital, Aravind Eye Care System, Madurai, Tamil Nadu, India
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Rosenberg CR, Prajna V, Srinivasan MK, Lalitha PC, Krishnan T, Rajaraman R, Venugopal A, Acharya N, Seitzman GD, Rose-Nussbaumer J, Woodward MA, Lietman TM, Campbell JP, Keenan JD, Redd TK. Locality is the strongest predictor of expert performance in image-based differentiation of bacterial and fungal corneal ulcers from India. Indian J Ophthalmol 2024; 72:526-532. [PMID: 38454845 PMCID: PMC11149525 DOI: 10.4103/ijo.ijo_3396_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 09/21/2023] [Indexed: 03/09/2024] Open
Abstract
PURPOSE This study sought to identify the sources of differential performance and misclassification error among local (Indian) and external (non-Indian) corneal specialists in identifying bacterial and fungal keratitis based on corneal photography. METHODS This study is a secondary analysis of survey data assessing the ability of corneal specialists to identify acute bacterial versus fungal keratitis by using corneal photography. One-hundred images of 100 eyes from 100 patients with acute bacterial or fungal keratitis in South India were previously presented to an international cohort of cornea specialists for interpretation over the span of April to July 2021. Each expert provided a predicted probability that the ulcer was either bacterial or fungal. Using these data, we performed multivariable linear regression to identify factors predictive of expert performance, accounting for primary practice location and surrogate measures to infer local fungal ulcer prevalence, including locality, latitude, and dew point. In addition, Brier score decomposition was used to determine experts' reliability ("calibration") and resolution ("boldness") and were compared between local (Indian) and external (non-Indian) experts. RESULTS Sixty-six experts from 16 countries participated. Indian practice location was the only independently significant predictor of performance in multivariable linear regression. Resolution among Indian experts was significantly better (0.08) than among non-Indian experts (0.01; P < 0.001), indicating greater confidence in their predictions. There was no significant difference in reliability between the two groups ( P = 0.40). CONCLUSION Local cornea experts outperformed their international counterparts independent of regional variability in tropical risk factors for fungal keratitis. This may be explained by regional characteristics of infectious ulcers with which local corneal specialists are familiar.
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Affiliation(s)
| | - Venkatesh Prajna
- Department of Ophthalmology, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | | | - Prajna C Lalitha
- Department of Ophthalmology, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | - Tiru Krishnan
- Department of Ophthalmology, Aravind Eye Hospital, Pondicherry, Tamil Nadu, India
| | - Revathi Rajaraman
- Department of Ophthalmology, Aravind Eye Hospital, Coimbatore, Tamil Nadu, India
| | - Anitha Venugopal
- Department of Ophthalmology, Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
| | - Nisha Acharya
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
| | - Gerami D Seitzman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
| | - John Peter Campbell
- Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
| | - Travis K Redd
- Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
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Chen L, Dahshan D, Mauger T. Fungal keratitis after amniotic membrane placement. Am J Ophthalmol Case Rep 2024; 33:101972. [PMID: 38188608 PMCID: PMC10770418 DOI: 10.1016/j.ajoc.2023.101972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/16/2023] [Accepted: 12/01/2023] [Indexed: 01/09/2024] Open
Abstract
Purpose We present two cases of fungal keratitis following amniotic membrane transplantation, including Sistotrema biggsiae and Fusarium keratitis. Observations A 76-year-old female with a history of anterior basement membrane dystrophy referred for reduced vision and left eye pain ten days following AMT at an outside facility. Despite topical management, the patient continued to worsen clinically, with a recalcitrant course of Fusarium keratitis requiring conjunctival flap, cryotherapy, and intracameral and intrastromal injection. The second case involved a 46-year-old male with a history of recurrent corneal erosions referred for blurry vision and pain in his left eye seven days following AMT. He was found to have Sistotrema biggsiae keratitis and had remarkable visual improvement with topical management. Conclusions Fungal keratitis following amniotic membrane placement has not been reported presenting within ten days after transplantation. This is the first report of Sistotrema biggsiae infection in humans. This case series highlights the risk of severe recalcitrant microbial keratitis presenting within days after AMT placement and recognizing fungal etiologies not previously reported in literature. The risk of keratitis following AMT should be considered with close patient follow up, especially in patients with monocular vision.
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Affiliation(s)
- Lena Chen
- West Virginia University Department of Ophthalmology, Morgantown, WV, USA
| | - Deena Dahshan
- West Virginia University Department of Ophthalmology, Morgantown, WV, USA
| | - Thomas Mauger
- West Virginia University Department of Ophthalmology, Morgantown, WV, USA
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Arboleda A, Durkee H, Miller D, Aguilar MC, Alawa K, Relhan N, Amescua G, Parel JM. Variations in irradiation energy and rose bengal concentration for photodynamic antimicrobial therapy of fungal keratitis isolates. Lasers Med Sci 2024; 39:72. [PMID: 38379056 DOI: 10.1007/s10103-024-04014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/02/2024] [Indexed: 02/22/2024]
Abstract
The purpose is to assess the efficacy of rose bengal photodynamic antimicrobial therapy (PDAT) using different irradiation energy levels and photosensitizer concentrations for the inhibition of fungal keratitis isolates. Seven different fungi (Aspergillus fumigatus, Candida albicans, Curvularia lunata, Fusarium keratoplasticum, Fusarium solani, Paecilomyces variotii, and Pseudallescheria boydii) were isolated from patients with confirmed infectious keratitis. Experiments were performed in triplicate with suspensions of each fungus exposed to different PDAT parameters including a control, green light exposure of 5.4 J/cm2, 2.7 J/cm2 (continuous and pulsed), and 1.8 J/cm2 and rose bengal concentrations of 0.1%, 0.05%, and 0.01%. Plates were photographed 72 h after experimentation, and analysis was performed to assess fungal growth inhibition. PDAT using 5.4 J/cm2 of irradiation and 0.1% rose bengal completely inhibited growth of five of the seven fungal species. Candida albicans and Fusarium keratoplasticum were the most susceptible organisms, with growth inhibited with the lowest fluence and minimum rose bengal concentration. Fusarium solani, Pseudallescheria boydii, and Paecilomyces variotii were inhibited by lower light exposures and photosensitizer concentrations. Aspergillus fumigatus and Curvularia lunata were not inhibited by any PDAT parameters tested. Continuous and pulsed irradiation using 2.7 J/cm2 produced similar results. Rose bengal PDAT successfully inhibits the in vitro growth of five fungi known to cause infectious keratitis. Differences in growth inhibition of the various fungi to multiple PDAT parameters suggest that susceptibilities to PDAT are unique among fungal species. These findings support modifying PDAT parameters based on the infectious etiology.
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Affiliation(s)
- Alejandro Arboleda
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Heather Durkee
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Darlene Miller
- Ocular Microbiology Laboratory, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
- Anne Bates Leach Eye Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mariela C Aguilar
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Karam Alawa
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nidhi Relhan
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Guillermo Amescua
- Anne Bates Leach Eye Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jean-Marie Parel
- Ophthalmic Biophysics Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA.
- Anne Bates Leach Eye Center, Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, FL, USA.
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Tuft S, Stone NRH, Burton MJ, Johnson EM, Borman AM. Antifungal susceptibility profiles for fungal isolates from corneas and contact lenses in the United Kingdom. Eye (Lond) 2024; 38:529-536. [PMID: 37684376 PMCID: PMC10858215 DOI: 10.1038/s41433-023-02719-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/09/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE To report the identification and results of susceptibility testing for fungal isolates from the cornea or contact lens care systems. MATERIALS AND METHODS In this retrospective epidemiological study, we searched the results of fungal cultures from cornea or contact lens systems referred for identification and susceptibility testing to the United Kingdom National Mycology Reference Laboratory between October 2016 and March 2022. For each fungal isolate, we recorded the genus and species of the fungus and the minimum inhibitory concentration (MIC) to six antifungal agents available to treat corneal infection (amphotericin, econazole, itraconazole, natamycin, posaconazole, and voriconazole). RESULTS There were 600 isolates from 585 patients, comprising 374 (62%) from corneal samples and 226 from contact lenses and care systems, of which 414 (69%) isolates were moulds (filamentous fungi) and 186 (31%) were yeasts. The most frequent moulds isolated were Fusarium spp (234 isolates, 39%) and Aspergillus spp (62, 10%). The most frequent yeasts isolated were Candida spp (112, 19%), predominantly Candida parapsilosis (65, 11%) and Candida albicans (33, 6%), with 35 isolates (6%) of Meyerozyma guilliermondii. In vitro susceptibility was greatest for natamycin (347 moulds tested, mode 4 mg/L, range 0.25-64 mg/L; 98 yeasts tested, mode 4 mg/L, range 0.5-32 mg/L), with susceptibility for 94% for moulds and 99% yeasts. Of the 16 isolates interpreted as highly resistant to natamycin (MIC ≥16 mg/L), 13 were Aspergillus flavus complex. CONCLUSIONS In vitro susceptibility supports the use of natamycin for the empiric treatment of fungal keratitis in the UK.
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Affiliation(s)
- Stephen Tuft
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK.
- UCL Institute of Ophthalmology, 11-43 Bath Street, London, EC1V 9EL, UK.
| | - Neil R H Stone
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London, NW1 2PG, UK
| | - Matthew J Burton
- Moorfields Eye Hospital, 162 City Road, London, EC1V 2PD, UK
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Elizabeth M Johnson
- UK National Mycology Reference Laboratory, UK Health Security Agency South-West, Bristol, and MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Andrew M Borman
- UK National Mycology Reference Laboratory, UK Health Security Agency South-West, Bristol, and MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
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12
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Arboleda A, Prajna NV, Lalitha P, Srinivasan M, Rajaraman R, Krishnan T, Mousa HM, Feghali J, Acharya NR, Lietman TM, Perez VL, Rose-Nussbaumer J. Validation of the C-DU(KE) Calculator as a Predictor of Outcomes in Patients Enrolled in Steroids for Corneal Ulcer and Mycotic Ulcer Treatment Trials. Cornea 2024; 43:166-171. [PMID: 37335849 DOI: 10.1097/ico.0000000000003313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/10/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE The aim of this study was to validate the C-DU(KE) calculator as a predictor of treatment outcomes on a data set derived from patients with culture-positive ulcers. METHODS C-DU(KE) criteria were compiled from a data set consisting of 1063 cases of infectious keratitis from the Steroids for Corneal Ulcer Trial (SCUT) and Mycotic Ulcer Treatment Trial (MUTT) studies. These criteria include corticosteroid use after symptoms, visual acuity, ulcer area, fungal etiology, and elapsed time to organism-sensitive therapy. Univariate analysis was performed followed by multivariable logistic regressions on culture-exclusive and culture-inclusive models to assess for associations between the variables and outcome. The predictive probability of treatment failure, defined as the need for surgical intervention, was calculated for each study participant. Discrimination was assessed using the area under the curve for each model. RESULTS Overall, 17.9% of SCUT/MUTT participants required surgical intervention. Univariate analysis showed that decreased visual acuity, larger ulcer area, and fungal etiology had a significant association with failed medical management. The other 2 criteria did not. In the culture-exclusive model, 2 of 3 criteria, decreased vision [odds ratio (OR) = 3.13, P < 0.001] and increased ulcer area (OR = 1.03, P < 0.001), affected outcomes. In the culture-inclusive model, 3 of 5 criteria, decreased vision (OR = 4.9, P < 0.001), ulcer area (OR = 1.02, P < 0.001), and fungal etiology (OR = 9.8, P < 0.001), affected results. The area under the curves were 0.784 for the culture-exclusive model and 0.846 for the culture-inclusive model which were comparable to the original study. CONCLUSIONS The C-DU(KE) calculator is generalizable to a study population from large international studies primarily taking place in India. These results support its use as a risk stratification tool assisting ophthalmologists in patient management.
