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Chen X, Li C, Peng X, Lum F, McLeod SD, Acharya NR. Use of Anterior Chamber Paracentesis for Diagnosis in Viral Anterior Uveitis. Ophthalmology 2024; 131:634-636. [PMID: 38184172 DOI: 10.1016/j.ophtha.2023.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/03/2023] [Accepted: 12/27/2023] [Indexed: 01/08/2024] Open
Affiliation(s)
- Xinyi Chen
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California; F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Charles Li
- American Academy of Ophthalmology, San Francisco, California
| | - Xuan Peng
- American Academy of Ophthalmology, San Francisco, California
| | - Flora Lum
- American Academy of Ophthalmology, San Francisco, California
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California; F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California; American Academy of Ophthalmology, San Francisco, California
| | - Nisha R Acharya
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California; F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California.
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2
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Deiner MS, Deiner NA, Hristidis V, McLeod SD, Doan T, Lietman TM, Porco TC. Use of Large Language Models to Assess the Likelihood of Epidemics From the Content of Tweets: Infodemiology Study. J Med Internet Res 2024; 26:e49139. [PMID: 38427404 PMCID: PMC10943433 DOI: 10.2196/49139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Previous work suggests that Google searches could be useful in identifying conjunctivitis epidemics. Content-based assessment of social media content may provide additional value in serving as early indicators of conjunctivitis and other systemic infectious diseases. OBJECTIVE We investigated whether large language models, specifically GPT-3.5 and GPT-4 (OpenAI), can provide probabilistic assessments of whether social media posts about conjunctivitis could indicate a regional outbreak. METHODS A total of 12,194 conjunctivitis-related tweets were obtained using a targeted Boolean search in multiple languages from India, Guam (United States), Martinique (France), the Philippines, American Samoa (United States), Fiji, Costa Rica, Haiti, and the Bahamas, covering the time frame from January 1, 2012, to March 13, 2023. By providing these tweets via prompts to GPT-3.5 and GPT-4, we obtained probabilistic assessments that were validated by 2 human raters. We then calculated Pearson correlations of these time series with tweet volume and the occurrence of known outbreaks in these 9 locations, with time series bootstrap used to compute CIs. RESULTS Probabilistic assessments derived from GPT-3.5 showed correlations of 0.60 (95% CI 0.47-0.70) and 0.53 (95% CI 0.40-0.65) with the 2 human raters, with higher results for GPT-4. The weekly averages of GPT-3.5 probabilities showed substantial correlations with weekly tweet volume for 44% (4/9) of the countries, with correlations ranging from 0.10 (95% CI 0.0-0.29) to 0.53 (95% CI 0.39-0.89), with larger correlations for GPT-4. More modest correlations were found for correlation with known epidemics, with substantial correlation only in American Samoa (0.40, 95% CI 0.16-0.81). CONCLUSIONS These findings suggest that GPT prompting can efficiently assess the content of social media posts and indicate possible disease outbreaks to a degree of accuracy comparable to that of humans. Furthermore, we found that automated content analysis of tweets is related to tweet volume for conjunctivitis-related posts in some locations and to the occurrence of actual epidemics. Future work may improve the sensitivity and specificity of these methods for disease outbreak detection.
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Affiliation(s)
- Michael S Deiner
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
| | - Natalie A Deiner
- College of Letters and Science, University of California, Santa Barbara, Santa Barbara, CA, United States
| | - Vagelis Hristidis
- Department of Computer Science and Engineering, University of California, Riverside, Riverside, CA, United States
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- American Academy of Ophthalmology, San Francisco, CA, United States
| | - Thuy Doan
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Thomas M Lietman
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Travis C Porco
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, CA, United States
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
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3
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Li C, Lum F, Chen EM, Collender PA, Head JR, Khurana RN, Cunningham ET, Moorthy RS, Parke DW, McLeod SD. Shifts in ophthalmic care utilization during the COVID-19 pandemic in the US. Commun Med (Lond) 2023; 3:181. [PMID: 38097811 PMCID: PMC10721809 DOI: 10.1038/s43856-023-00416-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/24/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Healthcare restrictions during the COVID-19 pandemic, particularly in ophthalmology, led to a differential underutilization of care. An analytic approach is needed to characterize pandemic health services usage across many conditions. METHODS A common analytical framework identified pandemic care utilization patterns across 261 ophthalmic diagnoses. Using a United States eye care registry, predictions of utilization expected without the pandemic were established for each diagnosis via models trained on pre-pandemic data. Pandemic effects on utilization were estimated by calculating deviations between observed and expected patient volumes from January 2020 to December 2021, with two sub-periods of focus: the hiatus (March-May 2020) and post-hiatus (June 2020-December 2021). Deviation patterns were analyzed using cluster analyses, data visualizations, and hypothesis testing. RESULTS Records from 44.62 million patients and 2455 practices show lasting reductions in ophthalmic care utilization, including visits for leading causes of visual impairment (age-related macular degeneration, diabetic retinopathy, cataract, glaucoma). Mean deviations among all diagnoses are 67% below expectation during the hiatus peak, and 13% post-hiatus. Less severe conditions experience greater utilization reductions, with heterogeneities across diagnosis categories and pandemic phases. Intense post-hiatus reductions occur among non-vision-threatening conditions or asymptomatic precursors of vision-threatening diseases. Many conditions with above-average post-hiatus utilization pose a risk for irreversible morbidity, such as emergent pediatric, retinal, or uveitic diseases. CONCLUSIONS We derive high-resolution insights on pandemic care utilization in the US from high-dimensional data using an analytical framework that can be applied to study healthcare disruptions in other settings and inform efforts to pinpoint unmet clinical needs.
