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Picken CAR, Brocchini S, Burton MJ, Blundell-Hunter G, Kuguminkiriza D, Kaur H, Hoffman JJ, Arunga S, Mohamed-Ahmed AHA. Local Ugandan Production of Stable 0.2% Chlorhexidine Eye Drops. Transl Vis Sci Technol 2023; 12:27. [PMID: 36705928 PMCID: PMC9896845 DOI: 10.1167/tvst.12.1.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose The purpose of this study was to develop a protocol to prepare buffered chlorhexidine (CHX) eye drops (0.2% w/v) in the United Kingdom that can be reproduced at a production facility in Uganda. Buffered CHX eye drops can prevent CHX degradation and improve ocular tolerability during the treatment of fungal keratitis. Methods Buffered CHX eye drops in amber glass containers were prepared using sodium acetate buffer at pH 5.90 to 6.75. Two commercial CHX solutions and CHX in water were used as controls. Eye drops were stored at 40°C (70% humidity, 21 months) in the United Kingdom and at ambient temperature in Uganda (30 months). High-performance liquid chromatography was used to determine CHX stability over time, and pH was monitored. Sterility was achieved using an autoclave (121°C, 15 minutes) and water bath (100°C, 30 minutes). Results The pH of acetate-buffered CHX eye drops did not change over 21 months at 40°C or at ambient temperature (30 months), whereas the pH of the unbuffered aqueous CHX displayed significant fluctuations, with an increase in acidity. The CHX concentration remained the same in both buffered and unbuffered eye-drop solutions. Eye drops sterilization was successful using an autoclave and a water bath. Conclusions Stable, sterile, buffered CHX eye drops (pH 6.75) were successfully prepared first in the United Kingdom and then reproducibly in Uganda. This eye drops can be prepared in a hospital or pharmacy setting with limited resources, thus providing a cost-effective treatment for fungal keratitis. Translational Relevance A protocol has been developed to prepare buffered CHX eye drops in low- and middle-income countries to treat fungal keratitis.
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Affiliation(s)
| | | | - Matthew J. Burton
- Clinical Research, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK,Moorfields Eye Hospital, London, UK
| | | | - Dan Kuguminkiriza
- Eye Drop Production Unit, Ruharo Eye Centre, Ruharu Mission Hospital, Mbarara, Uganda
| | - Harparkash Kaur
- Clinical Research, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jeremy J. Hoffman
- Clinical Research, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Simon Arunga
- Clinical Research, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK,Department of Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Abeer H. A. Mohamed-Ahmed
- Clinical Research, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
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Aydamirov AS, Harbiyeli II, Ozturk G, Yarkin F, Erdem E, Yagmur M. In Vitro efficacy of cyclosporine a and various antiseptics and antiviral drugs on adenovirus genotype 8, a common cause of epidemic keratoconjunctivitis. Int Ophthalmol 2022; 43:1701-1710. [PMID: 36346478 DOI: 10.1007/s10792-022-02567-0] [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: 12/20/2021] [Accepted: 10/16/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE To evaluate the in vitro efficacy of cidofovir, ganciclovir, povidone-iodine, chlorhexidine, and cyclosporine A on adenovirus genotype 8. METHODS Conjunctival samples were collected from patients with adenoviral conjunctivitis and cultured in A549 cells. Adenovirus diagnosis was confirmed by RT-PCR. For each drug, the 50% cytotoxic concentration (CC 50 ) was determined. Subsequently, the antiviral activity was tested at concentrations below CC 50, and the 50% inhibitor concentration (IC 50 ) of drugs was determined RESULTS: While the IC 50 of cidofovir against adenovirus genotype 8 was 3.07 ± 0.8 µM, ganciclovir, povidone-iodine, chlorhexidine, and cyclosporine A were not found to be effective against adenovirus genotype 8 at concentrations below the CC 50 value. CONCLUSIONS Cidofovir was found effective and the IC 50 value was within the ranges in the literature. Ganciclovir and cyclosporine A were found to be ineffective at doses below the cytotoxic dose, povidone-iodine and chlorhexidine was found to be highly cytotoxic.
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Affiliation(s)
| | | | - Gokhan Ozturk
- Division of Virology, Department of Microbiology, School of Medicine, Cukurova University, Adana, Turkey
| | - Fugen Yarkin
- Division of Virology, Department of Microbiology, School of Medicine, Cukurova University, Adana, Turkey
| | - Elif Erdem
- Department of Ophthalmology, School of Medicine, Cukurova University, Adana, Turkey
| | - Meltem Yagmur
- Department of Ophthalmology, School of Medicine, Cukurova University, Adana, Turkey
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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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4
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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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5
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Szaliński M, Zgryźniak A, Rubisz I, Gajdzis M, Kaczmarek R, Przeździecka-Dołyk J. Fusarium Keratitis-Review of Current Treatment Possibilities. J Clin Med 2021; 10:jcm10235468. [PMID: 34884170 PMCID: PMC8658515 DOI: 10.3390/jcm10235468] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 12/13/2022] Open
Abstract
In many parts of the world, fungi are the predominant cause of infectious keratitis; among which, Fusarium is the most commonly isolated pathogen. The clinical management of this ophthalmic emergency is challenging. Due to the retardation of the first symptoms from an injury and the inability to differentiate fungal from bacterial infections based on clinical symptoms and difficult microbial diagnostics, proper treatment, in many cases, is postponed. Moreover, therapeutical options of Fusarium keratitis remain limited. This paper summarizes the available treatment modalities of Fusarium keratitis, including antifungals and their routes of administration, antiseptics, and surgical interventions.
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Affiliation(s)
- Marek Szaliński
- Department of Ophthalmology, Wroclaw Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; (M.S.); (M.G.); (R.K.); (J.P.-D.)
- Clinic of Ophthalmology, University Teaching Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Aleksandra Zgryźniak
- Clinic of Ophthalmology, University Teaching Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
- Correspondence:
| | - Izabela Rubisz
- Okulus Ophthalmology Clinic, ul. Śródmiejska 34, 62-800 Kalisz, Poland;
| | - Małgorzata Gajdzis
- Department of Ophthalmology, Wroclaw Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; (M.S.); (M.G.); (R.K.); (J.P.-D.)
| | - Radosław Kaczmarek
- Department of Ophthalmology, Wroclaw Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; (M.S.); (M.G.); (R.K.); (J.P.-D.)
- Clinic of Ophthalmology, University Teaching Hospital, ul. Borowska 213, 50-556 Wrocław, Poland
| | - Joanna Przeździecka-Dołyk
- Department of Ophthalmology, Wroclaw Medical University, ul. Borowska 213, 50-556 Wrocław, Poland; (M.S.); (M.G.); (R.K.); (J.P.-D.)
- Department of Optics and Photonics, Wroclaw University of Science and Technology, Wyb. Stanisława Wyspiańskiego 27, 50-370 Wrocław, Poland
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Donovan C, Arenas E, Ayyala RS, Margo CE, Espana EM. Fungal keratitis: Mechanisms of infection and management strategies. Surv Ophthalmol 2021; 67:758-769. [PMID: 34425126 PMCID: PMC9206537 DOI: 10.1016/j.survophthal.2021.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/04/2021] [Accepted: 08/16/2021] [Indexed: 12/24/2022]
Abstract
Fungal corneal ulcers are an uncommon, yet challenging, cause of vision loss. In the United States, geographic location appears to dictate not only the incidence of fungal ulcers, but also the fungal genera most encountered. These patterns of infection can be linked to environmental factors and individual characteristics of fungal organisms. Successful management of fungal ulcers is dependent on an early diagnosis. New diagnostic modalities like confocal microscopy and polymerase chain reaction are being increasingly used to detect and identify infectious organisms. Several novel therapies, including crosslinking and light therapy, are currently being tested as alternatives to conventional antifungal medications. We explore the biology of Candida, Fusarium, and Aspergillus, the three most common genera of fungi causing corneal ulcers in the United States and discuss current treatment regimens for the management of fungal keratitis.
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Affiliation(s)
- Christopher Donovan
- Department of Ophthalmology, Cornea and External Disease Service, Morsani College of Medicine, university of South Florida, Tampa, USA
| | - Eduardo Arenas
- Departamento de Oftalmologia, Universidad Nacional de Colombia y Universidad el Bosque, Bogota, Colombia
| | - Ramesh S Ayyala
- Department of Ophthalmology, Cornea and External Disease Service, Morsani College of Medicine, university of South Florida, Tampa, USA
| | - Curtis E Margo
- Department of Ophthalmology, Cornea and External Disease Service, Morsani College of Medicine, university of South Florida, Tampa, USA; Pathology and Cell Biology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Edgar M Espana
- Department of Ophthalmology, Cornea and External Disease Service, Morsani College of Medicine, university of South Florida, Tampa, USA; Molecular Pharmacology and Physiology, Morsani College of Medicine, university of South Florida, Tampa, USA.
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7
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Arunga S, Mbarak T, Ebong A, Mwesigye J, Kuguminkiriza D, Mohamed-Ahmed AHA, Hoffman JJ, Leck A, Hu V, Burton M. Chlorhexidine gluconate 0.2% as a treatment for recalcitrant fungal keratitis in Uganda: a pilot study. BMJ Open Ophthalmol 2021; 6:e000698. [PMID: 34368461 PMCID: PMC8258663 DOI: 10.1136/bmjophth-2020-000698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/27/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Fungal keratitis is a major ophthalmic public health problem, particularly in low-income and middle-income countries. The options for treating fungal keratitis are limited. Our study aimed to describe the outcomes of using chlorhexidine 0.2% eye-drops as additional treatment in the management of patients with recalcitrant fungal keratitis. METHODS This study was nested within a large cohort study of people presenting with microbial keratitis in Uganda. We enrolled patients with recalcitrant fungal keratitis not improving with topical natamycin 5% and commenced chlorhexidine 0.2%. Follow-up was scheduled for 3 months and 1 year. The main outcome measures were healing, visual acuity and scar size at final follow-up. RESULTS Thirteen patients were followed in this substudy. The patients were aged 27-73 years (median 43 years). Filamentous fungi were identified by microscopy of corneal scrape samples in all cases. Isolated organisms included Aspergillus spp, Fusarium spp, Candida spp, Bipolaris spp and Acremoninum spp. At the final follow-up, nine patients (75%) had healed; three had vision of better than 6/18. Three patients lost their eyes due to infection. In the remaining nine cases, corneal scarring was variable ranging from 4.6 to 9.4 mm (median 6.6 mm, IQR 5.9-8.0 mm); of these five had dense scars, three had moderate scars and one had a mild scar. None of the patients demonstrated signs of chlorhexidine toxicity during the follow-up. CONCLUSION Chlorhexidine 0.2% was found to be a useful sequential adjunctive topical antifungal in cases of fungal keratitis not responding to natamycin 5%, which warrants further evaluation.
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Affiliation(s)
- Simon Arunga
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Tumu Mbarak
- Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Abel Ebong
- Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - James Mwesigye
- Ophthalmology, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Jeremy John Hoffman
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Astrid Leck
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Victor Hu
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- St Paul's Eye Unit, Liverpool, UK
| | - Matthew Burton
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Behrens-Baumann WJ. New Antimycotics in the Pipeline - For Ophthalmology Too? Klin Monbl Augenheilkd 2021; 238:1108-1112. [PMID: 34198353 DOI: 10.1055/a-1478-4248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Seven new antimycotics are presented that are at different points of development or approval. These substances are mainly first-in-class drugs. They are primarily developed for systemic administration. However, with the support of a pharmacist, the intravenous formulation may be used as eyedrops. In this short review, the activities of the substances against various fungal infections are described. After unsuccessful conventional therapy of fungal eye infections, one of these new substances might be suitable to cure the mycosis.