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Affiliation(s)
- Alejandro Arboleda
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Palo Alto, CA
| | | | - Prajna Lalitha
- Aravind Eye Care System, Aravind Eye Hospital, Tamil Nadu, India
| | | | | | | | - Hazem M Mousa
- Foster Center for Ocular Immunology, Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC
| | - James Feghali
- Department of Ophthalmology and Francis I. Proctor Foundation, University of California, San Francisco, CA
| | - Nisha R Acharya
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Thomas M Lietman
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Victor L Perez
- Foster Center for Ocular Immunology, Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC
| | - Jennifer Rose-Nussbaumer
- Byers Eye Institute, Department of Ophthalmology, Stanford University, Palo Alto, CA
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD; and
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Ghenciu LA, Faur AC, Bolintineanu SL, Salavat MC, Maghiari AL. Recent Advances in Diagnosis and Treatment Approaches in Fungal Keratitis: A Narrative Review. Microorganisms 2024; 12:161. [PMID: 38257986 PMCID: PMC10820712 DOI: 10.3390/microorganisms12010161] [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: 12/17/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Fungal keratitis represents a potentially sight-threatening infection associated with poor prognosis, as well as financial burden. Novel diagnostic methods include polymerase-chain-reaction (PCR)-based approaches, metagenomic deep sequences, in vivo confocal microscopy, and antifungal susceptibility testing. The ideal therapeutic approaches and outcomes have been widely discussed in recent times, with early therapy being of the utmost importance for the preservation of visual acuity, minimizing corneal damage and reducing the scar size. However, combination therapy can be more efficacious compared to monotherapy. Understanding the pathogenesis, early diagnosis, and prevention strategies can be of great importance. In this narrative, we discuss the recent progress that may aid our understanding of the diagnosis, treatment, and prevention of mycotic keratitis.
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Affiliation(s)
- Laura Andreea Ghenciu
- Department III Functional Sciences, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania;
- Department IX Surgery, Discipline of Ophtalmology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania;
| | - Alexandra Corina Faur
- Department of Anatomy and Embryology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania; (S.L.B.); (A.L.M.)
| | - Sorin Lucian Bolintineanu
- Department of Anatomy and Embryology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania; (S.L.B.); (A.L.M.)
| | - Madalina Casiana Salavat
- Department IX Surgery, Discipline of Ophtalmology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania;
| | - Anca Laura Maghiari
- Department of Anatomy and Embryology, Victor Babes University of Medicine and Pharmacy, E. Murgu Sq., no. 2, 300041 Timisoara, Romania; (S.L.B.); (A.L.M.)
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14
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Awad R, Ghaith AA, Awad K, Mamdouh Saad M, Elmassry AA. Fungal Keratitis: Diagnosis, Management, and Recent Advances. Clin Ophthalmol 2024; 18:85-106. [PMID: 38223815 PMCID: PMC10788054 DOI: 10.2147/opth.s447138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/09/2023] [Indexed: 01/16/2024] Open
Abstract
Fungal keratitis is one of the major causes of microbial keratitis that may lead to corneal blindness. Many problems related to diagnosis and therapy are encountered in fungal keratitis, including difficulty in obtaining laboratory diagnoses and the availability and efficacy of antifungal medications. Intensive and prolonged use of antifungal topical preparations may not be enough. The use of antifungal medications is considered the main treatment for fungal keratitis. It is recommended to start antifungal therapy after confirmation of the clinical diagnosis with a smear or positive cultures. Topical application of antifungal medications is a mainstay for the treatment of fungal keratitis; however, systemic, intra-stromal, or intra-cameral routes may be used. Therapeutic keratoplasty is the main surgical procedure approved for the management of fungal keratitis with good success rate. Intrastromal corneal injection of antifungal medications may result in steady-state drug levels within the corneal tissue and prevent intervals of decreased antifungal drug concentration below its therapeutic level. In cases of severe fungal keratitis with deep stromal infiltration not responding to treatment, intracameral injection of antifungal agents may be effective. Collagen cross-linking has been proposed to be beneficial for cases of fungal keratitis as a stand-alone therapy or as an adjunct to antifungal medications. Although collagen cross-linking has been extensively studied in the past few years, its protocol still needs many modifications to optimize UV fluence levels, irradiation time, and concentration of riboflavin to achieve 100% microbial killing.
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Affiliation(s)
- Ramy Awad
- Department of Ophthalmology, Alexandria General Ophthalmology Hospital, Alexandria, Egypt
| | - Alaa Atef Ghaith
- Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Khaled Awad
- Department of Ophthalmology, Alexandria General Ophthalmology Hospital, Alexandria, Egypt
| | - Marina Mamdouh Saad
- Department of Ophthalmology, Alexandria General Ophthalmology Hospital, Alexandria, Egypt
| | - Ahmed Ak Elmassry
- Department of Ophthalmology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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15
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Kim CK, Mekhail JT, Morcos DM, Yang CD, Kedhar SR, Kim C, Del Valle Estopinal M, Lee OL. Three cases of recalcitrant Paecilomyces keratitis in Southern California within a short period. J Ophthalmic Inflamm Infect 2024; 14:1. [PMID: 38175332 PMCID: PMC10766921 DOI: 10.1186/s12348-023-00380-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: 05/11/2023] [Accepted: 12/09/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The aim of this report is to describe the risk factors, clinical course, and characteristics of three cases of Paecilomyces keratitis presenting concurrently within three months in the same location. We used in vivo confocal microscopy and histopathology to corroborate our clinical findings. OBSERVATIONS Three eyes of three elderly patients with culture-proven Paecilomyces keratitis were included in this series. These patients resided within a 15-mile radius and presented to a tertiary care eye institute in Southern California between February and April 2022. All three eyes experienced a prolonged, recalcitrant course with recurrence of keratitis in donor corneal tissue despite antifungal therapy and multiple therapeutic penetrating keratoplasties. In vivo confocal microscopy, histopathology, and microbiologic findings corroborated the diagnosis of fungal keratitis with Paecilomyces. With surgical intervention and extensive medical therapy, all three cases resolved after the addition of oral Posaconazole. CONCLUSIONS Paecilomyces is a rare cause of infectious keratitis. Herein we report three similar cases in elderly patients. All had prolonged, recalcitrant infections that required multiple treatment modalities. Our cases, which were supported by in vivo confocal microscopy and histopathology, highlight the importance of timely and aggressive therapy to prevent recurrence.
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Affiliation(s)
- Christine K Kim
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, 850 Health Sciences Rd, Irvine, CA, 92617, USA.
| | - Joseph T Mekhail
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, 850 Health Sciences Rd, Irvine, CA, 92617, USA
| | - David M Morcos
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, 850 Health Sciences Rd, Irvine, CA, 92617, USA
| | - Christopher D Yang
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, 850 Health Sciences Rd, Irvine, CA, 92617, USA
| | - Sanjay R Kedhar
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, 850 Health Sciences Rd, Irvine, CA, 92617, USA
| | - Cinthia Kim
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, 850 Health Sciences Rd, Irvine, CA, 92617, USA
| | - Maria Del Valle Estopinal
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, 850 Health Sciences Rd, Irvine, CA, 92617, USA
- Department of Pathology, University of California Irvine, Irvine, CA, USA
| | - Olivia L Lee
- Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, 850 Health Sciences Rd, Irvine, CA, 92617, USA
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Przybek-Skrzypecka J, Skrzypecki J, Suh L, Szaflik JP. Corneal ring infiltrate- far more than Acanthamoeba keratitis: review of pathophysiology, morphology, differential diagnosis and management. J Ophthalmic Inflamm Infect 2023; 13:55. [PMID: 38112842 PMCID: PMC10730498 DOI: 10.1186/s12348-023-00379-6] [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: 07/28/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE Ring infiltrates usually accompany numerous infectious and sterile ocular disorders. Nevertheless, systemic conditions, drugs toxicity and contact lens wear may present with corneal ring infiltrate in substantial part. Considering its detrimental effect on vision, detailed knowledge on etiology, pathophysiology, differential diagnosis, and management should be considered essential for every ophthalmologist. METHODS The PUBMED database was searched for "corneal ring infiltrate" and "ring infiltrate" phrases, "sterile corneal infiltrate" and "corneal infiltrate". We analyzed articles written in English on risk factors, pathophysiology, clinical manifestation, morphological features, ancillary tests (anterior-segment optical coherence tomography, corneal scraping, in vivo confocal microscopy), differential diagnosis and management of corneal ring infiltrate. RESULTS Available literature depicts multifactorial origin of corneal ring infiltrate. Dual immunological pathophysiology, involving both antibodies-dependent and -independent complement activation, is underlined. Furthermore, we found that the worldwide most prevalent among non-infectious and infectious ring infiltrates are ring infiltrates related to contact-lens wear and bacterial keratitis respectively. Despite low incidence of Acanthamoeba keratitis, it manifests with corneal ring infiltrate with the highest proportion of the affected patients (one third). However, similar ring infiltrate might appear as a first sign of general diseases manifestation and require targeted treatment. Every corneal ring infiltrate with compromised epithelium should be scraped and treat as an infectious infiltrate until not proven otherwise. Of note, microbiological ulcer might also lead to immunological ring and therefore require anti-inflammatory treatment. CONCLUSION Corneal ring infiltrate might be triggered not only by ocular infectious and non-infectious factors, but also by systemic conditions. Clinical assessment is crucial for empirical diagnosis. Furthermore, treatment is targeted towards the underlying condition but should begin with anti-infectious regimen until not proven otherwise.
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Affiliation(s)
- J Przybek-Skrzypecka
- Department of Ophthalmology, Medical University of Warsaw, Marszałkowska 24/26, 00-576, Warsaw, Poland.
- SPKSO Ophthalmic University Hospital, Warsaw, Poland.
| | - J Skrzypecki
- SPKSO Ophthalmic University Hospital, Warsaw, Poland
- Department of Experimental Physiology and Pathophysiology, Medical University of Warsaw, Warsaw, Poland
| | - L Suh
- Cornea & Refractive Surgery, Edward S. Harkness Eye Institute, Columbia University Irving Medical Center, New York, USA
| | - J P Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Marszałkowska 24/26, 00-576, Warsaw, Poland
- SPKSO Ophthalmic University Hospital, Warsaw, Poland
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Tanna V, Bagga B, Sharma S, Ahirwar LK, Kate A, Mohamed A, Joseph J. Randomized Double-Masked Placebo-Controlled Trial for the Management of Pythium Keratitis: Combination of Antibiotics Versus Monotherapy. Cornea 2023; 42:1544-1550. [PMID: 36796011 DOI: 10.1097/ico.0000000000003251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/07/2023] [Indexed: 02/18/2023]
Abstract
PURPOSE The aim of this study was to compare the efficacy of monotherapy (topical linezolid 0.2%) versus a combination of antibiotics (topical linezolid 0.2% and topical azithromycin 1%) for the treatment of Pythium insidiosum keratitis. METHODS Cases of P. insidiosum keratitis were prospectively randomized into group A on topical 0.2% linezolid along with topical placebo (sodium carboxymethyl cellulose [CMC] 0.5%) and group B on a combination of topical 0.2% linezolid and topical 1% azithromycin. Both groups were compared by proportion of both clinical resolution and worsening of keratitis along with the number of therapeutic penetrating keratoplasty (TPK) performed at 3 months. RESULTS We initially planned N = 66 patients but later limited to 20 (N = 10 in each group) patients owing to one interim analysis. The average size of the infiltrate in group A and B was 5.6 ± 1.5 mm and 4.8 ± 2.0 mm, respectively, with a mean Logarithm of the Minimum Angle of Resolution (logMAR) visual acuity of 2.74 ± 0.55 and 1.79 ± 1.19. At 3 months, from group A, 7 (70%) patients needed TPK and 2 patients had signs of resolution, whereas from group B, 6 (60%) patients achieved complete resolution ( P = 0.0003) and 2 were improving while only 1 needed TPK ( P = 0.02). The median duration of treatment in group A and B, with the study drugs, was 31 days (17.8-47.8) and 101.5 days (80-123.3), P value = 0.003, respectively. Final visual acuity at 3 months was 2.50 ± 0.81 and 0.75 ± 0.87, P = 0.02, respectively. CONCLUSIONS A combination of topical linezolid and topical azithromycin was found to have superior efficacy than the monotherapy with topical linezolid for the management of Pythium keratitis.