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Affiliation(s)
- Charles Li
- American Academy of Ophthalmology, San Francisco, CA, USA.
| | - Flora Lum
- American Academy of Ophthalmology, San Francisco, CA, USA
| | - Evan M Chen
- Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Philip A Collender
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Jennifer R Head
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, CA, USA
| | - Rahul N Khurana
- Department of Ophthalmology, University of California, San Francisco, CA, USA
- Northern California Retina Vitreous Associates, Mountain View, CA, USA
| | - Emmett T Cunningham
- Department of Ophthalmology, California Pacific Medical Center, San Francisco, CA, USA
- The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, CA, USA
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ramana S Moorthy
- Associated Vitreoretinal and Uveitis Consultants, Carmel, IN, USA
- Department of Ophthalmology, Indiana University Medical Center, Indianapolis, IN, USA
| | - David W Parke
- American Academy of Ophthalmology, San Francisco, CA, USA
| | - Stephen D McLeod
- American Academy of Ophthalmology, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, CA, USA
- The Francis I. Proctor Foundation, UCSF School of Medicine, San Francisco, CA, USA
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4
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Deiner MS, Kaur G, McLeod SD, Schallhorn JM, Chodosh J, Hwang DH, Lietman TM, Porco TC. A Google Trends Approach to Identify Distinct Diurnal and Day-of-Week Web-Based Search Patterns Related to Conjunctivitis and Other Common Eye Conditions: Infodemiology Study. J Med Internet Res 2022; 24:e27310. [PMID: 35537041 PMCID: PMC9297131 DOI: 10.2196/27310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 08/18/2021] [Accepted: 05/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background Studies suggest diurnal patterns of occurrence of some eye conditions. Leveraging new information sources such as web-based search data to learn more about such patterns could improve the understanding of patients’ eye-related conditions and well-being, better inform timing of clinical and remote eye care, and improve precision when targeting web-based public health campaigns toward underserved populations. Objective To investigate our hypothesis that the public is likely to consistently search about different ophthalmologic conditions at different hours of the day or days of week, we conducted an observational study using search data for terms related to ophthalmologic conditions such as conjunctivitis. We assessed whether search volumes reflected diurnal or day-of-week patterns and if those patterns were distinct from each other. Methods We designed a study to analyze and compare hourly search data for eye-related and control search terms, using time series regression models with trend and periodicity terms to remove outliers and then estimate diurnal effects. We planned a Google Trends setting, extracting data from 10 US states for the entire year of 2018. The exposure was internet search, and the participants were populations who searched through Google’s search engine using our chosen study terms. Our main outcome measures included cyclical hourly and day-of-week web-based search patterns. For statistical analyses, we considered P<.001 to be statistically significant. Results Distinct diurnal (P<.001 for all search terms) and day-of-week search patterns for eye-related terms were observed but with differing peak time periods and cyclic strengths. Some diurnal patterns represented those reported from prior clinical studies. Of the eye-related terms, “pink eye” showed the largest diurnal amplitude-to-mean ratios. Stronger signal was restricted to and peaked in mornings, and amplitude was higher on weekdays. By contrast, “dry eyes” had a higher amplitude diurnal pattern on weekends, with stronger signal occurring over a broader evening-to-morning period and peaking in early morning. Conclusions The frequency of web-based searches for various eye conditions can show cyclic patterns according to time of the day or week. Further studies to understand the reasons for these variations may help supplement the current clinical understanding of ophthalmologic symptom presentation and improve the timeliness of patient messaging and care interventions.