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9
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Vogt PR, Aser R, Schmidlin D, Mohacsi P, Berdat PA, Went P, Flepp M, Mestres CA. Late outcome after surgical and topical treatment for Aspergillus mediastinitis after heart transplantation. J Card Surg 2021; 36:2558-2561. [PMID: 33880792 DOI: 10.1111/jocs.15544] [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: 10/28/2020] [Revised: 01/04/2021] [Accepted: 02/09/2021] [Indexed: 11/29/2022]
Abstract
The 7-year long-term survival after Aspergillus fumigatus mediastinitis after heart transplantation, an uncommonly described condition, is herein reported. A 66-year-old male developed an infection with A. fumigatus covering the entire thoracic cavity with a fungal turf after orthotopic heart transplantation. Repeated surgical removal of infectious and necrotic tissue together with innovative topical treatment using voriconazole and chlorhexidine combined with systemic antifungal treatment, helped in controlling the infection. Definitive wound closure was achieved by standard sternal refixation and latissimus dorsi muscle flap plasty. Survival after A. fumigatus mediastinitis after heart transplantation was achieved with sequential debridement in combination with topical application of antifungal agents.
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Affiliation(s)
- Paul R Vogt
- Department of Cardiovascular Surgery, Klinik Im Park, Zürich, Switzerland.,Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Raed Aser
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Daniel Schmidlin
- Department of Anaesthesia and Intensive Care, Klinik Im Park, Zürich, Switzerland
| | - Paul Mohacsi
- Department of Cardiology, Klinik Im Park, Zürich, Switzerland
| | - Pascal A Berdat
- Department of Cardiovascular Surgery, Klinik Im Park, Zürich, Switzerland
| | - Phillip Went
- Department of Pathology, Kantonsspital Graubünden, Chur, Switzerland
| | - Markus Flepp
- Department of Infectious Diseases, Klinik Im Park, Zürich, Switzerland
| | - Carlos A Mestres
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
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10
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Hoffman JJ, Burton MJ, Leck A. Mycotic Keratitis-A Global Threat from the Filamentous Fungi. J Fungi (Basel) 2021; 7:273. [PMID: 33916767 PMCID: PMC8066744 DOI: 10.3390/jof7040273] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/16/2022] Open
Abstract
Mycotic or fungal keratitis (FK) is a sight-threatening disease, caused by infection of the cornea by filamentous fungi or yeasts. In tropical, low and middle-income countries, it accounts for the majority of cases of microbial keratitis (MK). Filamentous fungi, in particular Fusarium spp., the aspergilli and dematiaceous fungi, are responsible for the greatest burden of disease. The predominant risk factor for filamentous fungal keratitis is trauma, typically with organic, plant-based material. In developed countries, contact lens wear and related products are frequently implicated as risk factors, and have been linked to global outbreaks of Fusarium keratitis in the recent past. In 2020, the incidence of FK was estimated to be over 1 million cases per year, and there is significant geographical variation; accounting for less than 1% of cases of MK in some European countries to over 80% in parts of south and south-east Asia. The proportion of MK cases is inversely correlated to distance from the equator and there is emerging evidence that the incidence of FK may be increasing. Diagnosing FK is challenging; accurate diagnosis relies on reliable microscopy and culture, aided by adjunctive tools such as in vivo confocal microscopy or PCR. Unfortunately, these facilities are infrequently available in areas most in need. Current topical antifungals are not very effective; infections can progress despite prompt treatment. Antifungal drops are often unavailable. When available, natamycin is usually first-line treatment. However, infections may progress to perforation in ~25% of cases. Future work needs to be directed at addressing these challenges and unmet needs. This review discusses the epidemiology, clinical features, diagnosis, management and aetiology of FK.
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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; (M.J.B.); (A.L.)
- Cornea Service, Sagarmatha Choudhary Eye Hospital, Lahan 56502, Nepal
- Department of Ophthalmology, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Matthew J. Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (M.J.B.); (A.L.)
- 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
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (M.J.B.); (A.L.)
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11
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Oliveira dos Santos C, Hanemaaijer NM, Ye J, van der Lee HAL, Verweij PE, Eggink CA. Chlorhexidine for the Treatment of Fusarium Keratitis: A Case Series and Mini Review. J Fungi (Basel) 2021; 7:255. [PMID: 33805369 PMCID: PMC8066532 DOI: 10.3390/jof7040255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/17/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
Fungal keratitis is difficult to treat, especially Fusarium keratitis. In vitro studies show that chlorhexidine could be an interesting option as monotherapy. We describe a case series of four patients (four eyes) with Fusarium keratitis at Radboud University Medical Center (Nijmegen, the Netherlands). The patients were treated with chlorhexidine 0.02% eye drops. The in vitro activity of eight antifungals and chlorhexidine was determined according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) broth microdilution method. We also reviewed the literature on the use of chlorhexidine in the treatment of fungal keratitis. Topical chlorhexidine was well tolerated, and all patients showed complete resolution of the keratitis upon treatment with chlorhexidine. A PubMed search of the available literature was conducted (last search 8 March 2020) and yielded two randomized clinical trials (natamycin versus chlorhexidine) and one case report addressing the treatment of fungal keratitis with chlorhexidine. Chlorhexidine was found to be safe with regard to toxicity and to be superior to natamycin in the clinical trials. Chlorhexidine showed in vitro fungicidal activity against Fusarium and clinical effectiveness in our cases, supporting further clinical evaluation. Advantages of chlorhexidine are its topical application, its general availability, its low costs, its broad-spectrum activity, and its fungicidal mechanism of action at low concentrations.
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Affiliation(s)
- Claudy Oliveira dos Santos
- Centre for Expertise in Mycology, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (N.M.H.); (H.A.L.v.d.L.); (P.E.V.)
- University Medical Center, Department of Medical Microbiology, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Nicolien M. Hanemaaijer
- Centre for Expertise in Mycology, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (N.M.H.); (H.A.L.v.d.L.); (P.E.V.)
| | - Jelina Ye
- Department of Ophthalmology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.Y.); (C.A.E.)
| | - Henrich A. L. van der Lee
- Centre for Expertise in Mycology, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (N.M.H.); (H.A.L.v.d.L.); (P.E.V.)
| | - Paul E. Verweij
- Centre for Expertise in Mycology, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (N.M.H.); (H.A.L.v.d.L.); (P.E.V.)
| | - Cathrien A. Eggink
- Department of Ophthalmology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (J.Y.); (C.A.E.)
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12
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Ho L, Jalbert I, Watt K, Hui A. Current understanding and therapeutic management of contact lens associated sterile corneal infiltrates and microbial keratitis. Clin Exp Optom 2021; 104:323-333. [PMID: 33689618 DOI: 10.1080/08164622.2021.1877530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Contact lenses are widely prescribed in clinical practice with multiple applications and advantages. However, contact lenses can be associated with various complications which range from innocuous to severe. Clinicians thus not only need to possess the ability to prescribe the most appropriate contact lenses for each individual patient but also be able to recognise and manage any associated complications. This review examines the existing literature on the management of corneal infiltrative events associated with soft contact lenses, including microbial keratitis, particularly in the context of practising in Australia. The definitions and diagnosis of corneal infiltrative events, as well as the current understanding of their aetiologies, will be explored. The various aspects of a successful management will be discussed, including the applications of therapeutic agents such as antimicrobial and anti-inflammatory agents, the role of microbiological investigations, and strategies to improve long-term prognosis. The currently available evidence supporting management options will be presented, highlighting the relative abundance of high-level evidence on management protocols, antimicrobial selection and treatment duration for microbial keratitis; and the relative paucity of studies and trials for sterile corneal infiltrative events, despite this condition being much more commonly encountered in clinical practice.
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Affiliation(s)
- Lily Ho
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, Australia
| | - Isabelle Jalbert
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, Australia
| | - Kathleen Watt
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, Australia
| | - Alex Hui
- School of Optometry and Vision Science, UNSW Sydney, Sydney, NSW, Australia
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13
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Menda SA, Das M, Panigrahi A, Prajna NV, Acharya NR, Lietman TM, McLeod SD, Keenan JD. Association of Postfungal Keratitis Corneal Scar Features With Visual Acuity. JAMA Ophthalmol 2020; 138:113-118. [PMID: 31804657 DOI: 10.1001/jamaophthalmol.2019.4852] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Corneal opacity is a leading cause of visual impairment worldwide; however, the specific features of corneal scars, which decrease visual acuity, have not been well characterized. Objective To investigate which features of a postfungal keratitis corneal scar contribute to decreased visual acuity after an episode of infectious keratitis and evaluate whether any corneal features may be used as outcomes for clinical trials. Design, Setting, and Participants In this ancillary, prospective cross-sectional study, a subset of study participants treated for fungal keratitis (n = 71) as part of the Mycotic Ulcer Treatment Trial I (MUTT I) underwent best spectacle-corrected visual acuity (BSCVA) and best contact lens-corrected visual acuity examination, Scheimpflug imaging, and anterior segment optical coherence tomography at a referral hospital in India approximately 2 years after enrollment. Data were collected from December 3, 2012, to December 19, 2012, and analyses were performed from December 2, 2013, to October 2, 2019. Main Outcomes and Measures Linear regression models were used to evaluate the importance of various corneal features for BSCVA and to assess whether these features could be used to differentiate the 2 treatment arms of the MUTT I trial. Results Seventy-one patients (42 men [59.1%]; median age, 48 [range, 39-60] years) were examined at a median (IQR) time of 1.8 (1.4-2.2) years after enrollment. The mean (SD) logMAR BSCVA was 0.17 (0.19) (Snellen equivalent, 20/32). In multivariable linear regression models, BSCVA was most associated with irregular astigmatism (1.0 line of worse BSCVA per 1-line difference between BSCVA and contact lens visual acuity; 95% CI, 0.6-1.4) and corneal scar density (1.5 lines of worse vision per 10-unit increase in the mean central corneal density; 95% CI, 0.8-2.3). The thinnest point of the cornea was the metric that best discriminated between the natamycin- and voriconazole-treated ulcers in MUTT I, with 29.3 μm (95% CI, 7.1-51.6 μm) less thinning in natamycin-treated eyes. Conclusions and Relevance Both irregular astigmatism and corneal scar density may be important risk factors for BSCVA in a population with relatively mild, healed fungal corneal ulcers. The thinnest point of the corneal scar may be a cornea-specific outcome that could be used to evaluate treatments for corneal ulcers.