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Affiliation(s)
- Vishakha Tanna
- The Ramoji Foundation Centre of Ocular Infections, Shantilal Shanghvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Bhupesh Bagga
- The Ramoji Foundation Centre of Ocular Infections, Shantilal Shanghvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, L V Prasad Eye Institute, Hyderabad, India; and
| | | | - Anahita Kate
- The Ramoji Foundation Centre of Ocular Infections, Shantilal Shanghvi Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Ashik Mohamed
- Ophthalmic Biophysics, L V Prasad Eye Institute, Hyderabad, India
| | - Joveeta Joseph
- Jhaveri Microbiology Centre, L V Prasad Eye Institute, Hyderabad, India; and
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Abstract
PURPOSE To summarize the evidence base on the use of topical corticosteroids for infectious keratitis. METHODS Narrative review. RESULTS Infectious keratitis is a painful condition that often results in visually significant corneal stromal scarring, even when antimicrobial therapy is successful. Corticosteroids may reduce inflammation and subsequent scar formation and while relieving the acute ocular pain associated with a corneal ulcer. However, corticosteroids also reduce the host immune response, which could hinder the ability to clear infection. The safety and effectiveness of corticosteroids depends to a large part on the efficacy of the antimicrobials being used to treat the underlying infection. Randomized trials have found that corticosteroids are safe and effective for herpetic keratitis when used with appropriate antiviral therapy, and are safe for bacterial keratitis when used with broad spectrum topical antibiotics. The effectiveness of corticosteroids for bacterial keratitis has not been shown conclusively, although more advanced bacterial corneal ulcers may do better with corticosteroids. No randomized trials have assessed the safety and effectiveness of steroids for fungal or acanthamoeba keratitis. Animal studies suggest corticosteroids may be harmful in fungal keratitis, and observational human studies have found that steroids are harmful for fungal and acanthamoeba keratitis when started prior to anti-amoebics. CONCLUSIONS Topical corticosteroids, when used as an adjunct to antimicrobial therapy, may be beneficial if the antimicrobial being used can effectively clear or suppress the infection, such as in bacterial and herpetic keratitis. Randomized trials would be helpful to further delineate the role of corticosteroids for infectious keratitis.
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Affiliation(s)
- Jeremy D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, CA; and
- Department of Ophthalmology, University of California, San Francisco, CA
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19
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Gunasekaran R, Chandrasekaran A, Rajarathinam K, Duncan S, Dhaliwal K, Lalitha P, Prajna NV, Mills B. Rapid Point-of-Care Identification of Aspergillus Species in Microbial Keratitis. JAMA Ophthalmol 2023; 141:966-973. [PMID: 37768674 PMCID: PMC10540059 DOI: 10.1001/jamaophthalmol.2023.4214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/30/2023] [Indexed: 09/29/2023]
Abstract
Importance Microbial keratitis (MK) is a common cause of unilateral visual impairment, blindness, and eye loss in low-income and middle-income countries. There is an urgent need to develop and implement rapid and simple point-of-care diagnostics for MK to increase the likelihood of good outcomes. Objective To evaluate the diagnostic performance of the Aspergillus-specific lateral-flow device (AspLFD) to identify Aspergillus species causing MK in corneal scrape and corneal swab samples of patients presenting with microbial keratitis. Design, Setting, and Participants This diagnostic study was conducted between May 2022 and January 2023 at the corneal clinic of Aravind Eye Hospital in Madurai, Tamil Nadu, India. All study participants were recruited during their first presentation to the clinic. Patients aged 15 years or older met the eligibility criteria if they were attending their first appointment, had a corneal ulcer that was suggestive of a bacterial or fungal infection, and were about to undergo diagnostic scrape and culture. Main Outcomes and Measures Sensitivity and specificity of the AspLFD with corneal samples collected from patients with MK. During routine diagnostic scraping, a minimally invasive corneal swab and an additional corneal scrape were collected and transferred to aliquots of sample buffer and analyzed by lateral-flow device (LFD) if the patient met the inclusion criteria. Photographs of devices were taken with a smartphone and analyzed using a ratiometric approach, which was developed for this study. The AspLFD results were compared with culture reports. Results The 198 participants who met the inclusion criteria had a mean (range) age of 51 (15-85) years and included 126 males (63.6%). Overall, 35 of 198 participants with corneal scrape (17.7%) and 17 of 40 participants with swab samples (42.5%) had positive culture results for Aspergillus species. Ratiometric analysis results for the scrape samples found that the AspLFD achieved high sensitivity (0.89; 95% CI, 0.74-0.95), high negative predictive value (0.97; 95% CI, 0.94-0.99), low negative likelihood ratio (0.12; 95% CI, 0.05-0.30), and an accuracy of 0.94 (95% CI, 0.90-0.97). Ratiometric analysis results for the swab samples showed that the AspLFD had high sensitivity (0.94; 95% CI, 0.73-1.00), high negative predictive value (0.95; 95% CI, 0.76-1.00), low negative likelihood ratio (0.07; 95% CI, 0.01-0.48), and an accuracy of 0.88 (95% CI, 0.73-0.96). Conclusions and Relevance Results of this diagnostic study suggest that AspLFD along with the ratiometric analysis of LFDs developed for this study has high diagnostic accuracy in identifying Aspergillus species from corneal scrapes and swabs. This technology is an important step toward the provision of point-of-care diagnostics for MK and could inform the clinical management strategy.
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Affiliation(s)
- Rameshkumar Gunasekaran
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Abinaya Chandrasekaran
- Department of Cornea and Refractive Surgery Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Karpagam Rajarathinam
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Sheelagh Duncan
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
| | - Kevin Dhaliwal
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
| | - Prajna Lalitha
- Department of Ocular Microbiology, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - N. Venkatesh Prajna
- Department of Cornea and Refractive Surgery Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Madurai, Tamil Nadu, India
| | - Bethany Mills
- Translational Healthcare Technologies Group, Centre for Inflammation Research, University of Edinburgh, United Kingdom
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Arimoto S, Inagaki K, Todokoro D, Suzuki T, Makimura K, Ishino T. Antifungal Efficacy of Luliconazole in an Experimental Rabbit Model of Fungal Keratitis Caused by Fusarium solani. Mycopathologia 2023; 188:775-782. [PMID: 37603230 DOI: 10.1007/s11046-023-00783-5] [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: 05/16/2023] [Accepted: 07/31/2023] [Indexed: 08/22/2023]
Abstract
Fungal keratitis is a corneal fungal infection that potentially leads to blindness and is mainly caused by filamentous fungi, such as Fusarium, with limited drug options available, such as natamycin and voriconazole. Therefore, this study aimed to evaluate the therapeutic effects of the imidazole antifungal drug-luliconazole-using a rabbit experimental model of fungal keratitis caused by Fusarium solani, which is the dominant causative agent of fungal keratitis. F. solani was inoculated into rabbit corneas. luliconazole 1% suspension or natamycin 5% eye drops were administered four times a day (N = 6 for each group) 3 days after inoculation. Signs were scored up to 14 days after inoculation to evaluate the efficacy of the drugs. Compared with the peak mean sign scores of the placebo control group, there was a significant decrease in the mean sign scores of both the treatment groups (P < 0.05). Sign score trends were similar between the two treatment groups. In conclusion, luliconazole demonstrated therapeutic efficacy comparable to that of natamycin in treating experimental fungal keratitis. This suggests that luliconazole can be a novel therapeutic agent for human fungal keratitis.
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Affiliation(s)
- Sho Arimoto
- Department of Parasitology and Tropical Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
- Nihon Nohyaku Co., Ltd., Tokyo, Japan.
| | | | - Daisuke Todokoro
- Department of Ophthalmology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takashi Suzuki
- Department of Ophthalmology, School of Medicine, Toho University, Tokyo, Japan
| | - Koichi Makimura
- Institute of Medical Mycology, Teikyo University, Tokyo, Japan
| | - Tomoko Ishino
- Department of Parasitology and Tropical Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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21
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Wang H, Yin X, Zhang Z, Wang Y, Zhang L, Guo J, Li M. Evaluation of 0.01% Hypochlorous Acid Eye Drops Combined with Conventional Treatment in the Management of Fungal Corneal Ulcers: Randomized Controlled Trial. Curr Eye Res 2023; 48:887-893. [PMID: 37493085 DOI: 10.1080/02713683.2023.2226374] [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: 06/30/2022] [Accepted: 06/13/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE To evaluate the efficacy and safety of hypochlorous acid (HOCI) eye drops in the treatment of fungal keratitis. METHODS A total of 96 patients (96 eyes) with fungal keratitis were randomly divided into two groups: group Ι (conventional treatment + topical HOCI eye drops); The group II (conventional treatment). According to its severity, those patients were divided into grade Ι or grade II. Use of fungal scraping and culture to identify the type of fungal infection, slit lamp examination, and corneal fluorescein staining to observe regression, and confocal corneal microscopy to assess fungal mycelial changes. The main outcome measures were the success rate, healing time, visual recovery, and complications. The Kaplan-Meier curve method was used to analysis of the survival function of days to cure between the two groups. RESULTS There were no statistical differences between the two groups in terms of general condition, medical history, and grading. Corneal scraping results showed that all patients had filamentous fungi. For grade Ι patients, all patients were cured, and the patients in Group I showed faster healing speed than that in Group II (t = -3.665, p < .01). For grade II patients, the recovery time (t = -4.121, p < .01) and the disappearance of hypopyon (t = -4.291, p < .01) were significantly faster in the combination group. In grade Ι and II patients, the final visual acuity and the incidence of complications such as corneal neovascularization, cataract, and hyphema showed no differences in both groups. The survival curve showed that the healing rate of ulcers in the combination treatment group was faster than that in the conventional treatment group (χ2 = 14.332, p = .001). CONCLUSION HOCI can accelerate the healing of fungal keratitis without obvious complications, indicating a promising future in the field of keratitis treatment.