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Affiliation(s)
- Michael S Deiner
- Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA, United States.,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, United States
| | - Gurbani Kaur
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, United States.,School of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Stephen D McLeod
- Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA, United States.,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, United States
| | - Julie M Schallhorn
- Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA, United States.,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, United States
| | - James Chodosh
- Department of Ophthalmology, Harvard Medical School, Boston, MA, United States.,Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Daniel H Hwang
- Stanford University, San Mateo, CA, United States.,The Nueva School, San Mateo, CA, United States
| | - Thomas M Lietman
- Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA, United States.,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, United States.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States.,Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Travis C Porco
- Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA, United States.,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, United States.,Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, United States.,Global Health Sciences, University of California San Francisco, San Francisco, CA, United States
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5
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Coleman AL, McLeod SD. Screening for Impaired Visual Acuity in Older Adults. JAMA 2022; 327:2090-2091. [PMID: 35608845 DOI: 10.1001/jama.2022.6688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anne L Coleman
- Stein and Doheny Eye Institutes, David Geffen School of Medicine, University of California, Los Angeles
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Stephen D McLeod
- Department of Ophthalmology, School of Medicine, University of California, San Francisco
- Francis I. Proctor Foundation, University of California, San Francisco
- American Academy of Ophthalmology, San Francisco, California
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O’Brien KS, Byanju R, Kandel RP, Poudyal B, Gonzales JA, Porco TC, Whitcher JP, Srinivasan M, Upadhyay M, Lietman TM, Keenan JD, Byanju R, Khadka KB, Bista D, Gautam M, Giri P, Kayastha S, Parajuli TP, Shah RK, Sharma N, Sharma P, Shrestha A, Shrestha M, Subedi P, Chaudhary DS, Ghimire R, Adhikari M, Hamal V, Bhandari G, Dahal G, Poudyal B, Bhandari S, Gurung J, Bhattarai D, Bhattarai R, Chapagain D, Chaudhary AK, Gautam SK, Gurau D, Kandel D, Lamichhane PC, Rijal R, Giri G, Upadhyay M, Lietman TM, Acharya NR, Gonzales JA, Keenan JD, McLeod SD, Ramirez DA, Ray KJ, Rose-Nussbaumer J, Whitcher JP, O'Brien KS, Cotter SY, Kim J, Lee S, Maamari RN, Porco TC, Basset K, Chase H, Evans L, Gilbert S, Kandel RP, Moses D, Tenzing C, Choudhary S, Dhakwa P, Fletcher DA, Reber CD. Village-integrated eye workers for prevention of corneal ulcers in Nepal (VIEW study): a cluster-randomised controlled trial. Lancet Glob Health 2022; 10:e501-e509. [PMID: 35303460 PMCID: PMC9814976 DOI: 10.1016/s2214-109x(21)00596-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Corneal ulcers are a common cause of blindness in low-income and middle-income countries, usually resulting from traumatic corneal abrasions during agricultural work. Antimicrobial prophylaxis of corneal abrasions can help prevent corneal ulcers, but delays in the initiation of therapy are frequent. We aimed to assess whether a community-based programme for corneal ulcer prevention would reduce the incidence of corneal ulceration. METHODS A cluster-randomised trial was performed in village development committees (VDCs) in Nepal. VDCs in the catchment area of Bharatpur Eye Hospital, Nepal with less than 15 000 people were eligible for inclusion. We randomly assigned (1:1) VDCs to either an intervention group or a control group. In the intervention VDCs, existing female community health volunteers (FCHVs) were trained to diagnose corneal abrasions and provide a 3-day course of ophthalmic antimicrobials to their patients. In the control VDCs, FCHVs did not provide this intervention. Participants were not masked given the nature of the intervention. Both groups were followed up for 3 years for photographic evidence of corneal ulceration. The primary outcome was the incidence of corneal ulceration, determined by masked assessment of corneal photographs. The analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT01969786. FINDINGS We assessed 112 VDCs, of which 24 were enrolled. The study was performed between Feb 4, 2014, and Oct 20, 2017. 12 VDCs were randomly assigned to the intervention group and 12 to the control group. 252 539 individuals were included in the study (130 579 in the intervention group and 121 960 in the control group). FCHVs diagnosed and provided antimicrobials for 4777 corneal abrasions. The census identified 289 corneal ulcers among 246 893 person-years in the intervention group (incidence 1·21 cases [95% CI 0·85-1·74] per 1000 person-years) and 262 corneal ulcers among 239 170 person-years in the control group (incidence 1·18 cases [0·82-1·70] per 1000 person-years; incidence rate ratio 1·03 [95% CI 0·63-1·67]; p=0·93). Medication allergy was self-reported in 0·2% of participants. INTERPRETATION We did not detect a reduction in the incidence of corneal ulceration during the first 3 years of a community-based corneal ulcer prevention programme. Further study might be warranted in more rural areas where basic eye care facilities are not available. FUNDING National Eye Institute.