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Affiliation(s)
- Shivali A Menda
- Department of Ophthalmology, University of Washington, Seattle
| | - Manoranjan Das
- Department of Cornea and Refractive Surgery, Aravind Eye Care System, Madurai, India
| | - Arun Panigrahi
- Department of Cornea and Refractive Surgery, Aravind Eye Care System, Madurai, India
| | - N Venkatesh Prajna
- Department of Cornea and Refractive Surgery, Aravind Eye Care System, Madurai, India
| | - Nisha R Acharya
- Department of Ophthalmology, University of California, San Francisco, San Francisco.,Francis I. Proctor Foundation, University of California, San Francisco, San Francisco
| | - Thomas M Lietman
- Department of Ophthalmology, University of California, San Francisco, San Francisco.,Francis I. Proctor Foundation, University of California, San Francisco, San Francisco.,Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco.,Institute for Global Health, University of California, San Francisco, San Francisco
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco, San Francisco.,Francis I. Proctor Foundation, University of California, San Francisco, San Francisco
| | - Jeremy D Keenan
- Department of Ophthalmology, University of California, San Francisco, San Francisco.,Francis I. Proctor Foundation, University of California, San Francisco, San Francisco
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14
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In-vitro assessment of first-line antifungal drugs against Aspergillus spp. caused human keratomycoses. J Infect Public Health 2020; 13:1907-1911. [PMID: 33162353 DOI: 10.1016/j.jiph.2020.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Aspergillus keratitis are in the increasing trend and reported as the second most common cause of mycotic keratitis in developing countries. The present study was designed to isolate, identify Aspergillus spp. from the keratits/corneal ulcer patients attending a tertiary care eye hospital, Coimbatore, South India and to assess the minimum inhibitory concentrations (MICs) against ten clinically used first-line antifungal drugs. METHODS A total of seventy-three Aspergillus strains isolated from corneal scrapings were included and assessed for a period of one year. All isolates were identified up to the species level by morphological observations. Antifungal drug susceptibilities were determined against a standard panel of antifungal agents. CONCLUSIONS Five different species of aspergilli, A. flavus (n=53), A. fumigatus (n=14), A. terreus (n=9), A. tamarii (n=6) and A. niger (n=3) were identified based on morphological features. Minimum inhibitory concentration analyses indicated that, voriconazole, natamycin, itraconazole, clotrimazole, econazole followed by ketoconazole shall be the order of choices for the effective treatment for Aspergillus keratitis.
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15
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Hoffman JJ, Yadav R, Das Sanyam S, Chaudhary P, Roshan A, Singh SK, Arunga S, Matayan E, Macleod D, Weiss HA, Leck A, Hu V, Burton MJ. Topical chlorhexidine 0.2% versus topical natamycin 5% for fungal keratitis in Nepal: rationale and design of a randomised controlled non-inferiority trial. BMJ Open 2020; 10:e038066. [PMID: 32998924 PMCID: PMC7528427 DOI: 10.1136/bmjopen-2020-038066] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Fungal infections of the cornea, fungal keratitis (FK), are challenging to treat. Current topical antifungals are not always effective and are often unavailable, particularly in low-income and middle-income countries where most cases occur. Topical natamycin 5% is usually first-line treatment, however, even when treated intensively, infections may progress to perforation of the eye in around a quarter of cases. Alternative antifungal medications are needed to treat this blinding disease.Chlorhexidine is an antiseptic agent with antibacterial and antifungal properties. Previous pilot studies suggest that topical chlorhexidine 0.2% compares favourably with topical natamycin. Full-scale randomised controlled trials (RCTs) of topical chlorhexidine 0.2% are warranted to answer this question definitively. METHODS AND ANALYSIS We will test the hypothesis that topical chlorhexidine 0.2% is non-inferior to topical natamycin 5% in a two-arm, single-masked RCT. Participants are adults with FK presenting to a tertiary ophthalmic hospital in Nepal. Baseline assessment includes history, examination, photography, in vivo confocal microscopy and cornea scrapes for microbiology. Participants will be randomised to alternative topical antifungal treatments (topical chlorhexidine 0.2% and topical natamycin 5%; 1:1 ratio, 2-6 random block size). Patients are reviewed at day 2, day 7 (with reculture), day 14, day 21, month 2 and month 3. The primary outcome is the best spectacle corrected visual acuity (BSCVA) at 3 months. Primary analysis (intention to treat) will be by linear regression, with treatment arm and baseline BSCVA prespecified covariates. Secondary outcomes include epithelial healing time, scar/infiltrate size, ulcer depth, hypopyon size, perforation and/or therapeutic penetrating keratoplasty (corneal transplant), positive reculture rate (day 7) and quality of life (EuroQol-5 dimensions, WHO/PBD-VF20, WHOQOL-BREF). ETHICS AND DISSEMINATION The Nepal Health Research Council, the Nepal Department of Drug Administration and the London School of Hygiene and Tropical Medicine ethics committee have approved the trial. The results will be presented at local and international meetings and submitted to peer-reviewed journals for publication. TRIAL REGISTRATION NUMBER ISRCTN14332621; pre-results.
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Affiliation(s)
- Jeremy John Hoffman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Cornea Department, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | - Reena Yadav
- Cornea Department, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | | | - Pankaj Chaudhary
- Cornea Department, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | - Abhishek Roshan
- Cornea Department, Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| | | | - Simon Arunga
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Mbarara University of Science and Technology Faculty of Medicine, Mbarara, Uganda
| | - Einoti Matayan
- Department of Ophthalmology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - David Macleod
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen Anne Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Astrid Leck
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Victor Hu
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of External Eye Disease, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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16
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Jiang T, Tang J, Wu Z, Sun Y, Tan J, Yang L. The combined utilization of Chlorhexidine and Voriconazole or Natamycin to combat Fusarium infections. BMC Microbiol 2020; 20:275. [PMID: 32891143 PMCID: PMC7487579 DOI: 10.1186/s12866-020-01960-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/28/2020] [Indexed: 12/14/2022] Open
Abstract
Background Fusarium species are the fungal pathogens most commonly responsible for the mycotic keratitis, which are resistant to the majority of currently available antifungal agents. The present study was designed to assess the efficacy of a combination of low doses chlorhexidine with two other commonly used drugs (voriconazole and natamycin) to treat Fusarium infections. Results We utilized combinations of chlorhexidine and natamycin or voriconazole against 20 clinical Fusarium strains in vitro using a checkerboard-based microdilution strategy. In order to more fully understand the synergistic interactions between voriconazole and chlorhexidine, we utilized a Galleria mellonella model to confirm the combined antifungal efficacy of chlorhexidine and voriconazole in vivo. We found that for voriconazole, natamycin, and chlorhexidine as single agents, the minimum inhibitory concentration (MIC) ranges were 2–8, 4–16, and > 16 μg/ml, respectively. In contrast, the MIC values for voriconazole and chlorhexidine were reduced to 0.25–1 and 1–2 μg/ml, respectively, when these agents were administered in combination, with synergy being observed for 90% of tested Fusarium strains. Combined chlorhexidine and natamycin treatment, in contrast, exhibited synergistic activity for only 10% of tested Fusarium strains. We observed no evidence of antagonism. Our in vivo model results further confirmed the synergistic antifungal activity of chlorhexidine and voriconazole. Conclusions Our results offer novel evidence that voriconazole and chlorhexidine exhibit synergistic activity when used to suppress the growth of Fusarium spp., and these agents may thus offer value as a combination topical antifungal treatment strategy.
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Affiliation(s)
- Tao Jiang
- Department of Clinical Laboratory, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, 434100, China
| | - Jing Tang
- Department of Stomatology, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, 434100, China
| | - Zhiqin Wu
- Department of Ophthalmology, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, 434100, China
| | - Yi Sun
- Department of Dermatology, Jingzhou Central Hospital, The Second Clinical Medical College, Yangtze University, Jingzhou, 434100, China
| | - Jingwen Tan
- Department of Medical Mycology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, 200443, China.
| | - Lianjuan Yang
- Department of Medical Mycology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Shanghai, 200443, China
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17
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Oliveira Dos Santos C, Kolwijck E, van Rooij J, Stoutenbeek R, Visser N, Cheng YY, Santana NTY, Verweij PE, Eggink CA. Epidemiology and Clinical Management of Fusarium keratitis in the Netherlands, 2005-2016. Front Cell Infect Microbiol 2020; 10:133. [PMID: 32318355 PMCID: PMC7146074 DOI: 10.3389/fcimb.2020.00133] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/12/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction: Recognizing fungal keratitis based on the clinical presentation is challenging. Topical therapy may be initiated with antibacterial agents and corticosteroids, thus delaying the fungal diagnosis. As a consequence, the fungal infection may progress ultimately leading to more severe infection and blindness. We noticed an increase of fungal keratitis cases in the Netherlands, especially caused by Fusarium species, which prompted us to conduct a retrospective cohort study, aiming to describe the epidemiology, clinical management, and outcome. Materials and Methods: As fungi are commonly sent to the Dutch mycology reference laboratory for identification and in vitro susceptibility testing, the fungal culture collection was searched for Fusarium isolates from corneal scrapings, corneal swabs, and from contact lens (CL) fluid, between 2005 and 2016. All Fusarium isolates had been identified up to species level through sequencing of the ITS1-5.8S-ITS2 region of the rDNA and TEF1 gene. Antifungal susceptibility testing was performed according to the EUCAST microbroth dilution reference method. Antifungal agents tested included amphotericin B, voriconazole, and natamycin. In addition, susceptibility to the antisepticum chlorhexidine was tested. Ophthalmologists were approached to provide demographic and clinical data of patients identified through a positive culture. Results: Between 2005 and 2016, 89 cases of Fusarium keratitis from 16 different hospitals were identified. The number of cases of Fusarium keratitis showed a significant increase over time (R2 = 0.9199), with one case in the first 5 years (2005–2009) and multiple cases from 2010 and onwards. The male to female ratio was 1:3 (p = 0.014). Voriconazole was the most frequently used antifungal agent, but treatment strategies differed greatly between cases including five patients that were treated with chlorhexidine 0.02% monotherapy. Keratitis management was not successful in 27 (30%) patients, with 20 (22%) patients requiring corneal transplantation and seven (8%) requiring enucleation or evisceration. The mean visual acuity (VA) was moderately impaired with a logMAR of 0.8 (95% CI 0.6–1, Snellen equivalent 0.16) at the time of Fusarium culture. Final average VA was within the range of normal vision [logMAR 0.2 (95% CI 0.1–0.3), Snellen equivalent 0.63]. CL wear was reported in 92.9% of patients with Fusarium keratitis. The time between start of symptoms and diagnosis of fungal keratitis was significantly longer in patients with poor outcome as opposed to those with (partially) restored vision; 22 vs. 15 days, respectively (mean, p = 0.024). Enucleation/evisceration occurred in patients with delayed fungal diagnosis of more than 14 days after initial presentation of symptoms. The most frequently isolated species was F. oxysporum (24.7%) followed by F. solani sensu stricto (18%) and F. petroliphilum (9%). The lowest MICs were obtained with amphotericin B followed by natamycin, voriconazole, and chlorhexidine. Conclusion: Although Fusarium keratitis remains a rare complication of CL wear, we found a significant increase of cases in the Netherlands. The course of infection may be severe and fungal diagnosis was often delayed. Antifungal treatment strategies varied widely and the treatment failure rate was high, requiring transplantation or even enucleation. Our study underscores the need for systematic surveillance of fungal keratitis and a consensus management protocol.