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Affiliation(s)
- He Wang
- Department of Ophthalmology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Xiaoyue Yin
- Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Zhaowei Zhang
- Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Yining Wang
- Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Ling Zhang
- Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Jianxin Guo
- Department of Ophthalmology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
| | - Mingxin Li
- Department of Ophthalmology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu Province, China
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22
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Kovalchuk B, Auffarth GU, Khoramnia R, Augustin VA. Fusarium Keratitis on the Rise - a Clinical Review. Klin Monbl Augenheilkd 2023. [PMID: 37673089 DOI: 10.1055/a-2120-7752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Fungal keratitis due to Fusarium species is a rare but serious ocular disease. Due to its rapid progression, often late diagnostic confirmation as well as limited topical treatment options, this is potentially sight threatening. Increasing contact lens use and global climate change have been suggested to be factors leading to an increase in cases of fusarium keratitis, even in regions with moderate climate. Early recognition and initiation of antimycotic treatment, as well as early surgical treatment by penetrating keratoplasty are decisive for the outcome.
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23
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Berger T, Seitz B, Flockerzi F, Daas L. Recurrent Filamentous Fungal Keratitis Caused When the Primarily Selected Graft Diameter was Too Small. Klin Monbl Augenheilkd 2023; 240:1098-1102. [PMID: 35320860 DOI: 10.1055/a-1756-5147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To establish the importance of using a sufficiently large corneal graft in primary penetrating keratoplasty in order to prevent recurrence of fungal keratitis. OBERSERVATIONS A 58-year-old female patient underwent emergency penetrating keratoplasty (diameter 7.0 mm, double running suture) for therapy-resistant fungal keratitis (Fusarium solani) at an external eye clinic. Despite intensive antifungal therapy, new fungal infiltrates appeared in the host cornea after a few days. The patient was referred to our department for further treatment. On first presentation, circular infiltrates were seen around the corneal graft with anterior chamber involvement and therapy-resistant hypopyon. We performed an emergency penetrating repeat keratoplasty (diameter of 13.0 mm, 32 interrupted sutures) combined with anterior chamber lavage and intracameral and intrastromal drug injection. CONCLUSION AND IMPORTANCE Fungal keratitis sometimes has a frustrating clinical course. Therefore, early diagnosis with effective therapy initiation is of the utmost importance. In cases of penetrating keratoplasty, optimal planning and timing (before anterior chamber involvement) should be provided. Sufficient safety distance must be ensured in the choice of graft diameter, fixation with multiple interrupted sutures, and anterior chamber lavage, as well as intracameral and intrastromal drug administration. Incomplete excision carries a risk of recurrence and endophthalmitis in the course. Close postoperative control is necessary to detect early recurrences.
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Affiliation(s)
- Tim Berger
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Berthold Seitz
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Fidelis Flockerzi
- Institut für Allgemeine und Spezielle Pathologie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - Loay Daas
- Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
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24
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Abd-Elmonem EM, Makky AM, Antar A, Abd-Elsalam WH, Khalil IA. Corneal targeted Amorolfine HCl-mixed micelles for the management of ocular candidiasis: Preparation, in vitro characterization, ex vivo and in vivo assessments. J Drug Deliv Sci Technol 2023; 85:104614. [DOI: 10.1016/j.jddst.2023.104614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Shekhawat NS, Hall LN, Sulewski ME, Woreta F, Wang J, Smith K, Kuo IC. Corneal Culture and Antibiotic Susceptibility Results for Microbial Keratitis in the Mid-Atlantic Region of the United States, 2016 to 2020. Eye Contact Lens 2023; 49:267-274. [PMID: 37166232 PMCID: PMC10330016 DOI: 10.1097/icl.0000000000000993] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To examine the microbial distribution and antimicrobial susceptibility of culture-positive microbial keratitis at a large tertiary referral center in the mid-Atlantic region of the United States. METHODS Retrospective review of culture-positive microbial keratitis cases at the Wilmer Eye Institute from 2016 through 2020. RESULTS Of the 474 culture-positive microbial keratitis cases, most were bacterial (N=450, 94.9%), followed by fungal (N=48, 10.1%) and Acanthamoeba keratitis (N=15, 3.1%). Of the 450 bacterial isolates, 284 (69.5%) were gram-positive organisms, whereas 157 (28.4%) were gram-negative organisms. The most common bacterial species isolated was coagulase-negative Staphylococcus spp (N=154, 24.8%), and the most common gram-negative isolate was Pseudomonas aeruginosa (N=76, 12.3%). Among fungi, the most common isolates were Candida (N=25, 45.4%), whereas Fusarium (N=6, 10.9%) and Aspergillus (N=3, 5.5%) were less common. Of the 217 bacterial isolates tested for erythromycin susceptibility, 121 (55.7%; ∼60% of coagulase-negative staphylococci and corynebacteria tested) showed resistance to erythromycin. CONCLUSIONS Microbial keratitis in the Baltimore Mid-Atlantic region of the United States is most commonly caused by bacteria, with fungi and acanthamoeba being less common. Gram-positive bacterial infections predominate. Among fungal keratitis cases, Candida species are more commonly encountered than are filamentous species. Use of erythromycin as infection prophylaxis should be reexamined. Findings from our study may guide empiric treatment in this geographic region.
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Affiliation(s)
- Nakul S. Shekhawat
- Wilmer Eye Institute, Department of Ophthalmology, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leangelo N. Hall
- Wilmer Eye Institute, Department of Ophthalmology, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael E. Sulewski
- Wilmer Eye Institute, Department of Ophthalmology, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fasika Woreta
- Wilmer Eye Institute, Department of Ophthalmology, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jiangxia Wang
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD, USA
| | - Kerry Smith
- Wilmer Eye Institute, Department of Ophthalmology, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Irene C. Kuo
- Wilmer Eye Institute, Department of Ophthalmology, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
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26
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Saad ZA, Elnashar H, Negm S, Elsayed HA, Abdallah MG, Abuamara TMM, Abd-Elhay WM, Elghonemy HM. Collagen cross-linking as monotherapy in experimentally induced corneal abscess in rabbits. BMC Ophthalmol 2023; 23:266. [PMID: 37312088 PMCID: PMC10262482 DOI: 10.1186/s12886-023-03007-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 05/31/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Collagen cross-linking (CXL) has evolved as an essential therapeutic approach for corneal infections, allowing for rapidly eliminating the infecting microorganism while reducing inflammation. This study aims to evaluate the efficacy of CXL as a monotherapy for managing infectious keratitis caused by Fusarium solani and Pseudomonas aeruginosa. MATERIALS AND METHODS Forty-eight white New Zealand rabbits weighing approximately 1.5-2 KG were included. The cornea of one eye of each rabbit was inoculated with either Fusarium solani or Pseudomonas aeruginosa. Group A served as a control and was subdivided into two subgroups, A1 and A2; each subgroup consisted of 8 eyes and was injected with either Fusarium solani or Pseudomonas aeruginosa, respectively. Group B (16 eyes) was inoculated with Fusarium solani, while group C (16 eyes) were inoculated with Pseudomonas aeruginosa. All animals in Group B and C received CXL treatment one week after inoculation of the organisms and after corneal abscess formation was confirmed. At the same time, animals in Group A were left untreated. RESULTS There was a statistically significant reduction in the number of colony-forming units (CFU) in Group B following CXL. No growth existed in any samples at the end of the 4th week. There was a statistically significant difference in the number of CFU between group B and the control group (p < 0.001). In group C, there was a statistically significant reduction in the CFU at the end of the first week after CXL. However, there was regrowth in all samples afterward. All 16 models in Group C showed uncountable and extensive growth during the subsequent follow-ups. There was no statistically significant difference between the number of CFU in Group C and the control group. Histopathology showed lesser corneal melting in CXL-treated Pseudomonas aeruginosa. CONCLUSIONS Collagen cross-linking is promising monotherapy and alternative treatment in managing infective keratitis caused by Fusarium solani but is less effective in Pseudomonas aeruginosa as monotherapy.
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Affiliation(s)
- Zeinab A Saad
- Memorial Institute of Ophthalmic Research, Giza, 12511, Egypt.
| | - Hazem Elnashar
- Memorial Institute of Ophthalmic Research, Giza, 12511, Egypt
| | - Sahar Negm
- Research Institute of Ophthalmology, Giza, Egypt
| | - Hala A Elsayed
- Memorial Institute of Ophthalmic Research, Giza, 12511, Egypt
| | - Mohamed Gaber Abdallah
- Faculty of Medicine, Department of Medical Biochemistry, Al-Azhar University, Cairo, Egypt
| | - Tamer M M Abuamara
- Faculty of Medicine, Histology Department, Al-Azhar University, Cairo, Egypt
| | - Wagih M Abd-Elhay
- Faculty of Medicine, Histology Department, Al-Azhar University, Cairo, Egypt
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27
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Reginatto P, Agostinetto GDJ, Fuentefria RDN, Marinho DR, Pizzol MD, Fuentefria AM. Eye fungal infections: a mini review. Arch Microbiol 2023; 205:236. [PMID: 37183227 PMCID: PMC10183313 DOI: 10.1007/s00203-023-03536-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023]
Abstract
Ocular fungal infections annually affect more than one million individuals worldwide. The management of these infections is problematic, mainly due to the limited availability of effective antifungal agents. Thus, ocular infections are increasingly recognized as important causes of morbidity and blindness, especially keratitis and endophthalmitis. Thus, this review aims to demonstrate the importance of fungal eye infections through the description of the main related aspects, with emphasis on the treatment of these infections. For this purpose, a search for scientific articles was conducted in databases, such as Medline, published from 2000 onwards, addressing important aspects involving fungal eye infections. In addition, this work highlighted the limited therapeutic arsenal available and the severity associated with these infections. Thus, highlighting the importance of constantly updating knowledge about these pathologies, as it contributes to agility in choosing the available and most appropriate therapeutic alternatives, aiming at positive and minimally harmful results for that particular patient.
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Affiliation(s)
- Paula Reginatto
- Laboratório de Pesquisa em Micologia Aplicada, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
| | - Giovanna de Jesus Agostinetto
- Laboratório de Pesquisa em Micologia Aplicada, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - Melissa Dal Pizzol
- Serviço de Oftalmologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Alexandre Meneghello Fuentefria
- Laboratório de Pesquisa em Micologia Aplicada, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Programa de Pós-Graduação em Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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28
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Cai Y, Song S, Chen Y, Xu X, Zou W. Oral voriconazole monotherapy for fungal keratitis: efficacy, safety, and factors associated with outcomes. Front Med (Lausanne) 2023; 10:1174264. [PMID: 37250626 PMCID: PMC10213751 DOI: 10.3389/fmed.2023.1174264] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/20/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose To provide preliminary data on the efficacy and safety of oral voriconazole (VCZ) as a primary treatment for fungal keratitis (FK). Method We performed a retrospective histopathological analysis of data on 90 patients with FK at The First Affiliated Hospital of Guangxi Medical University between September 2018 and February 2022. We recorded three outcomes: corneal epithelial healing, visual acuity (VA) improvement, and corneal perforation. Independent predictors were identified using univariate analysis, and multivariate logistic regression analysis was used to identify independent predictive factors associated with the three outcomes. The area under the curve was used to evaluate the predictive value of these factors. Results Ninety patients were treated with VCZ tablets as the only antifungal drug. Overall, 71.1% (n = 64) of the patients had extreme corneal epithelial healing, 56.7% (n = 51) showed an improvement in VA, and 14.4% (n = 13) developed perforation during treatment. Non-cured patients were more likely to have large ulcers (≥5 × 5 mm2) and hypopyon. Conclusion The results indicated that oral VCZ monotherapy was successful in the patients with FK in our study. Patients with ulcers larger than 5 × 5 mm2 and hypopyon were less likely to respond to this treatment.