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Affiliation(s)
- Kieran S O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | | | - Ram Prasad Kandel
- Bharatpur Eye Hospital, Bharatpur, Chitwan, Nepal,Seva Foundation, Berkeley, CA, USA and Kathmandu, Nepal
| | | | - John A Gonzales
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA,Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - John P Whitcher
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | | | - Madan Upadhyay
- BP Eye Foundation, Children’s Hospital for Eye, Ear, and Rehabilitation Services (CHEERS), Kathmandu, Nepal
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA,Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA,Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
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Greenwald MF, Redd TK, Doan T, McLeod SD, Seitzman GD. Very late onset LASIK flap Acremonium fungal keratitis confirmed by metagenomic deep sequencing. Am J Ophthalmol Case Rep 2022; 25:101294. [PMID: 35128155 PMCID: PMC8807967 DOI: 10.1016/j.ajoc.2022.101294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 07/21/2021] [Accepted: 01/16/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose To describe a unique case of LASIK flap fungal keratitis confirmed by next generation sequencing. Observations A 56-year-old female presented with refractory keratitis involving her LASIK flap 21 years after surgery. Confocal was positive for filamentous structures. The patient underwent immediate flap amputation followed by topical antifungal treatment. Corneal culture was positive for Acremonium sp. Metagenomic deep sequencing confirmed Acremonium as the primary source of infection and also identified Fusarium as a likely contributor of a mixed fungal infection. Sequencing also identified hay as the likely source of the infection. Treatment resulted in eradication of the infection. The patient's final best corrected visual acuity was 20/30 with rigid contact lens overrefraction. Conclusions Metagenomic deep sequencing is a novel diagnostic tool that is increasingly being utilized for diagnosis of refractory keratitis. This case demonstrates the diagnostic potential of deep sequencing for identifying post-LASIK keratitis and reinforces the utility of LASIK flap amputation in the setting of tectonic flap instability due to keratolysis. Importance This case highlights several important clinical points for treating LASIK flap keratitis and highlights the emerging role metagenomic sequencing has in the diagnosis of infectious keratitis. This is first known case using next generation sequencing to diagnose a post-LASIK infectious keratitis.
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McLeod SD. Science Matters. Ophthalmology 2022; 129:248-249. [PMID: 35190093 PMCID: PMC8853864 DOI: 10.1016/j.ophtha.2022.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 11/18/2022] Open
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9
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Deiner MS, Seitzman GD, Kaur G, McLeod SD, Chodosh J, Lietman TM, Porco TC. Sustained Reductions in Online Search Interest for Communicable Eye and Other Conditions During the COVID-19 Pandemic: Infodemiology Study. JMIR Infodemiology 2022; 2:e31732. [PMID: 35320981 PMCID: PMC8931841 DOI: 10.2196/31732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/26/2022] [Accepted: 02/16/2022] [Indexed: 12/20/2022]
Abstract
Background In a prior study at the start of the pandemic, we reported reduced numbers of Google searches for the term “conjunctivitis” in the United States in March and April 2020 compared with prior years. As one explanation, we conjectured that reduced information-seeking may have resulted from social distancing reducing contagious conjunctivitis cases. Here, after 1 year of continued implementation of social distancing, we asked if there have been persistent reductions in searches for “conjunctivitis,” and similarly for other communicable disease terms, compared to control terms. Objective The aim of this study was to determine if reduction in searches in the United States for terms related to conjunctivitis and other common communicable diseases occurred in the spring-winter season of the COVID-19 pandemic, and to compare this outcome to searches for terms representing noncommunicable conditions, COVID-19, and to seasonality. Methods Weekly relative search frequency volume data from Google Trends for 68 search terms in English for the United States were obtained for the weeks of March 2011 through February 2021. Terms were classified a priori as 16 terms related to COVID-19, 29 terms representing communicable conditions, and 23 terms representing control noncommunicable conditions. To reduce bias, all analyses were performed while masked to term names, classifications, and locations. To test for the significance of changes during the pandemic, we detrended and compared postpandemic values to those expected based on prepandemic trends, per season, computing one- and two-sided P values. We then compared these P values between term groups using Wilcoxon rank-sum and Fisher exact tests to assess if non-COVID-19 terms representing communicable diseases were more likely to show significant reductions in searches in 2020-2021 than terms not representing such diseases. We also assessed any relationship between a term’s seasonality and a reduced search trend for the term in 2020-2021 seasons. P values were subjected to false discovery rate correction prior to reporting. Data were then unmasked. Results Terms representing conjunctivitis and other communicable conditions showed a sustained reduced search trend in the first 4 seasons of the 2020-2021 COVID-19 pandemic compared to prior years. In comparison, the search for noncommunicable condition terms was significantly less reduced (Wilcoxon and Fisher exact tests, P<.001; summer, autumn, winter). A significant correlation was also found between reduced search for a term in 2020-2021 and seasonality of that term (Theil-Sen, P<.001; summer, autumn, winter). Searches for COVID-19–related conditions were significantly elevated compared to those in prior years, and searches for influenza-related terms were significantly lower than those for prior years in winter 2020-2021 (P<.001). Conclusions We demonstrate the low-cost and unbiased use of online search data to study how a wide range of conditions may be affected by large-scale interventions or events such as social distancing during the COVID-19 pandemic. Our findings support emerging clinical evidence implicating social distancing and the COVID-19 pandemic in the reduction of communicable disease and on ocular conditions.