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Affiliation(s)
- Claudy Oliveira Dos Santos
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, Netherlands.,Department of Medical Microbiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Eva Kolwijck
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, Netherlands
| | | | - Remco Stoutenbeek
- Department of Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Nienke Visser
- Maastricht University Medical Center+, University Eye Clinic, Maastricht, Netherlands
| | - Yanny Y Cheng
- Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands
| | - Nathalie T Y Santana
- Department of Ophthalmology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Paul E Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands.,Centre of Expertise in Mycology Radboudumc/CWZ, Nijmegen, Netherlands
| | - Cathrien A Eggink
- Department of Ophthalmology, Radboud University Medical Center, Nijmegen, Netherlands
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18
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Hewitt MG, Morrison PWJ, Boostrom HM, Morgan SR, Fallon M, Lewis PN, Whitaker D, Brancale A, Varricchio C, Quantock AJ, Burton MJ, Heard CM. In Vitro Topical Delivery of Chlorhexidine to the Cornea: Enhancement Using Drug-Loaded Contact Lenses and β-Cyclodextrin Complexation, and the Importance of Simulating Tear Irrigation. Mol Pharm 2020; 17:1428-1441. [PMID: 32125863 DOI: 10.1021/acs.molpharmaceut.0c00140] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Microbial keratitis is a severe, sight-threatening condition caused by various pathogens. Eyedrops are the standard delivery modality for treating these disorders; however, blinking reflex, elevated tear production, and nasolacrimal drainage eliminate much of the instilled dose within a few seconds. Therefore, eyedrops must be applied repeatedly for prolonged periods. The present study aimed to probe more effective ocular delivery of chlorhexidine based upon drug-loaded hydrogel contact lenses and β-cyclodextrin (β-CD), while also determining the effect of constant irrigation with simulated tear fluid (STF) in in vitro experiments. Chlorhexidine digluconate (as 0.2 and 2% solutions, β-CD inclusion complexes, and loaded hydrogel contact lenses) were applied to enucleated porcine eyes as single or multiple 10 μL doses, or as drug-loaded contact lenses, with and without β-CD. The corneas were then excised and drug-extracted quantified by high-performance liquid chromatography (HPLC). The effect of constant irrigation by STF was evaluated to test the effect of increased tear production on corneal delivery. Potential antimicrobial activity of the delivered drug was also assessed. Results showed that drug-loaded contact lenses delivered the greatest amount of chlorhexidine into the cornea over a 24 h period, while the eyedrop solution comparator delivered the least. The β-CD significantly enhanced chlorhexidine delivery to the cornea from eyedrop solution, although contact lenses loaded with chlorhexidine-β-CD failed to enhance delivery. β-CD within the hydrogel matrix impeded drug release. Constant irrigation with STF significantly reduced the amount of drug delivered to the cornea in all cases. Chlorhexidine retained antimicrobial activity in all delivery methods. Hydrogel contact lenses loaded with chlorhexidine delivered significantly higher levels to the cornea compared to eyedrops, either multiple hourly doses or a single dose. They also offer reduced application, in particular, to a nonulcerated corneal infection. Finally, the importance of fully accounting for tear production in in vitro ocular delivery experiments was highlighted.
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Affiliation(s)
- Melissa G Hewitt
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K
| | - Peter W J Morrison
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K.,School of Optometry and Vision Sciences, Cardiff University, Wales, Cardiff CF24 4HQ, U.K
| | - Hannah M Boostrom
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K
| | - Siân R Morgan
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K.,School of Optometry and Vision Sciences, Cardiff University, Wales, Cardiff CF24 4HQ, U.K
| | - Melissa Fallon
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K.,School of Optometry and Vision Sciences, Cardiff University, Wales, Cardiff CF24 4HQ, U.K
| | - Philip N Lewis
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K.,School of Optometry and Vision Sciences, Cardiff University, Wales, Cardiff CF24 4HQ, U.K
| | - David Whitaker
- School of Optometry and Vision Sciences, Cardiff University, Wales, Cardiff CF24 4HQ, U.K.,School of Healthcare Sciences, Cardiff University, Wales, Cardiff CF24 4HQ, U.K
| | - Andrea Brancale
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K
| | - Carmine Varricchio
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K
| | - Andrew J Quantock
- School of Optometry and Vision Sciences, Cardiff University, Wales, Cardiff CF24 4HQ, U.K
| | - Matthew J Burton
- International Centre for Eye Health, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine, London WC1E 7HT, U.K.,Moorfields Eye Hospital NHS Foundation Trust, London EC1V 2PD, U.K
| | - Charles M Heard
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Wales, Cardiff CF10 3NB, U.K
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19
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Svetozarskiy SN, Andreev AN, Shcherbakova SV. [Fungal keratitis after penetrating keratoplasty]. Vestn Oftalmol 2019; 135:98-102. [PMID: 31573563 DOI: 10.17116/oftalma201913504198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article presents a case of fungal keratitis after penetrating keratoplasty (PKP). A 35-years old patient had previously undergone surgical removal of an intraocular foreign body and developed chronic keratouveitis and epithelial-endothelial corneal dystrophy. PKP and early postoperative period were uneventful. The patient was frequently monitored with anterior segment photos. Two weeks later, fungal keratitis occurred on the edge of the donor flap. Direct microscopic evaluation revealed fungus spores and filaments, but growth of fungi in culture was negative. Instillation of steroids and antibiotics was discontinued, specific therapy included fluconazole and amphotericin B. Despite the ongoing treatment, keratitis has repeatedly recurred, and infiltrates were scraped. Topical and systemic voriconazole was administered instead of fluconazole in combination with regular scarification. After 3 weeks of treatment with voriconazole, stable corneal epithelialization was achieved and the cornea has restored its transparency. During 1.5 years of the follow-up, keratitis did not reccur; sutures were removed, corrected visual acuity increased to 1.0. Patients who had undergone PKP are at risk of developing fungal keratitis. Frequent monitoring of such patients contributes to early diagnosis of infectious complications. In the absence of officinal antifungal eye drops, specialist has to supply the patient with ex tempore antimycotic agents and change the treatment according to its effectiveness in each specific case.
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Affiliation(s)
- S N Svetozarskiy
- Volga District Medical Centre, Federal Medical and Biological Agency, 2 Nizhnevolzhskaya embankment, Nizhny Novgorod, Russian Federation, 603001
| | - A N Andreev
- Volga District Medical Centre, Federal Medical and Biological Agency, 2 Nizhnevolzhskaya embankment, Nizhny Novgorod, Russian Federation, 603001
| | - S V Shcherbakova
- Volga District Medical Centre, Federal Medical and Biological Agency, 2 Nizhnevolzhskaya embankment, Nizhny Novgorod, Russian Federation, 603001
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20
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Kunt Z, Yağmur M, Kandemir H, Harbiyeli I, Erdem E, Kalkancı A, De Hoog GS, Ilkit M. In Vitro Efficacy of Chlorhexidine and a riboflavin/UVA Combination on Fungal Agents of Keratitis. Curr Eye Res 2019; 45:7-11. [PMID: 31403321 DOI: 10.1080/02713683.2019.1652916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: Mycotic keratitis is a global ophthalmological problem because it is difficult to diagnose and treat. The aim of the current study was to evaluate the efficiency of using antifungal agents amphotericin B (AMB), voriconazole (VRC), 0.02% chlorhexidine (CHX), and a combination of riboflavin and UVA treatment against two fungal genera (Aspergillus and Fusarium) responsible for keratitis.Methods: We evaluated antifungal efficiencies of riboflavin/UVA and the antifungal drugs VRC, AMB, and CHX (alone and in combination) against fungal inocula at four concentrations. We recorded colony counts of isolates for Aspergillus terreus, A. flavus, A. fumigatus, Fusarium falciforme, F. proliferatum, and F. solani on Mueller-Hinton agar plates.Results: Fungal suspensions exposed to the following treatment combinations did not allow fungal growth: riboflavin/UVA and VRC, riboflavin/UVA and AMB, riboflavin/UVA and CHX, and CHX alone. We observed a statistically significant reduction (P < .05) in the number of colonies on agar plates when fungal suspensions were treated with riboflavin/UVA, VRC, and AMB only.Conclusions: Riboflavin/UVA treatment in combination with AMB, VRC, and CHX are capable of killing keratitis-inducing fungi (P < .05). The antiseptic CHX exerted a considerable antifungal effect on all strains we examined. Therefore, we recommend CHX as additional therapy against mycotic keratitis, particularly when keratitis is caused by multi-resistant members of Fusarium.
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Affiliation(s)
- Zeynep Kunt
- Department of Ophthalmology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Meltem Yağmur
- Department of Ophthalmology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Hazal Kandemir
- Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Inan Harbiyeli
- Department of Ophthalmology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Elif Erdem
- Department of Ophthalmology, Faculty of Medicine, University of Cukurova, Adana, Turkey
| | - Ayşe Kalkancı
- Department of Microbiology, Faculty of Medicine, University of Gazi, Ankara, Turkey
| | - G Sybren De Hoog
- Fungal Biodiversity Centre (CBC), Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands.,Centre of Expertise in Mycology Radboud, University Medical Centre/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Macit Ilkit
- Division of Mycology, Department of Microbiology, Faculty of Medicine, University of Cukurova, Adana, Turkey
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21
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In Vitro Activity of Chlorhexidine Compared with Seven Antifungal Agents against 98 Fusarium Isolates Recovered from Fungal Keratitis Patients. Antimicrob Agents Chemother 2019; 63:AAC.02669-18. [PMID: 31182529 PMCID: PMC6658757 DOI: 10.1128/aac.02669-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/03/2019] [Indexed: 12/17/2022] Open
Abstract
Fungal keratitis is a common but severe eye infection in tropical and subtropical areas of the world. In regions with a temperate climate, the frequency of infection is rising in patients with contact lenses and following trauma. Early and adequate therapy is important to prevent disease progression and loss of vision. The management of Fusarium keratitis is complex, and the optimal treatment is not well defined. We investigated the in vitro activity of chlorhexidine and seven antifungal agents against a well-characterized collection of Fusarium isolates recovered from patients with Fusarium keratitis. The fungus culture collection of the Center of Expertise in Mycology Radboudumc/CWZ was searched for Fusarium isolates that were cultured from cornea scrapings, ocular biopsy specimens, eye swabs, and contact lens fluid containers from patients with suspected keratitis. The Fusarium isolates that were cultured from patients with confirmed keratitis were all identified using conventional and molecular techniques. Antifungal susceptibility testing was performed according to the EUCAST broth microdilution reference method. The antifungal agents tested included amphotericin B, voriconazole, posaconazole, miconazole, natamycin, 5-fluorocytosine, and caspofungin. In addition, the activity of chlorhexidine was determined. The fungal culture collection contained 98 Fusarium isolates of confirmed fungal keratitis cases from 83 Dutch patients and 15 Tanzanian patients. The isolates were collected between 2007 and 2017. Fusarium oxysporum (n = 24, 24.5%) was the most frequently isolated species followed by Fusarium solani sensu stricto (n = 18, 18.4%) and Fusarium petroliphilum (n = 11, 11.2%). Amphotericin B showed the most favorable in vitro inhibition of Fusarium species followed by natamycin, voriconazole, and chlorhexidine, while 5-fluorocytosine, posaconazole, miconazole, and caspofungin showed no relevant inhibiting effect. However, chlorhexidine showed fungicidal activity against 90% of F. oxysporum strains and 100% of the F. solani strains. Our study supports the clinical efficacy of chlorhexidine and therefore warrants its further clinical evaluation for primary therapy of fungal keratitis, particularly in low and middle income countries where fungal keratitis is much more frequent and, currently, antifungal eye drops are often unavailable.