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29
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Khan L, Keche AY, Kumar A. Monotherapy with topical Natamycin to treat Scedosporium keratomycosis: A rare case from Central India. Oman J Ophthalmol 2023; 16:355-358. [PMID: 37602150 PMCID: PMC10433071 DOI: 10.4103/ojo.ojo_130_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/15/2022] [Accepted: 03/29/2023] [Indexed: 08/22/2023] Open
Abstract
Keratomycosis is common in Indian subcontinent. Diagnosis of the causal agent and successful management is a challenge for the clinician. Scedosporium is a rare fungus species, and it is relatively rare in causing keratomycosis. We report the case of a 29-year-old male who presented with complaints of redness, watering, and white lesion over his left eye. He sustained an injury in the left eye with vegetative matter. Corneal scraping was sent for potassium hydroxide staining and culture; fungal colony was seen in culture. Colony characters on Sabouraud dextrose agar and lactophenol cotton blue enabled a diagnosis of Scedosporium species. The patient was treated with topical Natamycin 5%, and complete resolution was seen at the end of 4 weeks. This case report highlights good response of keratitis caused by Scedosporium to topical Natamycin therapy.
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Affiliation(s)
- Lubna Khan
- Department of Ophthalmology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Archana Y. Keche
- Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
| | - Aseem Kumar
- Department of Ophthalmology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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30
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Chi M, Gu L, Zhang L, Lin J, Xu Q, Jiang N, Wang Y, Qi Y, Diao W, Yi W, Zhao G, Li C. Pentoxifylline treats Aspergillus fumigatus keratitis by reducing fungal burden and suppressing corneal inflammation. Eur J Pharmacol 2023; 945:175607. [PMID: 36822458 DOI: 10.1016/j.ejphar.2023.175607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/23/2023]
Abstract
Fungal keratitis (FK) is a blinding ocular disease, which mainly results from fungal damage and excessive inflammation. Pentoxifylline, a kind of methylxanthine, has been discovered to have anti-inflammatory properties in various infectious diseases, hinting a potential therapeutic effect on treating corneal fungal infection. Whereas, the therapeutic impact of pentoxifylline on fungal keratitis is still uncertain. This study investigated the antifungal capability against Aspergillus fumigatus and the anti-inflammatory role of pentoxifylline by activating nuclear factor, erythroid 2 like 2 (Nrf2)/heme oxygenase1 (HO1) pathway in the process of FK. In our research, we demonstrated that pentoxifylline could effectively inhibit fungal growth and inflammatory reaction. Pentoxifylline reduced the production of pro-inflammatory factors by stimulating the Nrf2/HO1 pathway. Although there was no statistical difference between the curative efficacy of pentoxifylline and natamycin application to FK, pentoxifylline could promote corneal epithelial repair and was less toxicity to the ocular surface than natamycin. In conclusion, pentoxifylline performs antifungal and anti-inflammatory effects by lessening the fungus burden and activating the Nrf2/HO1 pathway, hinting that it has the potential to be a new therapeutic medication for Aspergillus fumigatus keratitis.
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Affiliation(s)
- Menghui Chi
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Lingwen Gu
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Lina Zhang
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Jing Lin
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Qiang Xu
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Nan Jiang
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Yuwei Wang
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Yinghe Qi
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Weilin Diao
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Wendan Yi
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Guiqiu Zhao
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China.
| | - Cui Li
- Department of Ophthalmology, The Affiliated Hospital of Qingdao University, No. 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China.
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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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32
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Zemba M, Radu M, Istrate S, Dumitrescu OM, Ionescu MA, Vatafu A, Barac IR. Intrastromal Injections in the Management of Infectious Keratitis. Pharmaceutics 2023; 15:pharmaceutics15041091. [PMID: 37111577 PMCID: PMC10146496 DOI: 10.3390/pharmaceutics15041091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Infectious keratitis is a major global cause of vision loss and blindness. Prompt diagnosis and targeted antibiotic treatment are crucial for managing the condition. Topical antimicrobials are the most effective therapy for bacterial keratitis, but they can lead to unsatisfactory results due to ocular perforation, scarring, and melting. Intrastromal injection is a newer technique for delivering antimicrobials directly to the site of infection and has been successful in treating severe, treatment-resistant infectious keratitis, especially when surgery is not recommended. In cases where deep stromal disease is resistant to topical treatment, intrastromal antimicrobial injections may be necessary to achieve higher drug concentration at the infection site. However, the use of intrastromal antibiotics is limited, as topical antibacterial agents have better penetration than antifungal agents. Bacterial and fungal keratitis have been extensively researched for intrastromal medication injections, while there is limited evidence for viral keratitis. This review emphasizes the potential of intrastromal antimicrobial injections as an alternative for managing severe refractory infectious keratitis. The technique offers direct targeting of the infection site and faster resolution in some cases compared to topical therapy. However, further research is needed to determine the safest antimicrobials options, minimal effective doses, and concentrations for various pathogens. Intrastromal injections may serve as a non-surgical treatment option in high-risk cases, with benefits including direct drug delivery and reduced epithelial toxicity. Despite promising findings, more studies are required to confirm the safety and efficacy of this approach.
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Affiliation(s)
- Mihail Zemba
- Department of Ophthalmology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Department of Ophthalmology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Madalina Radu
- Department of Ophthalmology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania
- Correspondence:
| | - Sinziana Istrate
- Department of Ophthalmology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Otilia-Maria Dumitrescu
- Department of Ophthalmology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Mihai Alexandru Ionescu
- Department of Ophthalmology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Andrei Vatafu
- Department of Ophthalmology, “Dr. Carol Davila” Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Ileana Ramona Barac
- Department of Ophthalmology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
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Tuft S, Evans J, Gordon I, Leck A, Stone N, Neal T, Macleod D, Kaye S, Burton MJ. Antimicrobial resistance in topical treatments for microbial keratitis: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e069338. [PMID: 36882242 PMCID: PMC10008341 DOI: 10.1136/bmjopen-2022-069338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/13/2023] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION There is evidence for increased resistance against the antimicrobials used to treat keratitis. This review aims to provide global and regional prevalence estimates of antimicrobial resistance in corneal isolates and the range of minimum inhibitory concentrations (MIC) with their associated resistance breakpoints. METHODS AND ANALYSIS We report this protocol following Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols guidelines. We will conduct an electronic bibliographic search in MEDLINE, EMBASE, Web of Science and the Cochrane Library. Eligible studies will report in any language data for the resistance or MIC for antimicrobials against bacterial, fungal or amoebic organisms isolated from suspected microbial keratitis. Studies that only report on viral keratitis will not be included. There will be no time restrictions on the date of publication. Screening for eligible studies, assessment of risk of bias and data extraction will be conducted by two reviewers independently, using predefined inclusion criteria and prepiloted data extraction forms. We will resolve disagreements between the reviewers by discussion and, if required, a third (senior) reviewer will arbitrate. We will assess the risk of bias using a tool validated in prevalence studies. The certainty of the evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation approach. Pooled proportion estimates will be calculated using a random-effects model. Heterogeneity will be assessed using the I2 statistic. We will explore differences between Global Burden of Disease regions and temporal trends. ETHICS APPROVAL AND DISSEMINATION Ethics approval is not required as this is a protocol for a systematic review of published data. The findings of this review will be published in an open-access, peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023331126.
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Affiliation(s)
- Stephen Tuft
- Cornea and External Disease Department, Moorfields Eye Hospital NHS Foundation Trust, London, UK
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Jennifer Evans
- Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Iris Gordon
- Department of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Astrid Leck
- Department of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Neil Stone
- Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Timothy Neal
- Department of Microbiology, Royal Liverpool University Hospital, Liverpool, UK
| | - David Macleod
- Department of Medical Statistics, LSHTM, London, London, UK
| | - Stephen Kaye
- Department of Eye and Vision Science, University of Liverpool, Liverpool, Merseyside, UK
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Oremosu J, Ung L, Chodosh J, Cañete-Gibas C, Wiederhold NP, Davies EC, Bispo PJ. Fungal keratitis caused by Coniochaeta mutabilis – a case report. J Mycol Med 2023; 33:101384. [PMID: 37012189 DOI: 10.1016/j.mycmed.2023.101384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
We present a rare case of recalcitrant fungal keratitis caused by Coniochaeta mutabilis, successfully managed with a course of oral, topical, intrastromal, and intracameral antifungals. A 57-year-old male on their fourth week of treatment for presumed left herpes simplex keratitis presented to clinic with severe left-sided foreign body sensation after gardening in his yard. On examination, a white corneal plaque was observed at 8 o'clock, shown to be a dense collection of fungal hyphae on confocal microscopy. Corneal cultures revealed yeast-like cells, initially identified as Kabatiella zeae by matching 100% identity with K. zeae strains CBS 767.71 and CBS 265.32 in BLASTn search using the internal transcribed spacer (ITS) sequence. Treated for over four months with topical amphotericin B and oral voriconazole without improvement, recourse to intrastromal and intracameral amphotericin B injections, coupled with the application of cyanoacrylate glue to the lesion and a bandage contact lens, led to eventual resolution. The patient subsequently underwent cataract surgery, achieving a BCVA of 20/20 in the eye. Surprisingly, upon further sequence analyses of combined ITS and large subunit ribosomal ribonucleic acid (LSU) and investigation of the K. zeae German strain CBS 767.71, the organism was revealed to be Coniochaeta mutabilis (formerly Lecythospora mutabilis). This means that the correct name for CBS 767.71 and CBS 265.32 is C. mutabilis and should be corrected in the GenBank record to avoid misleading identification in the future. This case also underscores the urgent unmet need for improved molecular diagnostic modalities in the care of corneal infections.
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Gong Y, Zhang L, Liu S, Zhang H, Peng L, Li H, Dai S, Chen B. Continuous voriconazole lavage in managing moderate and severe fungal keratitis: a randomized controlled trial. Graefes Arch Clin Exp Ophthalmol 2023; 261:1639-1649. [PMID: 36642766 DOI: 10.1007/s00417-022-05969-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: 09/15/2022] [Revised: 11/30/2022] [Accepted: 12/28/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE To assess the effectiveness and safety of continuous lavage with 1% voriconazole (CL) for moderate and severe fungal keratitis. METHODS Thirty-one patients were randomized to receive topical eye drops either alone (T) or combined with continuous 1% voriconazole lavage (CL-T). The primary outcome was the cure rate at 3 months. The secondary outcomes were the 6-day efficacy, 3-day infiltration size and depth, hypopyon height, central corneal thickness (CCT), epithelial defect size, and subject feelings and clinical signs assessment scores. RESULTS At 3 months, the cure rate was comparable between the groups in patients with moderate fungal keratitis (66.7% vs. 62.5%, P = 0.60). However, among severe cases, 4 cases (44.4%) in the CL-T group healed successfully, while none in the T group; this difference was not significant (P = 0.08), although it was very close to 0.05. This may be related to the small sample size. After 6 days, the percentage of patients with "worsened" ulcers in the CL-T group was lower than that in the T group (0% vs. 31%, P = 0.043). The infiltration size, infiltration depth, and hypopyon height in the CL-T group were smaller than those in the T group after 3 days (all P < 0.05). There was no difference in CCT, epithelial defect size, subject feelings scores, or clinical signs scores between groups. CONCLUSION These outcomes suggest that CL is an effective and safe adjuvant method for controlling the progression of moderate and severe fungal keratitis. TRIAL REGISTRATION NUMBER ChiCTR2100050565.