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Affiliation(s)
- Michael S Deiner
- Francis I Proctor Foundation University of California San Francisco San Francisco, CA United States.,Department of Ophthalmology University of California San Francisco San Francisco, CA United States
| | - Gerami D Seitzman
- Francis I Proctor Foundation University of California San Francisco San Francisco, CA United States.,Department of Ophthalmology University of California San Francisco San Francisco, CA United States
| | - Gurbani Kaur
- School of Medicine University of California San Francisco San Francisco, CA United States
| | - Stephen D McLeod
- Francis I Proctor Foundation University of California San Francisco San Francisco, CA United States.,Department of Ophthalmology University of California San Francisco San Francisco, CA United States
| | - James Chodosh
- Department of Ophthalmology Massachusetts Eye and Ear Harvard Medical School Boston, MA United States
| | - Thomas M Lietman
- Francis I Proctor Foundation University of California San Francisco San Francisco, CA United States.,Department of Ophthalmology University of California San Francisco San Francisco, CA United States.,Department of Epidemiology and Biostatistics Global Health Sciences University of California San Francisco San Francisco, CA United States
| | - Travis C Porco
- Francis I Proctor Foundation University of California San Francisco San Francisco, CA United States.,Department of Ophthalmology University of California San Francisco San Francisco, CA United States.,Department of Epidemiology and Biostatistics Global Health Sciences University of California San Francisco San Francisco, CA United States
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10
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Tan TE, Chodosh J, McLeod SD, Parke DW, Yeh S, Wong TY, Ting DSW. Global Trends in Ophthalmic Practices in Response to COVID-19. Ophthalmology 2021; 128:1505-1515. [PMID: 34412877 PMCID: PMC8367739 DOI: 10.1016/j.ophtha.2021.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 02/04/2023] Open
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Kaur G, Seitzman GD, Lietman TM, McLeod SD, Porco TC, Doan T, Deiner MS. Keeping an eye on pink eye: a global conjunctivitis outbreak expert survey. Int Health 2021; 14:542-544. [PMID: 34409991 PMCID: PMC9450638 DOI: 10.1093/inthealth/ihab049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Recurrent conjunctivitis epidemics are prevalent worldwide. Aetiologies are often undetermined. METHODS We surveyed conjunctivitis researchers about perceived trends in prevalence, incidence and aetiologies of conjunctivitis epidemics. RESULTS Of the 155 participants, 7% endorsed globally variable and dynamic microbial aetiologies of conjunctivitis epidemics. Increased incidence of conjunctivitis epidemics over the last decade were reported by 21% of respondents. Peak seasons differed between the northern and southern hemispheres. CONCLUSIONS There is regional equipoise regarding the increasing incidence and emerging underlying aetiologies of epidemic conjunctivitis. Further investigation of global surveillance and microbial characterization of conjunctivitis outbreaks could improve prevention and outcomes.