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22
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Wei A, Wang K, Wang Y, Gong L, Xu J, Shao T. Evaluation of corneal cross-linking as adjuvant therapy for the management of fungal keratitis. Graefes Arch Clin Exp Ophthalmol 2019; 257:1443-1452. [PMID: 31041523 DOI: 10.1007/s00417-019-04314-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/27/2019] [Accepted: 04/01/2019] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate the efficacy of corneal cross-linking (CXL) as adjuvant therapy for the treatment of fungal ulcerative keratitis. METHODS Forty-one patients with fungal ulcerative keratitis were recruited and assigned into two randomized controlled groups. These groups were treated with CXL combined with antifungal medications (CXL-M) or antifungal medications alone (M). The ulcers were assessed by slit-lamp biomicroscopy, slit-lamp images, in vivo confocal microscopy (IVCM), and anterior segment optical coherence tomography (AS-OCT). The patients were followed up before surgery/first visit (FV), 1 day after surgery, 1 and 2 weeks, and 1, 2, 3, 4, 5, and 6 months after surgery/FV. RESULTS In the cured patients, the area of corneal ulcers, the duration of ulcer healing, the time to non-observed fungal hyphae by IVCM, the number of antifungal medications, the frequency of administered medications, and the maximum ulcer depth decreased significantly after CXL (all P < 0.05) compared with the M group. There were no significant differences in either corneal thickness or epithelial thickness of ulcers after healing between 5 and 6 months after surgery in the CXL-M group, while these were increased significantly at 6 months compared with 5 months after FV in the M group (both P < 0.05). CONCLUSIONS In our study, CXL accelerated healing of the fungal ulcers, shortened the treatment duration, and minimized the need for medications and surgery. It appears that CXL is an effective procedure and adjuvant therapy for managing fungal keratitis.
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Affiliation(s)
- Anji Wei
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital, School of Shanghai Medicine, Fudan University, 83 Fenyang Road, Shanghai, 20003, China
| | - Kaidi Wang
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital, School of Shanghai Medicine, Fudan University, 83 Fenyang Road, Shanghai, 20003, China
| | - Yan Wang
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital, School of Shanghai Medicine, Fudan University, 83 Fenyang Road, Shanghai, 20003, China
| | - Lan Gong
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital, School of Shanghai Medicine, Fudan University, 83 Fenyang Road, Shanghai, 20003, China
| | - Jianjiang Xu
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital, School of Shanghai Medicine, Fudan University, 83 Fenyang Road, Shanghai, 20003, China
| | - Tingting Shao
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital, School of Shanghai Medicine, Fudan University, 83 Fenyang Road, Shanghai, 20003, China.
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23
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Das M, Menda SA, Panigrahi AK, Venkatesh Prajna N, Yen M, Tsang B, Kumar A, Rose-Nussbaumer J, Acharya NR, McCulloch CE, Lietman TM, McLeod SD, Keenan JD. Repeatability and Reproducibility of Slit Lamp, Optical Coherence Tomography, and Scheimpflug Measurements of Corneal Scars. Ophthalmic Epidemiol 2019; 26:251-256. [PMID: 31018742 DOI: 10.1080/09286586.2019.1600199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To determine the repeatability and reproducibility of anterior segment optical coherence tomography (AS-OCT) and Scheimpflug photography for several measurements of corneal scars, including scar size, scar depth, and corneal thickness. Methods: A series of patients treated for fungal keratitis at a tertiary eye care center in South India were recalled two years after successful treatment. Eyes with corneal scars had a slit lamp examination performed by two ophthalmologists masked to the other's examination. For AS-OCT and Scheimpflug photography, each eye had two scans taken by one technician and a third scan taken by a separate technician. Scar measurements were subsequently assessed from AS-OCT images by three graders masked to each other's results. Repeatability and reproducibility were assessed by calculating the intra-class correlation coefficient (ICC) from mixed effects linear regression models. Results: Fifty eyes had all measurements taken. The corneal scar size, measured as the geometric mean of the two longest perpendicular meridians, ranged from 0.8 to 5.4 (mean 2.8 mm, 95%CI 2.6 to 3.1). Scar size measurements taken by two separate individuals were most reproducible when the border of the scar was traced from the OCT (ICC 0.90, 95%CI 0.86 to 0.94), and least repeatable when assessed from slit lamp examination (ICC 0.80, 95%CI 0.70 to 0.90). Conclusions: AS-OCT and Scheimpflug imaging of corneal scars produced measurements with acceptable reproducibility that could be useful as cornea-specific outcomes for clinical trials.
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Affiliation(s)
- Manoranjan Das
- a Department of Cornea and External Disease , Aravind Eye Care System , Madurai , India
| | - Shivali A Menda
- b Department of Ophthalmology , University of California , San Francisco , USA
| | - Arun K Panigrahi
- a Department of Cornea and External Disease , Aravind Eye Care System , Madurai , India
| | - N Venkatesh Prajna
- a Department of Cornea and External Disease , Aravind Eye Care System , Madurai , India
| | - Michael Yen
- c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Betty Tsang
- c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Alisha Kumar
- c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Jennifer Rose-Nussbaumer
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Nisha R Acharya
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Charles E McCulloch
- d Department of Epidemiology & Biostatistics, University of California , San Francisco , USA
| | - Thomas M Lietman
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA.,d Department of Epidemiology & Biostatistics, University of California , San Francisco , USA.,e Institute for Global Health , University of California , San Francisco , USA
| | - Stephen D McLeod
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA
| | - Jeremy D Keenan
- b Department of Ophthalmology , University of California , San Francisco , USA.,c Francis I. Proctor Foundation, University of California , San Francisco , USA
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24
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Abstract
BACKGROUND Fungal keratitis is much less common in Europe than in Asia. Antifungal therapy can be applied topically as well as systemically and in advanced situations surgical intervention can become necessary. CASE REPORT We present the case of a 60-year-old woman who suffered from Fusarium keratitis that showed progression to endophthalmitis following contact lens wearing. Due to numerous resistances against antimycotic drugs the eye had to be enucleated to prevent the pathogens from spreading. Histologically, major inflammatory activity could be detected but no causative organism could be found. The failure to detect a pathogen was in clear contrast to the clinical findings and was interpreted as being an overreaction of the immune response even after the Fusarium had been destroyed. CONCLUSION If a fungal infection of the cornea is suspected, antimycotic therapy should be initiated as early as possible. In cases involving highly resistant pathogens the eye cannot always be saved.
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25
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Carnt N, Samarawickrama C, White A, Stapleton F. The diagnosis and management of contact lens-related microbial keratitis. Clin Exp Optom 2017; 100:482-493. [PMID: 28815736 DOI: 10.1111/cxo.12581] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 05/22/2017] [Accepted: 05/27/2017] [Indexed: 01/10/2023] Open
Abstract
Contact lens-associated microbial keratitis poses a diagnostic dilemma for optometrists on two fronts. The distinction between sterile inflammation and microbial infection is often blurred. In addition, there is a requirement with nearly 50 per cent of the Australian and New Zealand optometric profession being therapeutically endorsed, to distinguish between cases of infection that can be managed in the community verses those that require escalation to public hospitals that have access to laboratory diagnostic tools and advanced imaging techniques, such as in vivo confocal microscopy. Pattern recognition and incorporation of knowledge of aetiology and risk factors assists optometrists to decide on optimal management strategies. Skilled optometrists will utilise emerging diagnostic and therapeutic technologies to ensure safe management strategies and better outcomes for these cases.
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Affiliation(s)
- Nicole Carnt
- School of Optometry and Vision Science, The University of New South Wales, Sydney, New South Wales, Australia.,The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Chameen Samarawickrama
- The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew White
- The Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Fiona Stapleton
- School of Optometry and Vision Science, The University of New South Wales, Sydney, New South Wales, Australia
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26
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Ray KJ, Lalitha P, Prajna NV, Rajaraman R, Krishnan T, Srinivasan M, Ryg P, McLeod S, Acharya NR, Lietman TM, Rose-Nussbaumer J. The Utility of Repeat Culture in Fungal Corneal Ulcer Management: A Secondary Analysis of the MUTT-I Randomized Clinical Trial. Am J Ophthalmol 2017; 178:157-162. [PMID: 28385473 DOI: 10.1016/j.ajo.2017.03.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 03/24/2017] [Accepted: 03/27/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine whether patients who had a positive repeated culture was predictive of worse clinical outcome than those who achieved microbiological cure at 6 days in the Mycotic Ulcer Treatment Trial I (MUTT-I). DESIGN Secondary analysis from a multicenter, double-masked, randomized clinical trial. METHODS setting: Multiple hospital sites of the Aravind Eye Care System, India. STUDY POPULATION Patients with culture-positive filamentous fungal ulcers and visual acuity of 20/40 to 20/400 reexamined 6 days after initiation of treatment. INTERVENTION Corneal scraping and cultures were obtained from study participants at day 6 after enrollment. MAIN OUTCOME MEASURES We assessed 3-month best spectacle-corrected visual acuity (BSCVA), 3-month infiltrate/scar size, corneal perforation, and re-epithelialization rates stratified by culture positivity at day 6. RESULTS Of the 323 patients with smear-positive ulcers enrolled in MUTT-I, 299 (92.6%) were scraped and cultured 6 days after enrollment. Repeat culture positivity was 31% (92/299). Among patients who tested positive at enrollment, those with positive 6-day cultures had significantly worse 3-month BSCVA (0.39 logMAR; 95% confidence interval [CI]: 0.24-0.44; P < .001), had larger 3-month scar size (0.39 mm; 95% CI: 0.06-0.73; P = .02), were more likely to perforate or require therapeutic penetrating keratoplasty (odds ratio: 6.27; 95% CI: 2.73-14.40; P < .001), and were slower to re-epithelialize (hazard ratio: 0.33; 95% CI: 0.21-0.50; P < .001) than those with a negative 6-day culture result. CONCLUSIONS Early microbiological cure on culture is a predictor of clinical response to treatment.
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Affiliation(s)
- Kathryn J Ray
- Francis I. Proctor Foundation, San Francisco, California
| | - Prajna Lalitha
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | | | - Peter Ryg
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Stephen McLeod
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Nisha R Acharya
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, San Francisco, California; Department of Ophthalmology, University of California San Francisco, San Francisco, California.
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27
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Fungal Keratitis Associated With Airborne Organic Debris and Soft Contacts Lenses: Case Reports and Review of the Literature. Eye Contact Lens 2017; 44 Suppl 1:S16-S21. [PMID: 28520596 DOI: 10.1097/icl.0000000000000395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To report two cases of fungal keratitis in soft contact lens wearers who were exposed to environmental mold. METHODS Case reports, with review of the relevant literature. RESULTS Two otherwise healthy middle-aged women who were soft contact lens wearers developed fungal keratitis about 1 week after heavy exposure to environmental mold. Culture results showed Aspergillus from one patient and the unusual combination of Trichoderma and Penicillium from the other. Both were treated with topical natamycin, topical fluoroquinolone antibiotic prophylaxis, and periodic ulcer debridement. After many weeks of treatment, both ulcers healed with subsequent scarring. Because the ulcers were located in the peripheral cornea in both cases, excellent final visual acuities were achieved. Fungal keratitis cases like these are rarely seen at our referral clinic, which is located in the temperate climate of northeastern Indiana. CONCLUSIONS In addition to the usual recommended contact lens care guidelines, it may be prudent for eye care providers to warn patients against wearing their contact lenses in situations likely to result in heavy exposure to organic matter or, at the very least, to wear tight-fitting goggles for eye protection.