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Affiliation(s)
- Yujia Gong
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Liwei Zhang
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Shaohua Liu
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Hongyan Zhang
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Li Peng
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Haoyu Li
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Shirui Dai
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China.,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China
| | - Baihua Chen
- Department of Ophthalmology, The Second Xiangya Hospital of Central South University, Changsha, 410011, China. .,Hunan Clinical Research Center of Ophthalmic Disease, Changsha, 410011, China.
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Sun T, Zhang BW, Xiong R, Zhou WT, Qiu JJ. Clinical Observation of Low-Temperature Plasma Ablation Combined with Drug Therapy in the Treatment of Fungal Keratitis. Infect Drug Resist 2023; 16:1895-1904. [PMID: 37020797 PMCID: PMC10069428 DOI: 10.2147/idr.s399715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/07/2023] [Indexed: 04/07/2023] Open
Abstract
Objective To observe the efficacy and prognosis of low-temperature plasma ablation + drug therapy in the treatment of fungal corneal ulcers. Methods The present paper presents a retrospective clinical study with a subject base of 34 eyes. Patients with a fungal corneal ulcer who visited the Affiliated Eye Hospital of Nanchang University between August 2019 and December 2021 were selected as the study participants. They were found to have highly reflective fungal hyphae in the corneal stroma layer via confocal microscope examination, which were revealed to be positive on etiology examination, with the ulcer and infiltration depths ≤1/2 of the corneal thickness. The efficacy and prognosis were observed after treatment with low-temperature plasma ablation + drug therapy. Results A total of 34 cases (34 eyes) had clinical manifestations of corneal infiltration and corneal ulcer formation, with a corneal lesion diameter of 1.31-8.64 mm (average = 4.79 ± 2.03 mm). The average healing time of corneal ulcers was 6.2 ± 1.7 days. Among a total of 34 cases (34 eyes) in patients with fungal keratitis, the infection was controlled and the ulcers gradually healed after treatment with low-temperature plasma system + drug therapy in a total of 30 cases (30 eyes, 88%). A total of three cases (3 eyes, 9%) exhibited no clear improvement after the treatment, and the patients underwent conjunctival flap covering surgery. One case (one eye, 3%) exhibited no clear improvement after further treatment, with the patient experiencing corneal perforation and ultimately undergoing penetrating keratoplasty. Conclusion Low-temperature plasma ablation + drug therapy can effectively control the progression of fungal keratitis infection, as well as significantly shorten the ulcer healing time, and is, therefore, an effective method.
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Affiliation(s)
- Tao Sun
- Affiliated Eye Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People’s Republic of China
- Jiangxi Clinical Research Center for Ophthalmic Disease, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Jiangxi Research Institute of Ophthalmology and Visual Science, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
| | - Bo-Wen Zhang
- Affiliated Eye Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People’s Republic of China
- Jiangxi Clinical Research Center for Ophthalmic Disease, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Jiangxi Research Institute of Ophthalmology and Visual Science, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
| | - Rui Xiong
- Affiliated Eye Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People’s Republic of China
- Jiangxi Clinical Research Center for Ophthalmic Disease, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Jiangxi Research Institute of Ophthalmology and Visual Science, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
| | - Wen-Tian Zhou
- Affiliated Eye Hospital of Nanchang University, Nanchang, Jiangxi, 330006, People’s Republic of China
- Jiangxi Clinical Research Center for Ophthalmic Disease, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Jiangxi Research Institute of Ophthalmology and Visual Science, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Jiangxi Provincial Key Laboratory for Ophthalmology, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
| | - Jing-Jing Qiu
- Department of Ophthalmology of The Second Affiliated Hospital of Nanchang University, Nanchang City, Jiangxi Province, 330006, People’s Republic of China
- Correspondence: Jing-Jing Qiu, Department of Ophthalmology of The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Nanchang City, Jiangxi Province, 330006, People’s Republic of China, Tel +86 15070001118, Email
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Vanathi M, Naik R, Sidhu N, Ahmed NH, Gupta N, Tandon R. Evaluation of antifungal susceptibility and clinical characteristics in fungal keratitis in a tertiary care center in North India. Indian J Ophthalmol 2022; 70:4270-4283. [PMID: 36453329 PMCID: PMC9940598 DOI: 10.4103/ijo.ijo_855_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose To study the antifungal susceptibility of common corneal pathogenic fungi to antifungal agents in the North Indian population. Methods Prospective study of the antifungal sensitivity testing (natamycin, amphotericin B, voriconazole, itraconazole, fluconazole, posaconazole, caspofungin, micafungin) of fungal isolates from 50 cases of culture positive fungal keratitis by using E test method. Details noted included demographic data, visual acuity, clinical details, grade of keratitis, healing time, and success in medical management. Results Of 50 patients with fungal keratitis (mean age: 40.28 ± 16.77 years), 12 eyes healed within 3 weeks, 14 had a delayed healing response, and 24 had chronic keratitis. Among the 15 cases of Fusarium isolates, 93.3% were sensitive to natamycin, while 40% to amphotericin B; 66.6% to voriconazole, 13.4% to itraconazole and fluconazole each. 80% of Fusarium cases (n = 12) showed susceptibility to posaconazole. Among Aspergillus flavus isolates, 53.4% (n = 8) were sensitive to natamycin, with only 40% (n = 7) showing sensitivity to amphotericin B and good susceptibility to azoles. MIC against susceptible Fusarium spp. for natamycin was 3-16 μg/mL, amphotericin B: 1-8 μg/mL, voriconazole: 0.5-1.5 μg/mL, itraconazole: 0.5-12 μg/mL, posaconazole: 0.094-1.5 μg/mL. MIC against Aspergillus flavus was natamycin: 8-32 μg/mL, amphotericin B: 0.5-16 μg/mL, voriconazole: 0.025-4 μg/mL, itraconazole: 0.125-8 μg/mL, posaconazole: 0.047-0.25 μg/mL; against Aspergillus niger isolates, to natamycin was 6 μg/mL (n=1), amphotericin B 8-12 μg/mL (n = 3), voriconazole: 0.125-0.19 μg/mL (n = 3), itraconazole: 0.38-0.75 μg/mL, posaconazole: 0.064-0.19 μg/mL and against Aspergillus fumigatus (n = 1), was natamycin4 μg/mL, amphotericin B - 8 μg/mL, voriconazole 0.25 μg/mL, itraconazole 1 μg/mL, and posaconazole 0.19 μg/mL. MIC against susceptible Acremonium spp. for natamycin was 1.5-16 μg/mL, amphotericin B: 0.5-8 μg/mL, voriconazole: 0.19-3 μg/mL, itraconazole: 0.125 μg/mL, posaconazole: 0.125-0.5 μg/mL and against susceptible Curvularia was natamycin 0.75-4 μg/mL, amphotericin B 0.5-1 μg/mL, voriconazole 0.125-0.19 μg/mL, itraconazole 0.047-0.094 μg/mL, posaconazole 0.047-0.094 μg/mL. MIC against Mucor spp.+ Rhizopus spp. (n = 1) was natamycin: 8 μg/mL, amphotericin B: 0.75 μg/mL, posaconazole: 1.5 μg/mL. MIC against of Alternaria (n = 1) was voriconazole: 0.19 μg/mL, posaconazole: 0.094 μg/mL. MIC against Penicillium (n=1) was natamycin: 8 μg/mL, voriconazole: 0.25 μg/mL, itraconazole: 0.5 μg/mL, and Posaconazole: 0.125 μg/mL. Conclusion Our observations highlight the variations in susceptibility to antifungal agents. Posaconazole seems to be effective with low MIC against common corneal pathogenic fungal isolates.
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Affiliation(s)
- Murugesan Vanathi
- Cornea, Lens and Refractive Surgery Services, All India Institute of Medical Sciences, New Delhi, India,Correspondence to: Dr. Murugesan Vanathi, Professor of Ophthalmology Cornea and Ocular Surface, Cataract and Refractive Services Dr. R. P. Center for Ophthalmic Sciences All India Institute of Medical Sciences, New Delhi - 110 029, India. E-mail:
| | - Ravinder Naik
- Cornea, Lens and Refractive Surgery Services, All India Institute of Medical Sciences, New Delhi, India
| | - Navneet Sidhu
- Cornea, Lens and Refractive Surgery Services, All India Institute of Medical Sciences, New Delhi, India
| | - Nishat Hussain Ahmed
- Ocular Microbiology Services, Dr. R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Noopur Gupta
- Cornea, Lens and Refractive Surgery Services, All India Institute of Medical Sciences, New Delhi, India
| | - Radhika Tandon
- Cornea, Lens and Refractive Surgery Services, All India Institute of Medical Sciences, New Delhi, India
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Nissan S, Boelens J, Lagrou K, Roels D. Pyrenocheata unguis-hominis: A new cause of fungal keratitis in a contact lens wearer. Am J Ophthalmol Case Rep 2022; 28:101731. [PMCID: PMC9614820 DOI: 10.1016/j.ajoc.2022.101731] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/12/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose Observations Conclusions
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Affiliation(s)
- Sima Nissan
- Department of Ophthalmology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium,Corresponding author.
| | - Jerina Boelens
- Department of Clinical Biology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Herestraat 49, 3000, Leuven, Belgium,National Reference Centre for Mycosis, Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Dimitri Roels
- Department of Ophthalmology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
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Hoffman JJ, Arunga S, Mohamed Ahmed AHA, Hu VH, Burton MJ. Management of Filamentous Fungal Keratitis: A Pragmatic Approach. J Fungi (Basel) 2022; 8:1067. [PMID: 36294633 PMCID: PMC9605596 DOI: 10.3390/jof8101067] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 11/02/2023] Open
Abstract
Filamentous fungal infections of the cornea known as filamentous fungal keratitis (FK) are challenging to treat. Topical natamycin 5% is usually first-line treatment following the results of several landmark clinical trials. However, even when treated intensively, infections may progress to corneal perforation. Current topical antifungals are not always effective and are often unavailable. Alternatives topical therapies to natamycin include voriconazole, chlorhexidine, amphotericin B and econazole. Surgical therapy, typically in the form of therapeutic penetrating keratoplasty, may be required for severe cases or following corneal perforation. Alternative treatment strategies such as intrastromal or intracameral injections of antifungals may be used. However, there is often no clear treatment strategy and the evidence to guide therapy is often lacking. This review describes the different treatment options and their evidence and provides a pragmatic approach to the management of fungal keratitis, particularly for clinicians working in tropical, low-resource settings where fungal keratitis is most prevalent.
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Affiliation(s)
- Jeremy J. Hoffman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Sagarmatha Choudhary Eye Hospital, Lahan 56500, Nepal
| | - Simon Arunga
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara P.O. Box 1410, Uganda
| | - Abeer H. A. Mohamed Ahmed
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Victor H. Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
- National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London EC1V 9EL, UK
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Brown L, Kamwiziku G, Oladele RO, Burton MJ, Prajna NV, Leitman TM, Denning DW. The Case for Fungal Keratitis to Be Accepted as a Neglected Tropical Disease. J Fungi (Basel) 2022; 8:jof8101047. [PMID: 36294612 PMCID: PMC9605065 DOI: 10.3390/jof8101047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/17/2022] Open
Abstract
Amongst the treatable cause of blindness among young people, fungal keratitis ranks high. There are an estimated 1,051,787 to 1,480,916 eyes affected annually, with 8–11% of patients having to have the eye removed. Diagnosis requires a corneal scraping, direct microscopy and fungal culture with a large number of airborne fungi implicated. Treatment involves the intensive application of antifungal eye drops, preferably natamycin, often combined with surgery. In low-resource settings, inappropriate corticosteroid eye drops, ineffective antibacterial therapy, diagnostic delay or no diagnosis all contribute to poor ocular outcomes with blindness (unilateral or bilateral) common. Modern detailed guidelines on fungal keratitis diagnosis and management are lacking. Here, we argue that fungal keratitis should be included as a neglected tropical disease, which would facilitate greater awareness of the condition, improved diagnostic capability, and access to affordable antifungal eye medicine.