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Affiliation(s)
- Gurbani Kaur
- University of California, San Francisco School of Medicine, San Francisco, CA 94143, USA.,University of California, San Francisco Department of Ophthalmology, San Francisco, CA 94158, USA
| | - Gerami D Seitzman
- University of California, San Francisco Department of Ophthalmology, San Francisco, CA 94158, USA.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, CA 94158, USA
| | - Thomas M Lietman
- University of California, San Francisco Department of Ophthalmology, San Francisco, CA 94158, USA.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, CA 94158, USA
| | - Stephen D McLeod
- University of California, San Francisco Department of Ophthalmology, San Francisco, CA 94158, USA.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, CA 94158, USA
| | - Travis C Porco
- University of California, San Francisco Department of Ophthalmology, San Francisco, CA 94158, USA.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, CA 94158, USA
| | - Thuy Doan
- University of California, San Francisco Department of Ophthalmology, San Francisco, CA 94158, USA.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, CA 94158, USA
| | - Michael S Deiner
- University of California, San Francisco Department of Ophthalmology, San Francisco, CA 94158, USA.,Francis I. Proctor Foundation for Research in Ophthalmology, San Francisco, CA 94158, USA
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Deiner MS, Seitzman GD, McLeod SD, Chodosh J, Hwang DH, Lietman TM, Porco TC. Ocular Signs of COVID-19 Suggested by Internet Search Term Patterns Worldwide. Ophthalmology 2021; 128:167-169. [PMID: 32562704 PMCID: PMC7832289 DOI: 10.1016/j.ophtha.2020.06.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Michael S Deiner
- F. I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Gerami D Seitzman
- F. I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Stephen D McLeod
- F. I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | | | - Thomas M Lietman
- F. I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Travis C Porco
- F. I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, Global Health Sciences, University of California, San Francisco, San Francisco, California.
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13
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Rose-Nussbaumer J, Lin CC, Austin A, Liu Z, Clover J, McLeod SD, Porco TC, Lietman TM, Dresner SM, Benetz BA, Lass JH, Chamberlain WD. Descemet Endothelial Thickness Comparison Trial: Two-Year Results from a Randomized Trial Comparing Ultrathin Descemet Stripping Automated Endothelial Keratoplasty with Descemet Membrane Endothelial Keratoplasty. Ophthalmology 2020; 128:1238-1240. [PMID: 33359556 DOI: 10.1016/j.ophtha.2020.12.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Charles C Lin
- Byers Eye Institute, Stanford University, Palo Alto, California
| | - Ariana Austin
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Zijun Liu
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Departmet of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Departmet of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Samuel M Dresner
- Cornea Image Analysis Reading Center, University Hospitals Eye Institute and Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Beth Ann Benetz
- Cornea Image Analysis Reading Center, University Hospitals Eye Institute and Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Jonathan H Lass
- Cornea Image Analysis Reading Center, University Hospitals Eye Institute and Department of Ophthalmology and Visual Sciences, Case Western Reserve University, Cleveland, Ohio
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Zhang Q, Liu Y, Thanapaisal S, Oatts J, Luo Y, Ying GS, Wang J, McLeod SD, Gedde SJ, Han Y. The Effect of Tube Location on Corneal Endothelial Cells in Patients with Ahmed Glaucoma Valve. Ophthalmology 2020; 128:218-226. [PMID: 32603727 DOI: 10.1016/j.ophtha.2020.06.050] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/05/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To compare the effects of the Ahmed glaucoma valve (AGV; New World Medical, Rancho Cucamonga, CA) with sulcus versus anterior chamber (AC) tube placement on the corneal endothelial density and morphology over time. DESIGN Nonrandomized, interventional study. PARTICIPANTS This study included 106 eyes from 101 pseudophakic patients who had the AGV tube placed in the AC (acAGV) and 105 eyes from 94 pseudophakic patients who had the AGV tube placed in the ciliary sulcus (sAGV). METHODS All patients underwent preoperative specular microscopy, which was repeated postoperatively in 2019. The patients' demographic information, glaucoma diagnoses, and basic ocular information were obtained on chart review. Anterior segment OCT was conducted for patients who underwent sAGV to evaluate the sulcus tube position. Gonioscopy was performed to document peripheral anterior synechiae (PAS). Linear mixed-effects models were used to compare the different ocular and endothelial measurements between the 2 groups and to identify risk factors for endothelial cell density (ECD) loss over time. MAIN OUTCOME MEASURES Monthly change in corneal endothelial measurements, including ECD and coefficient of variation (CV), calculated as the difference between preoperative and postoperative measurements divided by the number of months from the time of surgery to postoperative specular microscopy. RESULTS The acAGV and sAGV groups were comparable in all baseline characteristics except that the acAGV group had longer follow-up (37.6 vs. 20.1 months, respectively, P < 0.001). Mean monthly loss in central ECD was significantly more in the acAGV group (mean ± standard deviation: 29.3±29.7 cells/mm2) than in the sAGV group (15.3±20.7 cells/mm2, P < 0.0001). Mean monthly change in CV was similar between the 2 groups (P = 0.28). Multivariate analyses revealed that younger age and tube location in the AC were associated with faster central ECD loss (P = 0.02, P < 0.0001, respectively). For patients with sAGV, while PAS was associated with faster central ECD loss (P = 0.002), a more forward tube position tenting the iris was not (P > 0.05). CONCLUSIONS Compared with anterior segment placement, ciliary sulcus tube implantation may be a preferred surgery approach to reduce endothelial cell loss in pseudophakic patients.