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28
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Burden of serious fungal infections in Bangladesh. Eur J Clin Microbiol Infect Dis 2017; 36:993-997. [PMID: 28161744 DOI: 10.1007/s10096-017-2921-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 12/29/2022]
Abstract
In Bangladesh there are several published papers on superficial mycoses. Deep mycoses are also recognized as an important emerging problem. Here, we estimate the annual incidence and prevalence of serious fungal infections in Bangladesh. Demographic data were obtained from world population reports and the data on TB and HIV extracted from the online publications on tuberculosis in Bangladesh and Asia Pacific research statistical data information resources AIDS Data HUB. All the published papers on fungal infections in Bangladesh were identified through extensive search of literature. We estimated the number of affected people from populations at risk and local epidemiological data. Bangladesh has a population of ∼162.6 million, 31% children and only 6% over the age of 60 years. The pulmonary TB caseload reported in 2014 was 119,520, and we estimate a prevalence of 30,178 people with chronic pulmonary aspergillosis, 80% attributable to TB. An anticipated 90,262 and 119,146 patients have allergic bronchopulmonary aspergillosis or severe asthma with fungal sensitization. Only 8,000 people are estimated to be HIV-infected, of whom 2900 are not on ART with a CD4 count <350 μL, Pneumocystis pneumonia and cryptococcal meningitis being rare. Superficial mycoses are very common with Trichophyton rubrum as the predominant etiological agent (80.6%). Numerous cases of mycotic keratitis have been reported from several parts of Bangladesh. Candida bloodstream infection was estimated based on a 5 per 100,000 rate (8100 cases) and invasive aspergillosis based primarily on leukemia and COPD rates, at 5166 cases. Histoplasmosis was documented in 16 cases mostly with disseminated disease and presumed in 21 with HIV infection. This study constitutes the first attempt to estimate the burden of several types of serious fungal infections in Bangladesh.
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29
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Conjunctivitis, Keratitis and Infections of Periorbital Structures. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00016-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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30
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Ong HS, Fung SSM, Macleod D, Dart JKG, Tuft SJ, Burton MJ. Altered Patterns of Fungal Keratitis at a London Ophthalmic Referral Hospital: An Eight-Year Retrospective Observational Study. Am J Ophthalmol 2016; 168:227-236. [PMID: 27287820 DOI: 10.1016/j.ajo.2016.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/16/2016] [Accepted: 05/31/2016] [Indexed: 05/28/2023]
Abstract
PURPOSE In previous studies of fungal keratitis (FK) from temperate countries, yeasts were the predominant isolates, with ocular surface disease (OSD) being the leading risk factor. Since the 2005-2006 outbreak of contact lens (CL)-associated Fusarium keratitis, there may have been a rise in CL-associated filamentary FK in the United Kingdom. This retrospective case series investigated the patterns of FK from 2007 to 2014. We compared these to 1994-2006 data from the same hospital. DESIGN Retrospective observational study. METHODS All cases of FK presenting to Moorfields Eye Hospital between 2007 and 2014 were identified. The definition of FK was either a fungal organism isolated by culture or fungal structures identified by light microscopy (LM) of scrape material, histopathology, or in vivo corneal confocal microscopy (IVCM). Main outcome measure was cases of FK per year. RESULTS A total of 112 patients had confirmed FK. Median age was 47.2 years. Between 2007 and 2014, there was an increase in annual numbers of FK (Poisson regression, P = .0001). FK was confirmed using various modalities: 79 (70.5%) by positive culture, 16 (14.3%) by LM, and 61 (54.5%) by IVCM. Seventy-eight patients (69.6%) were diagnosed with filamentary fungus alone, 28 (25%) with yeast alone, and 6 (5.4%) with mixed filamentary and yeast infections. This represents an increase in the proportion of filamentary fungal infections from the pre-2007 data. Filamentary fungal and yeast infections were associated with CL use and OSD, respectively. CONCLUSIONS The number of FK cases has increased. This increase is due to CL-associated filamentary FK. Clinicians should be aware of these changes, which warrant epidemiologic investigations to identify modifiable risk factors.
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Affiliation(s)
- Hon Shing Ong
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom.
| | - Simon S M Fung
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John K G Dart
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom
| | - Stephen J Tuft
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom
| | - Matthew J Burton
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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31
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Ong HS, Fung SSM, Macleod D, Dart JKG, Tuft SJ, Burton MJ. Altered Patterns of Fungal Keratitis at a London Ophthalmic Referral Hospital: An Eight-Year Retrospective Observational Study. Am J Ophthalmol 2016; 168:227-236. [PMID: 27287820 PMCID: PMC4977014 DOI: 10.1016/j.ajo.2016.05.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 05/16/2016] [Accepted: 05/31/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE In previous studies of fungal keratitis (FK) from temperate countries, yeasts were the predominant isolates, with ocular surface disease (OSD) being the leading risk factor. Since the 2005-2006 outbreak of contact lens (CL)-associated Fusarium keratitis, there may have been a rise in CL-associated filamentary FK in the United Kingdom. This retrospective case series investigated the patterns of FK from 2007 to 2014. We compared these to 1994-2006 data from the same hospital. DESIGN Retrospective observational study. METHODS All cases of FK presenting to Moorfields Eye Hospital between 2007 and 2014 were identified. The definition of FK was either a fungal organism isolated by culture or fungal structures identified by light microscopy (LM) of scrape material, histopathology, or in vivo corneal confocal microscopy (IVCM). Main outcome measure was cases of FK per year. RESULTS A total of 112 patients had confirmed FK. Median age was 47.2 years. Between 2007 and 2014, there was an increase in annual numbers of FK (Poisson regression, P = .0001). FK was confirmed using various modalities: 79 (70.5%) by positive culture, 16 (14.3%) by LM, and 61 (54.5%) by IVCM. Seventy-eight patients (69.6%) were diagnosed with filamentary fungus alone, 28 (25%) with yeast alone, and 6 (5.4%) with mixed filamentary and yeast infections. This represents an increase in the proportion of filamentary fungal infections from the pre-2007 data. Filamentary fungal and yeast infections were associated with CL use and OSD, respectively. CONCLUSIONS The number of FK cases has increased. This increase is due to CL-associated filamentary FK. Clinicians should be aware of these changes, which warrant epidemiologic investigations to identify modifiable risk factors.
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Affiliation(s)
- Hon Shing Ong
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom.
| | - Simon S M Fung
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John K G Dart
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom
| | - Stephen J Tuft
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and the UCL Institute of Ophthalmology, London, United Kingdom
| | - Matthew J Burton
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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32
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Fungal Keratitis Due to Beauveria bassiana in a Contact Lenses Wearer and Review of Published Reports. Mycopathologia 2016; 181:745-52. [DOI: 10.1007/s11046-016-0027-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/02/2016] [Indexed: 10/21/2022]
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33
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Heredero-Bermejo I, Sánchez-Nieves J, Soliveri J, Gómez R, de la Mata FJ, Copa-Patiño JL, Pérez-Serrano J. In vitro anti-Acanthamoeba synergistic effect of chlorhexidine and cationic carbosilane dendrimers against both trophozoite and cyst forms. Int J Pharm 2016; 509:1-7. [PMID: 27173821 DOI: 10.1016/j.ijpharm.2016.04.075] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/28/2022]
Abstract
Acanthamoeba sp. are the causative agents of severe illnesses in humans such as Acanthamoeba keratitis (AK) and granulomatous amoebic encephalitis (GAE). Medical therapy is not yet well established. Treatments of AK last for several months and generate toxicity, resistances appear due to the cysts stage and recurrences can occur. In this study has been demonstrated that the combination of chlorhexidine digluconate (CLX) and carbosilane dendrimers containing ammonium or guanidine moieties has in vitro synergistic effect against Acanthamoeba polyphaga. This synergy provokes an important reduction in the minimal trophozoite amoebicidal concentration (MTAC) of CLX, which means a reduction of their toxic effects on human cells. Moreover, some CLX/dendrimer combinations show important activity against the cyst resistance stage.
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Affiliation(s)
- I Heredero-Bermejo
- Departamento de Biomedicina y Biotecnología, Facultad de Farmacia, Universidad de Alcalá, 28871 Alcalá de Henares, Madrid, Spain.
| | - J Sánchez-Nieves
- Departamento de Química Orgánica y Química Inorgánica, Facultad de Farmacia, Universidad de Alcalá, 28871 Alcalá de Henares, Madrid, Spain; Networking Research Center for Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - J Soliveri
- Departamento de Biomedicina y Biotecnología, Facultad de Farmacia, Universidad de Alcalá, 28871 Alcalá de Henares, Madrid, Spain
| | - R Gómez
- Departamento de Química Orgánica y Química Inorgánica, Facultad de Farmacia, Universidad de Alcalá, 28871 Alcalá de Henares, Madrid, Spain; Networking Research Center for Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - F J de la Mata
- Departamento de Química Orgánica y Química Inorgánica, Facultad de Farmacia, Universidad de Alcalá, 28871 Alcalá de Henares, Madrid, Spain; Networking Research Center for Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Madrid, Spain
| | - J L Copa-Patiño
- Departamento de Biomedicina y Biotecnología, Facultad de Farmacia, Universidad de Alcalá, 28871 Alcalá de Henares, Madrid, Spain
| | - J Pérez-Serrano
- Departamento de Biomedicina y Biotecnología, Facultad de Farmacia, Universidad de Alcalá, 28871 Alcalá de Henares, Madrid, Spain
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Paradiso P, Serro AP, Saramago B, Colaço R, Chauhan A. Controlled Release of Antibiotics From Vitamin E–Loaded Silicone-Hydrogel Contact Lenses. J Pharm Sci 2016; 105:1164-72. [DOI: 10.1016/s0022-3549(15)00193-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 11/12/2015] [Accepted: 11/20/2015] [Indexed: 11/24/2022]
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Ong HS, Corbett MC. Corneal infections in the 21st century. Postgrad Med J 2015; 91:565-71. [PMID: 26354125 DOI: 10.1136/postgradmedj-2015-133323] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 08/14/2015] [Indexed: 11/04/2022]
Abstract
Ninety years ago, the first issue of the Postgraduate Medical Journal published a review of an article written by Mr Robert Lindsay-Rea, a consultant ophthalmic surgeon in the Western Ophthalmic Hospital and an oculist in the West End Hospital for Nervous Diseases, entitled "A preliminary report on the treatment of keratitis". Today, microbial keratitis remains an important cause of avoidable visual impairment in the world. The aetiology of microbial keratitis has changed greatly over the past century due to the discovery of antibiotics, improvement in sanitation and education, the rising trend of contact lens wear and increased air travel. Significant advances have also been made in our understanding and management of this important disorder. This article highlights some of these changes and discusses the current management and research.
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Affiliation(s)
- Hon Shing Ong
- Department of Corneal and Ocular Surface Disease, The Western Eye Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Melanie C Corbett
- Department of Corneal and Ocular Surface Disease, The Western Eye Hospital, Imperial College Healthcare NHS Trust, London, UK
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Qiu S, Zhao GQ, Lin J, Wang X, Hu LT, Du ZD, Wang Q, Zhu CC. Natamycin in the treatment of fungal keratitis: a systematic review and Meta-analysis. Int J Ophthalmol 2015; 8:597-602. [PMID: 26086015 DOI: 10.3980/j.issn.2222-3959.2015.03.29] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/09/2015] [Indexed: 11/02/2022] Open
Abstract
AIM To review published clinical studies examining the effect of natamycin in the treatment of fungal keratitis. METHODS We selected the publications in CENTRAL, MEDLINE, EMBASE, CNKI, and CBM. This study systematically reviewed published randomized controlled trials (RCTs) that compared natamycin to other antifungal agents, and conducted feasible Meta-analysis of efficacy results using Revman 5.2 software. RESULTS We included seven trials which were mainly carried out in developing countries of Asia, with five trials conducted in India, one each in China and Bangladesh. A total of 804 participants were randomized to following comparisons: 2% econazole versus 5% natamycin showed little difference in the effects of treatment of fungal keratitis [RR=0.99, 95% confidence interval (CI), 0.8 to 1.21]; chlorhexidine gluconate versus 5% natamycin indicated that the results on healing of the ulcer at 21d was less conclusive (RR=0.77, 95% CI, 0.55 to 1.08; I (2)=0%); 1% voriconazole versus 5% natamycin suggested that natamycin treatment appeared to be significantly better outcomes than voriconazole (regression coefficient =-0.18 logMAR; 95% CI, -0.30 to -0.05; P=0.006), especially in Fusarium cases (regression coefficient=-0.41 logMAR; 95% CI, -0.61 to -0.20; P<0.001); natamycin versus fluconazole showed a significant difference in cure rate (χ(2)=5.048, P<0.05) and natamycin group was more effective than fluconazole in average period of therapy (t=7.94, P<0.01). CONCLUSION Natamycin was a preferable choice in the treatment of fungal keratitis, especially in the early period of Fusarium cases.