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Affiliation(s)
- Lottie Brown
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Guyguy Kamwiziku
- Kinshasa University Hospital, M8R4+CF3, Kinshasa P.O. Box 8842, Democratic Republic of the Congo
| | - Rita O. Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos 101017 , Nigeria
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - N. Venkatesh Prajna
- Aravind Eye Hospitals and Postgraduate Institute of Ophthalmology, Madurai 625020, Tamil Nadu, India
| | - Thomas M. Leitman
- Departments of Ophthalmology, Epidemiology & Biostatistics, University of California, San Francisco, CA 94143, USA
| | - David W. Denning
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Global Action for Fungal Infections, Rue Le Corbusier 12, 1208 Geneva, Switzerland
- Correspondence: or
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Kovalchuk B, Khoramnia R, Tóth M, Horner S, Auffarth GU, Augustin VA. [Fusarium Keratitis-an upcoming threat in Germany?]. DIE OPHTHALMOLOGIE 2022; 119:1022-1034. [PMID: 35925324 DOI: 10.1007/s00347-022-01646-y] [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: 03/23/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Fungal keratitis due to Fusarium species is known to be typical of developing countries; however, with the increasing use of contact lenses a rise of Fusarium keratitis has been observed in Germany. METHODS In a monocentric retrospective study, we analyzed all patients who presented to our university eye hospital with infectious keratitis between January 2011 and December 2021 and had a proof of Fusarium species in either microscopy, culture or PCR. RESULTS We could identify 13 patients with a proof of Fusarium species. A significant increase of cases in 2021 was observed. In 76.9% of our cases the patients were female and in 76.9% the patients had a history of prior contact lens use. In only 4 cases the initial corneal sample gave a positive result for Fusarium. On average the suspicion of fungal keratitis arose 13.1 days after onset of symptoms, correct diagnosis was achieved after 14.6 days. All isolated specimens showed resistance against at least one of the common fungicides. In 70% of our cases treatment with penetrating keratoplasty was necessary. The patients showed a 57.1% recurrence rate after penetrating keratoplasty. In 80% of our cases best documented visual acuity after Fusarium keratitis was ≤ 0.4. CONCLUSION Due to difficult detection and a high resistance rate to common antifungals, Fusarium keratitis is prone to delayed diagnosis and limited treatment outcomes. Whenever risk factors are present and infectious keratitis does not respond to antibiotics, antimycotic treatment must be initiated. Early keratoplasty may be necessary.
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Affiliation(s)
- Bogdana Kovalchuk
- Univ.-Augenklinik Heidelberg, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Ramin Khoramnia
- Univ.-Augenklinik Heidelberg, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Marcell Tóth
- Pathologisches Institut, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Susanne Horner
- Zentrum für Infektiologie: Medizinische Mikrobiologie und Hygiene, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Gerd U Auffarth
- Univ.-Augenklinik Heidelberg, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Victor A Augustin
- Univ.-Augenklinik Heidelberg, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
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Atta S, Perera C, Kowalski RP, Jhanji V. Fungal Keratitis: Clinical Features, Risk Factors, Treatment, and Outcomes. J Fungi (Basel) 2022; 8:jof8090962. [PMID: 36135687 PMCID: PMC9504427 DOI: 10.3390/jof8090962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 11/26/2022] Open
Abstract
Fungal keratitis (FK) can be challenging to diagnose and treat. In this retrospective case series, FK cases presenting at the University of Pittsburgh Medical Center, Pennsylvania, USA, from 2015 to 2021 were reviewed for ocular risk factors, clinical presentation, management, and outcomes. Twenty-eight cases of FK were included. The median presenting age was 58.5 (18.5) years, and the median symptom duration prior to presentation was 10 (35.8) days. Predisposing ocular risk factors included contact lens use (67.9%), recent ocular trauma/abrasion (42.9%), and history of ocular surgery (42.9%). The median presenting visual acuity (VA) was 1.35 (1.72) LogMAR. About half presented with a central ulcer (42.9%), large infiltrate (6.7 (6.3) mm2), corneal thinning (50.0%), and hypopyon (32.1%). The majority of isolated fungal species were filamentous (75.0%). Most common antifungal medications included topical voriconazole (71.4%) and natamycin (53.6%) drops and oral voriconazole (64.3%). Surgical management was necessary in 32.1% of cases and enucleation in one case. Defect resolution occurred in 42.5 (47.0) days, and median final VA was 0.5 (1.84) LogMAR. Features associated with poor final visual outcomes included poor initial VA (p < 0.001) and larger defect size (p = 0.002). In conclusion, unlike prior studies in the northeast region of the USA, FK was commonly caused by filamentous fungi, and antifungal management most often consisted of topical and oral voriconazole.
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Affiliation(s)
- Sarah Atta
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Chandrashan Perera
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Regis P. Kowalski
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- The Charles T. Campbell Ophthalmic Microbiology Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
- The Charles T. Campbell Ophthalmic Microbiology Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
- Correspondence:
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Sourlis C, Seitz B, Roth M, Hamon L, Daas L. Outcomes of Severe Fungal Keratitis Using in vivo Confocal Microscopy and Early Therapeutic Penetrating Keratoplasty. Clin Ophthalmol 2022; 16:2245-2254. [PMID: 35855739 PMCID: PMC9288216 DOI: 10.2147/opth.s358709] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/25/2022] [Indexed: 12/31/2022] Open
Abstract
Purpose The purpose of this study was to assess the impact of early diagnosis using in vivo confocal microscopy and early therapeutic penetrating keratoplasty (TPK) on the outcomes of severe cases of fungal keratitis. Methods This retrospective single-center study included 38 patients (40 eyes) with fungal keratitis who presented between December 2013 and February 2020. Preoperative, intraoperative, and postoperative parameters were recorded to assess the role of early correct diagnosis and early surgical therapy on visual acuity outcome and enucleation rate during follow-up. Results The mean patient age was 51 years (71% females). The initial external diagnosis was correct in 20 cases (50%). The mean time from symptom onset until admission to our department was 46.8 ± 68.0 (median 28.5) days. The mean time to correct diagnosis after admission to our department was 1 day with in vivo confocal microscopy (IVCM). IVCM was performed in 38 cases, of which 36 (sensitivity: 94.7%) were positive for fungal infection. Twenty-seven out of 40 (67.5%) eyes received a TPK 4.2 ± 3.9 days after admission, with a mean graft size of 8.9 ± 1.9 mm. Three eyes (7.5%) were enucleated. The corrected distance visual acuity of the entire study population increased from 2.0 ± 1.2 LogMAR to 0.96 ± 1.17 LogMAR. Conclusion In vivo confocal microscopy is a powerful tool for the early detection of fungal organisms in infectious keratitis. An early TPK with a large graft helps to eradicate the infection timely and results in a favorable visual acuity outcome and lower enucleation rate, especially when treating filamentous fungi.
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Affiliation(s)
- Chrysovalantis Sourlis
- Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany
| | - Mathias Roth
- Department of Ophthalmology, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Loïc Hamon
- Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center, UKS, Homburg/Saar, Germany
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Jeang L, Tuli SS. Therapy for contact lens-related ulcers. Curr Opin Ophthalmol 2022; 33:282-289. [PMID: 35779052 DOI: 10.1097/icu.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current review covers the current literature and practice patterns of antimicrobial therapy for contact lens-related microbial keratitis (CLMK). Although the majority of corneal ulcers are bacterial, fungus and acanthamoeba are substantial contributors in CLMK and are harder to treat due to the lack of commercially available topical medications and low efficacy of available topical therapy. RECENT FINDINGS Topical antimicrobials remain the mainstay of therapy for corneal ulcers. Fluoroquinolones may be used as monotherapy for small, peripheral bacterial ulcers. Antibiotic resistance is a persistent problem. Fungal ulcers are less responsive to topical medications and adjunct oral or intrastromal antifungal medications may be helpful. Acanthamoeba keratitis continues to remain a therapeutic challenge but newer antifungal and antiparasitic agents may be helpful adjuncts. Other novel and innovative therapies are being studied currently and show promise. SUMMARY Contact lens-associated microbial keratitis is a significant health issue that can cause vision loss. Treatment remains a challenge but many promising diagnostics and procedures are in the pipeline and offer hope.
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Affiliation(s)
- Lauren Jeang
- Department of Ophthalmology, University of Florida, Gainesville, Florida, USA
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Ferguson TJ, Downes RA, Isada CM, Goshe JM. High-Dose Oral Posaconazole for the Treatment of Recalcitrant Fungal Keratitis. Cornea 2022; 41:852-856. [PMID: 34469337 DOI: 10.1097/ico.0000000000002832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/04/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To report the successful treatment of 3 cases of recalcitrant fungal keratitis (FK) with high-dose oral posaconazole. METHODS This is a series of 3 patients from a single academic center with a culture-positive FK who were treated with oral posaconazole after failing to respond to conventional treatments. RESULTS All 3 patients had a history of contact lens wear. Two of the 3 cases were culture positive for Fusarium and the other for Paecilomyces . The infections of all 3 failed to respond to conventional antifungal therapies including varying combinations of topical, systemic, and intraocular antifungal therapies. All 3 cases rapidly responded to high-dose oral posaconazole ranging from 500 to 600 mg once daily. In 1 case, multiple courses of high-dose therapy were required to treat delayed recurrences of a latent infection. There were no significant adverse effects with the elevated dose, and treatment was administered with the guidance of an infectious disease specialist. CONCLUSIONS In cases of recalcitrant FK failing to respond to conventional therapies, high-dose posaconazole, in the delayed-release tablet formulation, can be an effective treatment option.
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Affiliation(s)
| | | | - Carlos M Isada
- Department of Infectious Disease, Cleveland Clinic, Cleveland, OH
| | - Jeff M Goshe
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH; and
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Puri LR, Burn H, Roshan A, Biswakarma R, Burton M. Epidemiology and clinical outcomes of microbial keratitis in South East Nepal: a mixed-methods study. BMJ Open Ophthalmol 2022; 7:bmjophth-2022-001031. [PMID: 36161837 PMCID: PMC9214385 DOI: 10.1136/bmjophth-2022-001031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/17/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To describe the epidemiology of microbial keratitis in patients presenting to a tertiary eye hospital in South East Nepal alongside qualitative interviews exploring patient perspectives on barriers to accessing eye care services. Methods and analysis All patients with microbial keratitis (>16 years) presenting to Sagarmatha Choudhary Eye Hospital, Nepal between 1 May 2017 and 31 July 2017 were recruited. Data were collected on patient demographics, precipitating factors and pathway to care. Clinical examination was performed and microbiological samples collected. Visual acuity was measured at final follow-up. Semistructured interviews and focus group discussions explored the patient journey and barriers to accessing care. Results We recruited 174 participants; 88 (51%) were male (mean age of 47 years) and 126 (72%) were farmers. Ocular trauma with vegetative matter was reported by 79 (45%) and 84 (48%) had fungal infections. Visual acuity was <3/60 in 107 (61%) of affected eyes at presentation, reducing to 73 (42%) at last follow-up. Factors associated with poor visual outcome were trauma with vegetative matter, delayed presentation and poor visual acuity at presentation. Qualitative interviews with 40 patients identified lack of awareness of the disease and available services, poor knowledge and practice of community health workers and lack of affordability and accessibility of treatment as important barriers. Conclusion The epidemiology of microbial keratitis in this region was similar to other tropical regions. Patient interviews highlighted need for public health awareness campaigns on microbial keratitis, training of community health staff on the urgency of this condition and improvements in accessibility and affordability of ocular treatments.