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Affiliation(s)
- Qi Zhang
- Department of Ophthalmology, University of California San Francisco, San Francisco, California; The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology and Chongqing Eye Institute, Chongqing, China
| | - Yingna Liu
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Sukhumal Thanapaisal
- Department of Ophthalmology, University of California San Francisco, San Francisco, California; Department of Ophthalmology, Khon Kaen University, Khon Kaen, Thailand
| | - Julius Oatts
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Yetao Luo
- Department of Clinical Epidemiology and Biostatistics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Gui-Shuang Ying
- Center for Preventive Ophthalmology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Junming Wang
- Department of Ophthalmology, Tonji Hospital, Tongji Medial College, Huazhong University of Science and Technology, Wuhan, China
| | - Stephen D McLeod
- Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | - Steven J Gedde
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Ying Han
- Department of Ophthalmology, University of California San Francisco, San Francisco, California.
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16
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Olivia Li JP, Shantha J, Wong TY, Wong EY, Mehta J, Lin H, Lin X, Strouthidis NG, Park KH, Fung AT, McLeod SD, Busin M, Parke DW, Holland GN, Chodosh J, Yeh S, Ting DSW. Preparedness among Ophthalmologists: During and Beyond the COVID-19 Pandemic. Ophthalmology 2020; 127:569-572. [PMID: 32327128 PMCID: PMC7167498 DOI: 10.1016/j.ophtha.2020.03.037] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 01/02/2023] Open
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17
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Ung L, Acharya NR, Agarwal T, Alfonso EC, Bagga B, Bispo PJM, Burton MJ, Dart JKG, Doan T, Fleiszig SMJ, Garg P, Gilmore MS, Gritz DC, Hazlett LD, Iovieno A, Jhanji V, Kempen JH, Lee CS, Lietman TM, Margolis TP, McLeod SD, Mehta JS, Miller D, Pearlman E, Prajna L, Prajna NV, Seitzman GD, Shanbhag SS, Sharma N, Sharma S, Srinivasan M, Stapleton F, Tan DTH, Tandon R, Taylor HR, Tu EY, Tuli SS, Vajpayee RB, Van Gelder RN, Watson SL, Zegans ME, Chodosh J. Infectious corneal ulceration: a proposal for neglected tropical disease status. Bull World Health Organ 2019; 97:854-856. [PMID: 31819296 PMCID: PMC6883276 DOI: 10.2471/blt.19.232660] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/16/2019] [Accepted: 07/22/2019] [Indexed: 11/27/2022] Open
Affiliation(s)
- Lawson Ung
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, Massachusetts 02114United States of America (USA)
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, USA
| | - Tushar Agarwal
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Eduardo C Alfonso
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, USA
| | - Bhupesh Bagga
- Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Paulo JM Bispo
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, Massachusetts 02114United States of America (USA)
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene & Tropical Medicine, London, England
| | | | - Thuy Doan
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, USA
| | | | - Prashant Garg
- Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Michael S Gilmore
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, Massachusetts 02114United States of America (USA)
| | - David C Gritz
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Linda D Hazlett
- Department of Ophthalmology, Visual and Anatomical Sciences, Wayne State University School of Medicine, Detroit, USA
| | - Alfonso Iovieno
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Vishal Jhanji
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - John H Kempen
- MCM Eye Unit, MyungSung Medical School, Addis Ababa, Ethiopia
| | - Cecilia S Lee
- Department of Ophthalmology, University of Washington School of Medicine, Seattle, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, USA
| | - Todd P Margolis
- Department of Ophthalmology and Visual Sciences, Washington University in Saint Louis School of Medicine, Saint Louis, USA
| | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, USA
| | - Jod S Mehta
- Singapore National Eye Centre, Duke-NUS Graduate Medical School, Singapore
| | - Darlene Miller
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, USA
| | - Eric Pearlman
- Institute of Immunology, University of California, Irvine, USA
| | | | | | - Gerami D Seitzman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, USA
| | - Swapna S Shanbhag
- Tej Kohli Cornea Institute, L.V. Prasad Eye Institute, Hyderabad, India
| | - Namrata Sharma
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Savitri Sharma
- Jhaveri Microbiology Centre, L.V. Prasad Eye Institute, Hyderabad, India
| | | | - Fiona Stapleton
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Donald TH Tan
- Singapore National Eye Centre, Duke-NUS Graduate Medical School, Singapore
| | - Radhika Tandon
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Hugh R Taylor
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Elmer Y Tu
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, USA
| | - Sonal S Tuli
- Department of Ophthalmology, University of Florida, Gainesville, USA
| | - Rasik B Vajpayee
- Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia
| | - Russell N Van Gelder
- Department of Ophthalmology, University of Washington School of Medicine, Seattle, USA