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Affiliation(s)
- Sheng Qiu
- Department of Ophthalmology, Medical College, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Gui-Qiu Zhao
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Jing Lin
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Xue Wang
- Department of Ophthalmology, Medical College, Qingdao University, Qingdao 266071, Shandong Province, China
| | - Li-Ting Hu
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Zhao-Dong Du
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Qian Wang
- Department of Ophthalmology, the Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Cheng-Cheng Zhu
- Department of Ophthalmology, Medical College, Qingdao University, Qingdao 266071, Shandong Province, China
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Rajaraman R, Bhat P, Vaidee V, Maskibail S, Raghavan A, Sivasubramaniam S, Namperumalsamy VP. Topical 5% Natamycin With Oral Ketoconazole in Filamentous Fungal Keratitis: A Randomized Controlled Trial. Asia Pac J Ophthalmol (Phila) 2015; 4:146-50. [PMID: 26065500 DOI: 10.1097/apo.0000000000000035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To assess the role of additive oral antifungal therapy in deep keratitis caused by filamentous fungi. DESIGN A randomized, masked, double-blind clinical trial. METHODS All patients presenting with culture-positive fungal keratitis with a size measuring 2 to 60 mm2 and involving more than 50% of stromal depth were enrolled in 1 of the 2 treatment arms. Group A received 5% natamycin, whereas Group B was given 200mg of oral ketoconazole twice a day in addition to 5% natamycin. Patients were followed up for 4 weeks. Liver function was assessed at baseline and at exit. Tests for significance included t test to compare the means of continuous variables, chi-square and Fisher's exact tests for comparing categorical variables and Kaplan-Meier procedure to estimate the survival rate. RESULTS Of the 115 patients enrolled, 108 completed the study. Fifty-eight patients were in group A and 57 in group B. There was no significant difference in baseline characteristics or in ulcer characteristics between the 2 groups. In group A, 68.5% of the patients responded favorably to medical therapy, whereas in group B, 72.2% responded favorably. There was no statistically significant difference in healing between the 2 groups (P = -0.618). All patients had normal liver functions during the study. CONCLUSIONS Although safe, oral ketoconazole did not add significant benefit to topical natamycin therapy in treating deep fungal keratitis. The efficacy of newer antifungal agents and drug delivery routes needs to be explored.
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Affiliation(s)
- Revathi Rajaraman
- From the *Department of Cornea and Refractive Services, Aravind Eye Hospital, Coimbatore; and †Department of Cornea and Refractive Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
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Abstract
BACKGROUND Fungal keratitis is a fungal infection of the cornea. It is common in lower income countries, particularly in agricultural areas but relatively uncommon in higher income countries. Although there are medications available, their effectiveness is unclear. OBJECTIVES To assess the effects of different antifungal drugs in the management of fungal keratitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 2), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to March 2015), EMBASE (January 1980 to March 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to March 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 16 March 2015. SELECTION CRITERIA We included randomised controlled trials of medical therapy for fungal keratitis. DATA COLLECTION AND ANALYSIS Two review authors selected studies for inclusion in the review, assessed trials for risk of bias and extracted data. The primary outcome was clinical cure at two to three months. Secondary outcomes included best-corrected visual acuity, time to clinical cure, compliance with treatment, adverse outcomes and quality of life. MAIN RESULTS We included 12 trials in this review; 10 trials were conducted in India, one in Bangladesh and one in Egypt. Seven of these trials were at high risk of bias in one or more domains, two of these studies were at low risk of bias in all domains. Participants were randomised to the following comparisons: topical 5% natamycin compared to topical 1% voriconazole; topical 5% natamycin compared to topical 2% econazole; topical 5% natamycin compared to topical chlorhexidine gluconate (0.05%, 0.1% and 0.2%); topical 1% voriconazole compared to intrastromal voriconazole 50 g/0.1 mL (both treatments combined with topical 5% natamycin); topical 1% voriconazole combined with oral voriconazole compared to both oral voriconazole and oral itraconazole (both combined with topical 5% natamycin); topical 1% itraconazole compared to topical 1% itraconazole combined with oral itraconazole; topical amphotericin B compared to topical amphotericin B combined with subconjunctival injection of fluconazole; intracameral injection of amphotericin B with conventional treatment compared to conventional treatment alone (severe fungal ulcers); topical 0.5% and 1% silver sulphadiazine compared to topical 1% miconazole. Overall the results were inconclusive because for most comparisons only one small trial was available. The exception was the comparison of topical natamycin and topical voriconazole for which three trials were available. In one of these trials clinical cure (healed ulcer) was reported in all 15 people allocated to natamycin and in 14/15 people allocated to voriconazole (risk ratio (RR) 1.07; 95% confidence interval (CI) 0.89 to 1.28, low quality evidence). In one trial people randomised to natamycin were more likely to have a microbiological cure at six days (RR 1.64; 95% CI 1.38 to 1.94, 299 participants). On average, people randomised to natamycin had better spectacle-corrected visual acuity at two to three months compared to people randomised to voriconazole but the estimate was uncertain and the 95% confidence intervals included 0 (no difference) (mean difference -0.12 logMAR, 95% CI -0.31 to 0.06, 434 participants; 3 studies, low quality evidence) and a decreased risk of corneal perforation or therapeutic penetrating keratoplasty, or both (RR 0.61; 95% CI 0.40 to 0.94, 434 participants, high quality evidence). There was inconclusive evidence on time to clinical cure. Compliance with treatment and quality of life were not reported. One trial comparing natamycin and voriconazole found the effect of treatment greater in Fusarium species, but this subgroup analysis was not prespecified by this review. AUTHORS' CONCLUSIONS The trials included in this review were of variable quality and were generally underpowered. There is evidence that natamycin is more effective than voriconazole in the treatment of fungal ulcers. Future research should evaluate treatment effects according to fungus species.
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Affiliation(s)
- Nilo Vincent FlorCruz
- University of the Phillipines‐Philippine General HospitalDepartment of Ophthalmology and Visual SciencesTaft AvenueManilaPhilippines1000
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision Group, ICEHKeppel StreetLondonUKWC1E 7HT
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Kredics L, Narendran V, Shobana CS, Vágvölgyi C, Manikandan P. Filamentous fungal infections of the cornea: a global overview of epidemiology and drug sensitivity. Mycoses 2015; 58:243-60. [PMID: 25728367 DOI: 10.1111/myc.12306] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 01/27/2015] [Accepted: 02/13/2015] [Indexed: 11/30/2022]
Abstract
Fungal keratitis is a serious suppurative, usually ulcerative corneal infection which may result in blindness or reduced vision. Epidemiological studies indicate that the occurrence of fungal keratitis is higher in warm, humid regions with agricultural economy. The most frequent filamentous fungal genera among the causal agents are Fusarium, Aspergillus and Curvularia. A more successful therapy of fungal keratitis relies on precise identification of the pathogen to the species level using molecular tools. As the sequence analysis of the internal transcribed spacer (ITS) region of the ribosomal RNA gene cluster (rDNA) is not discriminative enough to reveal a species-level diagnosis for several filamentous fungal species highly relevant in keratitis infections, analysis of other loci is also required for an exact diagnosis. Molecular identifications may also reveal the involvement of fungal species which were not previously reported from corneal infections. The routinely applied chemotherapy of fungal keratitis is based on the topical and systemic administration of polyenes and azole compounds. Antifungal susceptibility testing of the causal agents is of special importance due to the emergence and spread of resistance. Testing the applicability of further available antifungals and screening for new, potential compounds for the therapy of fungal keratitis are of highlighted interest.
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Affiliation(s)
- László Kredics
- Department of Microbiology, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
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Abstract
This is a detailed review of purulent corneal ulcer signs and symptoms, problems in diagnosis, and conservative treatment options.
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Affiliation(s)
- Evg A Kasparova
- Research Institute of Eye Diseases, 11 A, B, Rossolimo St., Moscow, Russian Federation, 119021
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Lalitha P, Sun CQ, Prajna NV, Karpagam R, Geetha M, O'Brien KS, Cevallos V, McLeod SD, Acharya NR, Lietman TM. In vitro susceptibility of filamentous fungal isolates from a corneal ulcer clinical trial. Am J Ophthalmol 2014; 157:318-26. [PMID: 24439440 DOI: 10.1016/j.ajo.2013.10.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To describe the minimum inhibitory concentration (MIC) of fungal isolates to natamycin and voriconazole, and to compare these MICs to previous ocular susceptibility studies. DESIGN Experimental laboratory study using isolates from a randomized clinical trial. METHODS The Mycotic Ulcer Treatment Trial I was a randomized, double-masked, multicenter trial comparing topical natamycin and voriconazole for fungal keratitis treatment. Susceptibility testing to natamycin and voriconazole were performed according to Clinical and Laboratory Standards Institute methods. The relationship between organism and MIC was assessed. A literature review was performed to compare results to previous ocular susceptibility studies. RESULTS Of the 323 patients enrolled in the trial, MICs were available for 221 (68%). Fusarium (n = 126) and Aspergillus species (n = 52) were the most commonly isolated organisms. MICs to natamycin and voriconazole were significantly different across all genera (P < .001). The MIC median (MIC50) and 90th percentile (MIC90) for natamycin were equal to or higher than voriconazole for all organisms except Curvularia species. Compared to other organisms, Fusarium species isolates had the highest MICs to voriconazole and Aspergillus flavus isolates had the highest MICs to natamycin. Our results were similar to previous reports except that the voriconazole MIC90 against Aspergillus species was 2-fold higher and the natamycin MIC90 against Aspergillus fumigatus was 4-fold higher in our study. CONCLUSION In this large susceptibility study, Fusarium isolates were least susceptible to voriconazole and A flavus isolates were least susceptible to natamycin when compared to other filamentous fungi. In the future, susceptibility testing may help guide therapy if performed in a timely manner.
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Pouyeh B, Galor A, Miller D, Alfonso EC. New horizons in one of ophthalmology’s challenges: fungal keratitis. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.11.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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McDonald EM, Ram FSF, Patel DV, McGhee CNJ. Effectiveness of Topical Antifungal Drugs in the Management of Fungal Keratitis: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Asia Pac J Ophthalmol (Phila) 2014; 3:41-7. [PMID: 26107307 DOI: 10.1097/apo.0b013e3182a618dd] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Fungal keratitis (FK) typically requires intensive therapy with topical antifungal agents. To date, evidence from clinical trials has been conflicting with respect to the most effective topical antifungal drug in the treatment of FK. Therefore, a systematic review and meta-analysis of randomized controlled trials (RCTS) using the Cochrane methodology was undertaken to evaluate the effectiveness of topical antifungals in management of FK. Outcomes included time to cure, treatment failure, complications of infection, visual acuity and adverse effects. A comprehensive search for studies was undertaken resulting in inclusion of 8 RCTs, predominantly from India, involving a total of 793 participants, the majority of whom were infected with filamentous fungi. Topical voriconazole was more likely to result in therapeutic keratoplasty compared with natamycin [relative risk (RR) 1.89 95% CI: 1.14, 3.12] with a number needed to treat of 13 (95% CI: 7, 50). Final visual acuity was significantly better with natamycin compared with voriconazole [weighted mean difference (WMD) 0.13, 95% CI 0.00, 0.27]. There was no difference in risk of treatment failure across all topical antifungal treatments studied (chlorhexidine gluconate, econazole, miconazole, natamycin, silver sulphadiazine and voriconazole). This study suggests treatment failure was comparable among antifungal treatments reviewed. However, natamycin resulted in better visual acuity following acute infection, compared with voriconazole. Voriconazole had a significantly greater risk of therapeutic keratoplasty compared with natamycin in the populations studied.