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Affiliation(s)
- Lila Raj Puri
- The Fred Hollows Foundation, Alexandria, New South Wales, Australia
| | - Helen Burn
- London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | | | | | - Matthew Burton
- London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
- National Institute for Health Research Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Redd TK, Prajna NV, Srinivasan M, Lalitha P, Krishnan T, Rajaraman R, Venugopal A, Acharya N, Seitzman GD, Lietman TM, Keenan JD, Campbell JP, Song X. Image-Based Differentiation of Bacterial and Fungal Keratitis Using Deep Convolutional Neural Networks. OPHTHALMOLOGY SCIENCE 2022; 2:100119. [PMID: 36249698 PMCID: PMC9560557 DOI: 10.1016/j.xops.2022.100119] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/11/2022] [Accepted: 01/21/2022] [Indexed: 01/02/2023]
Abstract
Purpose Develop computer vision models for image-based differentiation of bacterial and fungal corneal ulcers and compare their performance against human experts. Design Cross-sectional comparison of diagnostic performance. Participants Patients with acute, culture-proven bacterial or fungal keratitis from 4 centers in South India. Methods Five convolutional neural networks (CNNs) were trained using images from handheld cameras collected from patients with culture-proven corneal ulcers in South India recruited as part of clinical trials conducted between 2006 and 2015. Their performance was evaluated on 2 hold-out test sets (1 single center and 1 multicenter) from South India. Twelve local expert cornea specialists performed remote interpretation of the images in the multicenter test set to enable direct comparison against CNN performance. Main Outcome Measures Area under the receiver operating characteristic curve (AUC) individually and for each group collectively (i.e., CNN ensemble and human ensemble). Results The best-performing CNN architecture was MobileNet, which attained an AUC of 0.86 on the single-center test set (other CNNs range, 0.68-0.84) and 0.83 on the multicenter test set (other CNNs range, 0.75-0.83). Expert human AUCs on the multicenter test set ranged from 0.42 to 0.79. The CNN ensemble achieved a statistically significantly higher AUC (0.84) than the human ensemble (0.76; P < 0.01). CNNs showed relatively higher accuracy for fungal (81%) versus bacterial (75%) ulcers, whereas humans showed relatively higher accuracy for bacterial (88%) versus fungal (56%) ulcers. An ensemble of the best-performing CNN and best-performing human achieved the highest AUC of 0.87, although this was not statistically significantly higher than the best CNN (0.83; P = 0.17) or best human (0.79; P = 0.09). Conclusions Computer vision models achieved superhuman performance in identifying the underlying infectious cause of corneal ulcers compared with cornea specialists. The best-performing model, MobileNet, attained an AUC of 0.83 to 0.86 without any additional clinical or historical information. These findings suggest the potential for future implementation of these models to enable earlier directed antimicrobial therapy in the management of infectious keratitis, which may improve visual outcomes. Additional studies are ongoing to incorporate clinical history and expert opinion into predictive models.
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Affiliation(s)
- Travis K. Redd
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | | | | | | | - Tiru Krishnan
- Aravind Eye Hospital, Pondicherry, Tamil Nadu, India
| | | | | | - Nisha Acharya
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Gerami D. Seitzman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Jeremy D. Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - J. Peter Campbell
- Casey Eye Institute, Oregon Health & Science University, Portland, Oregon
| | - Xubo Song
- Department of Medical Informatics and Clinical Epidemiology and Program of Computer Science and Electrical Engineering, Oregon Health & Science University, Portland, Oregon
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Effect of Voriconazole on Biofilm of Filamentous Species Isolated from Keratitis. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2022. [DOI: 10.5812/archcid-122452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Biofilm formation is a vital feature of the pathogenesis in filamentous fungi. Objectives: Herein, we investigated in vitro antifungal pattern of biofilm of filamentous species keratitis isolates, and the effect of different concentrations of voriconazole on biofilm morphology changes using scanning electron microscopy. Methods: Here 25 ocular fungal isolates were included (Fusarium solani; (n = 15) and Aspergillus flavus; (n = 10). We determined the biofilm formation of isolates in terms of their susceptibilities to different antifungals on sessile cells. This procedure was performed according to CLSI-M38-3rd. Biofilm morphology changes revealed with scanning electron microscopy (SEM). Results: Twelve F. solani strains displayed the capacity to form biofilms from patients wearing contact lenses, while 8 A. flavus strains were recovered from cornea scrapings of trauma. Itraconazole, posaconazole and natamycin had the maximum activity against biofilms of all tested filamentous strains (MIC ranging from 0.031 - 0.25 µg/mL, 0.031 - 0.25 µg/mL and 2 - 4 µg/mL), respectively. Three F. solani and one A. flavus strains showed the high MIC values against voriconazole (MIC ≥ 1 µg/mL). Posaconazole revealed the lowest MIC values against biofilms of two strains (MIC ranging from 0.031 - 0.25 µg/mL); however, no significant difference was observed for itraconazole (P > 0.05). The efficacy of 16 µg/mL and 4 µg/mL of voriconazole was confirmed for biofilm of F. solani and A. flavus, respectively. The considerable changes in the morphologies of improved biofilms were seen by SEM. Conclusions: For the successful treatment of fungal biofilm infections, it was necessary to have knowledge of the mechanism of action, penetration rates, and therapeutic concentrations of drugs.
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Hoffman JJ, Yadav R, Sanyam SD, Chaudhary P, Roshan A, Singh SK, Singh SK, Mishra SK, Arunga S, Hu VH, Macleod D, Leck A, Burton MJ. Topical Chlorhexidine 0.2% versus Topical Natamycin 5% for the Treatment of Fungal Keratitis in Nepal: A Randomized Controlled Noninferiority Trial. Ophthalmology 2022; 129:530-541. [PMID: 34896126 PMCID: PMC9037000 DOI: 10.1016/j.ophtha.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/02/2021] [Accepted: 12/02/2021] [Indexed: 11/01/2022] Open
Abstract
PURPOSE To investigate if topical chlorhexidine 0.2%, which is low cost and easy to formulate, is noninferior to topical natamycin 5% for the treatment of filamentous fungal keratitis. DESIGN Randomized controlled, single-masked, noninferiority clinical trial. PARTICIPANTS Adults attending a tertiary-level ophthalmic hospital in Nepal with filamentous fungal infection confirmed on smear or confocal microscopy. METHODS Participants were randomly allocated to receive topical chlorhexidine 0.2% or topical natamycin 5%. Primary analysis (intention-to-treat) was by linear regression, using baseline logarithm of the minimum angle of resolution (logMAR) best spectacle-corrected visual acuity (BSCVA) and treatment arm as prespecified covariates. Mixed fungal-bacterial infections were excluded from the primary analysis but included in secondary analyses and secondary safety-related outcomes. The noninferiority margin was 0.15 logMAR. This trial was registered with ISRCTN, number ISRCTN14332621. MAIN OUTCOME MEASURES The primary outcome measure was BSCVA at 3 months. Secondary outcome measures included perforation or therapeutic penetrating keratoplasty by 90 days. RESULTS Between June 3, 2019, and November 9, 2020, 354 eligible participants were enrolled and randomly assigned: 178 to chlorhexidine and 176 to natamycin. Primary outcome data were available for 153 and 151 of the chlorhexidine and natamycin groups, respectively. Of these, mixed bacterial-fungal infections were found in 20 cases (12/153 chlorhexidine, 8/151 natamycin) and excluded from the primary analysis. Therefore, 284 patients were assessed for the primary outcome (141 chlorhexidine, 143 natamycin). We did not find evidence to suggest chlorhexidine was noninferior to natamycin and in fact found strong evidence to suggest that natamycin-treated participants had significantly better 3-month BSCVA than chlorhexidine-treated participants, after adjusting for baseline BSCVA (regression coefficient, -0.30; 95% confidence interval [CI], -0.42 to -0.18; P < 0.001). There were more perforations and emergency corneal grafts in the chlorhexidine arm (24/175, 13.7%) than in the natamycin arm (10/173, 5.8%; P = 0.018, mixed infections included), whereas natamycin-treated cases were less likely to perforate or require an emergency corneal graft, after adjusting for baseline ulcer depth (odds ratio, 0.34; 95% CI, 0.15-0.79; P = 0.013). CONCLUSIONS Treatment with natamycin is associated with significantly better visual acuity, with fewer adverse events, compared with treatment with chlorhexidine. Natamycin remains the preferred first-line monotherapy treatment for filamentous fungal keratitis.
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Affiliation(s)
- Jeremy J Hoffman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; Sagarmatha Choudhary Eye Hospital, Lahan, Nepal; Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
| | - Reena Yadav
- Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | | | | | | | | | | | | | - Simon Arunga
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; Mbarara University of Science and Technology, Mbarara, Uganda
| | - Victor H Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Macleod
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom; National Institute for Health Research Biomedical Research Centre for Ophthalmology at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
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Alsarhani W, Lam PW, Kus JV, Rowsell C, Tsui GK, Tadros M, Fattouh R, Yucel Y, Kertes PJ, Chew HF. Post-traumatic Fungal Keratitis and Endophthalmitis Caused by Coniochaeta Hoffmannii with Late Recurrence following Therapeutic Full-thickness Penetrating Keratoplasty. Ocul Immunol Inflamm 2022; 31:826-829. [PMID: 35404731 DOI: 10.1080/09273948.2022.2048028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND To report a rare case of fungal keratitis and endophthalmitis due to Coniochaeta hoffmannii. METHODS Case report. RESULTS A 71-year-old immunocompetent male sustained a corneal laceration, traumatic cataract, and retinal detachment due to penetrating injury from a nail pulled from a wooden deck. The patient's postoperative course was complicated by infectious keratitis. Fungal cultures, DNA sequencing and analysis of the internal transcribed spacer sequence confirmed Coniochaeta hoffmannii. Topical and oral voriconazole treatments were initiated; however, due to impending perforation, a therapeutic corneal transplant was required. One year later, the patient developed a new corneal infiltrate at the graft-host junction: Corneal scrapings were culture positive for Coniochaeta hoffmannii. This was treated with topical and intrastromal voriconazole along with oral itraconazole 200 mg once daily for 8 months. CONCLUSIONS Coniochaeta hoffmannii may cause recalcitrant keratitis and endophthalmitis, which required longstanding antifungal treatment.
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Affiliation(s)
- Waleed Alsarhani
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, ON, Canada
- Department of Ophthalmology, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Philip W. Lam
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Julianne V. Kus
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
| | - Corwyn Rowsell
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine, St. Michael’s Hospital, Unity Health, Toronto, ON, Canada
| | | | - Manal Tadros
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Ramzi Fattouh
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine, St. Michael’s Hospital, Unity Health, Toronto, ON, Canada
| | - Yeni Yucel
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Laboratory Medicine, St. Michael’s Hospital, Unity Health, Toronto, ON, Canada
| | - Peter J. Kertes
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, ON, Canada
- Department of Ophthalmology & Vision Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hall F. Chew
- Department of Ophthalmology & Vision Sciences, University of Toronto, Toronto, ON, Canada
- Department of Ophthalmology & Vision Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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