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Affiliation(s)
- Elissa M McDonald
- From the *Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland; and †School of Health Sciences, Massey University, Auckland, New Zealand
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Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Prajna L, Srinivasan M, Raghavan A, Oldenburg CE, Ray KJ, Zegans ME, McLeod SD, Porco TC, Acharya NR, Lietman TM. The mycotic ulcer treatment trial: a randomized trial comparing natamycin vs voriconazole. JAMA Ophthalmol 2013; 131:422-429. [PMID: 23710492 PMCID: PMC3769211 DOI: 10.1001/jamaophthalmol.2013.1497] [Citation(s) in RCA: 200] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
OBJECTIVE To compare topical natamycin vs voriconazole in the treatment of filamentous fungal keratitis. METHODS This phase 3, double-masked, multicenter trial was designed to randomize 368 patients to voriconazole (1%) or natamycin (5%), applied topically every hour while awake until reepithelialization, then 4 times daily for at least 3 weeks. Eligibility included smear-positive filamentous fungal ulcer and visual acuity of 20/40 to 20/400. MAIN OUTCOME MEASURES The primary outcome was best spectacle-corrected visual acuity at 3 months; secondary outcomes included corneal perforation and/or therapeutic penetrating keratoplasty. RESULTS A total of 940 patients were screened and 323 were enrolled. Causative organisms included Fusarium (128 patients [40%]), Aspergillus (54 patients [17%]), and other filamentous fungi (141 patients [43%]). Natamycintreated cases had significantly better 3-month best spectacle-corrected visual acuity than voriconazole-treated cases (regression coefficient=0.18 logMAR; 95% CI, 0.30 to 0.05; P=.006). Natamycin-treated cases were less likely to have perforation or require therapeutic penetrating keratoplasty (odds ratio=0.42; 95% CI, 0.22 to 0.80; P=.009). Fusarium cases fared better with natamycin than with voriconazole (regression coefficient=0.41 logMAR; 95% CI,0.61 to 0.20; P<.001; odds ratio for perforation=0.06; 95% CI, 0.01 to 0.28; P<.001), while non-Fusarium cases fared similarly (regression coefficient=0.02 logMAR; 95% CI, 0.17 to 0.13; P=.81; odds ratio for perforation=1.08; 95% CI, 0.48 to 2.43; P=.86). CONCLUSIONS Natamycin treatment was associated with significantly better clinical and microbiological outcomes than voriconazole treatment for smear-positive filamentous fungal keratitis, with much of the difference attributable to improved results in Fusarium cases. APPLICATION TO CLINICAL PRACTICE Voriconazole should not be used as monotherapy in filamentous keratitis. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00996736
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Abstract
OBJECTIVE To report a case of multidrug-resistant Fusarium sp keratitis that progressed to endophthalmitis and that eventually required enucleation. METHODS Case report and literature review. Isolate identification and susceptibility testing were performed by the Fungus Testing Laboratory at San Antonio, TX. RESULTS A 52-year-old soft contact lens wearer had a corneal abrasion and developed a corneal infiltrate. Examination of corneal scrapings revealed filamentous hyphae with septation and conidia. Despite aggressive antifungal therapy with topical natamycin, amphotericin B, and systemic fluconazole, the keratitis progressed, and a penetrating keratoplasty was performed. Histopathologic analysis of the corneal button showed disruption of Descemet's membrane with periodic acid-Schiff-positive fungal hyphae on both sides. Recurrent infection of the graft and progression to endophthalmitis was treated with repeated intravitreal amphotericin B injections, repeat penetrating keratoplasties, and pars plana vitrectomies. Even after systemic use of itraconazole, voriconazole, and posaconazole and topical use of voriconazole, the infection progressed and an enucleation was required. Isolate identification and susceptibility testing found a multidrug-resistant Fusarium solani species complex, partially sensitive to natamycin only. CONCLUSIONS Multidrug-resistant Fusarium sp is rare and may have devastating consequences in patients with advanced keratitis progressing to endophthalmitis. Such an extensive multidrug resistance is surprising in that resistance to antifungal treatment is supposedly rare. Empirical antifungal therapy is usually instituted using one or more antifungal agents, without checking antifungal sensitivities. In light of the growing concern for increased emergence of resistant strains, we propose a lower threshold to check for sensitivities in the face of unresponsive fungal infections.
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Manikandan P, Varga J, Kocsubé S, Anita R, Revathi R, Németh TM, Narendran V, Vágvölgyi C, Panneer Selvam K, Shobana CS, Babu Singh YR, Kredics L. Epidemiology of Aspergillus keratitis at a tertiary care eye hospital in South India and antifungal susceptibilities of the causative agents. Mycoses 2012; 56:26-33. [PMID: 22487304 DOI: 10.1111/j.1439-0507.2012.02194.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In recent years, Aspergillus species are reported frequently as aetiological agents of fungal keratitis in tropical countries such as India. Our aim was to evaluate the epidemiological features of Aspergillus keratitis cases over a 3-year period in a tertiary eye care hospital and to determine the antifungal susceptibilities of the causative agents. This study included culture proven Aspergillus keratitis cases diagnosed between September 2005 and August 2008. Data including prevalence, predisposing factors and demography were recorded, the isolates were identified by morphological and molecular methods and the minimum inhibitory concentration values of antifungal agents towards the isolates were determined by the microdilution method. Two hundred Aspergillus isolates were identified among 1737 culture proven cases. Most of the aspergilli (75%) proved to be A. flavus, followed by A. fumigatus (11.5%). Sixteen (8%) isolates belonged to species that are recently identified causative agents of mycotic keratitis. Most of the infected patients (88%) were adults ranging from 21 to 70 years of age. Co-existing ocular disease was confirmed in 16.5% of the patients. Econazole, clotrimazole and ketoconazole were notably active against A. flavus. Aspergillus keratitis is a significant problem in patients with ocular lesions in South-Indian States, warranting early diagnosis and initiation of specific antifungal therapy to improve outcome.
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Affiliation(s)
- Palanisamy Manikandan
- Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore, Tamilnadu, India
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Abstract
BACKGROUND Fungal keratitis is a fungal infection of the cornea. It is common in agricultural tropical countries but relatively uncommon in developed countries. Although there are medications available, their effectiveness is unclear. OBJECTIVES To examine the effect of different antifungal drugs in the management of fungal keratitis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 8), MEDLINE (January 1950 to August 2011), EMBASE (January 1980 to August 2011), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to August 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 29 August 2011. SELECTION CRITERIA We included all relevant randomised controlled trials (RCTs) on medical therapy for fungal keratitis. DATA COLLECTION AND ANALYSIS Two review authors selected studies for inclusion into the review, assessed trials for risk of bias and extracted data. Interventions were compared by the proportions of participants that did not heal after a specific time of therapy. No meta-analysis was performed because the trials studied different medications with different concentrations. MAIN RESULTS We included nine trials in this review; seven conducted in India, one in Bangladesh and one in Egypt. A total of 568 participants were randomised to the following comparisons: 1% topical itraconazole versus 1% topical itraconazole and oral itraconazole, different concentrations of silver sulphadiazine versus 1% miconazole, 1% silver sulphadiazine ointment versus 1% miconazole ointment, 2% econazole versus 5% natamycin, different concentrations of topical chlorhexidine gluconate versus 5% natamycin, 0.2% chlorhexidine gluconate versus 2.5% natamycin and voriconazole 1% versus natamycin 5%. The included trials were small and of variable quality. Differences between different regimens were not statistically different, which may reflect the low sample sizes. AUTHORS' CONCLUSIONS Based on the trials included in this review, there is no evidence to date that any particular drug, or combination of drugs, is more effective in the management of fungal keratitis. The trials included in this review were of variable quality and were generally underpowered.
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Affiliation(s)
- Nilo Vincent FlorCruz
- Department of Ophthalmology and Visual Sciences, University of the Phillipines-Philippine General Hospital, Manila, Philippines
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Nayak N, Satpathy G, Prasad S, Titiyal JS, Pandey RM, Vajpayee RB. Molecular characterization of drug-resistant and drug-sensitive Aspergillus isolates causing infectious keratitis. Indian J Ophthalmol 2012; 59:373-7. [PMID: 21836343 PMCID: PMC3159319 DOI: 10.4103/0301-4738.83614] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To study the susceptibilities of Aspergillus species against amphotericin B in infectious keratitis and to find out if drug resistance had any association with the molecular characteristics of the fungi. MATERIALS AND METHODS One hundred and sixty Aspergillus isolates from the corneal scrapings of patients with keratitis were tested for susceptibilities to amphotericin B by broth microdilution method. These included Aspergillus flavus (64 isolates), A. fumigatus (43) and A. niger (53). Fungal DNA was extracted by glass bead vertexing technique. Polymerase chain reaction (PCR) assay was standardized and used to amplify the 28S rRNA gene. Single-stranded conformational polymorphism (SSCP) of the PCR product was performed by the standard protocol. RESULTS Of the 160 isolates, 84 (52.5%) showed low minimum inhibitory concentration (MIC) values (≤ 1.56 μg/ml) and were designated as amphotercin B-sensitive. Similarly, 76 (47.5%) had high MICs (≥ 3.12 μg/ml) and were categorized as amphotericin B-resistant. MIC 50 and MIC 90 values ranged between 3.12-6.25 μg/ml and 3.12-12.5 μg/ml respectively. A. flavus and A. niger showed higher MIC 50 and MIC 90 values than A. fumigatus. The SSCP pattern exhibited three extra bands (150 bp, 200 bp and 250 bp each) in addition to the 260 bp amplicon. Strains (lanes 1 and 7) lacking the 150 bp band showed low MIC values (≤ 1.56 μg/ml). CONCLUSION A. niger and A. flavus isolates had higher MICs compared to A. fumigatus, suggesting a high index of suspicion for amphotericin B resistance. PCR-SSCP was a good molecular tool to characterize Aspergillus phenotypes in fungal keratitis.
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Affiliation(s)
- Niranjan Nayak
- Department of Ocular Microbiology, Dr. Rajendra Prasad Centre for Ophthalmic Science, New Delhi-110 029, India.
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Abstract
CLINICAL QUESTION What is the most appropriate management of fungal keratitis? RESULTS Traditionally, topical Natamycin is the most commonly used medication for filamentous fungi while Amphotericin B is most commonly used for yeast. Voriconazole is rapidly becoming the drug of choice for all fungal keratitis because of its wide spectrum of coverage and increased penetration into the cornea. IMPLEMENTATION Repeated debridement of the ulcer is recommended for the penetration of topical medications. While small, peripheral ulcers may be treated in the community, larger or central ulcers, especially if associated with signs suggestive of anterior chamber penetration should be referred to a tertiary center. Prolonged therapy for approximately four weeks is usually necessary.
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