| | - Stephanie L Watson
- Save Sight Institute, University of Sydney Medical School, Sydney, Australia
| | - Michael E Zegans
- Department of Surgery (Ophthalmology), Geisel School of Medicine at Dartmouth, Hanover, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, 243 Charles Street, Boston, Massachusetts 02114United States of America (USA)
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18
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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19
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McLeod SD. December consultation #3. J Cataract Refract Surg 2018; 44:1529-1530. [PMID: 30473083 DOI: 10.1016/j.jcrs.2018.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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20
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Deiner MS, McLeod SD, Chodosh J, Oldenburg CE, Fathy CA, Lietman TM, Porco TC. Clinical Age-Specific Seasonal Conjunctivitis Patterns and Their Online Detection in Twitter, Blog, Forum, and Comment Social Media Posts. Invest Ophthalmol Vis Sci 2018; 59:910-920. [PMID: 29450538 PMCID: PMC5815847 DOI: 10.1167/iovs.17-22818] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose We sought to determine whether big data from social media might reveal seasonal trends of conjunctivitis, most forms of which are nonreportable. Methods Social media posts (from Twitter, and from online forums and blogs) were classified by age and by conjunctivitis type (allergic or infectious) using Boolean and machine learning methods. Based on spline smoothing, we estimated the circular mean occurrence time (a measure of central tendency for occurrence) and the circular variance (a measure of uniformity of occurrence throughout the year, providing an index of seasonality). Clinical records from a large tertiary care provider were analyzed in a similar way for comparison. Results Social media posts machine-coded as being related to infectious conjunctivitis showed similar times of occurrence and degree of seasonality to clinical infectious cases, and likewise for machine-coded allergic conjunctivitis posts compared to clinical allergic cases. Allergic conjunctivitis showed a distinctively different seasonal pattern than infectious conjunctivitis, with a mean occurrence time later in the spring. Infectious conjunctivitis for children showed markedly greater seasonality than for adults, though the occurrence times were similar; no such difference for allergic conjunctivitis was seen. Conclusions Social media posts broadly track the seasonal occurrence of allergic and infectious conjunctivitis, and may be a useful supplement for epidemiologic monitoring.
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Affiliation(s)
- Michael S Deiner
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, California, United States.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States
| | - Stephen D McLeod
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, California, United States.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States
| | - James Chodosh
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, California, United States.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States.,Department of Epidemiology and Biostatistics, Global Health Sciences, University of California San Francisco, San Francisco, California, United States
| | - Cherie A Fathy
- Beth Israel Deaconess Medical Center/Brockton Signature Hospital, Brockton, Massachusetts, United States
| | - Thomas M Lietman
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, California, United States.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States.,Department of Epidemiology and Biostatistics, Global Health Sciences, University of California San Francisco, San Francisco, California, United States
| | - Travis C Porco
- Francis I. Proctor Foundation for Research in Ophthalmology, University of California, San Francisco, San Francisco, California, United States.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California, United States.,Department of Epidemiology and Biostatistics, Global Health Sciences, University of California San Francisco, San Francisco, California, United States
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Ray KJ, Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Patel S, Das M, Shah R, Dhakhwa K, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J. The Significance of Repeat Cultures in the Treatment of Severe Fungal Keratitis. Am J Ophthalmol 2018; 189:41-46. [PMID: 29438654 DOI: 10.1016/j.ajo.2018.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 02/02/2018] [Accepted: 02/03/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE To identify fungal keratitis patients who are at risk of a poor outcome and may benefit from closer follow-up or more aggressive treatment. DESIGN Secondary analysis of randomized clinical trial data. METHODS We compared the clinical outcomes of patients who had positive 6-day fungal cultures with those who did not, using backward stepwise regression with covariates for all baseline clinical characteristics. SUBJECTS Patients presenting with a smear-positive filamentous fungal ulcer and visual acuity of 20/400 or worse, and who subsequently had a 6-day fungal culture performed at the Aravind Eye Care system (India), Lumbini Eye Hospital (Nepal), or Bharatpur Eye Hospital (Nepal). MAIN OUTCOME MEASURES The primary outcome is rate of corneal perforation and/or the need for therapeutic penetrating keratoplasty. Secondary outcomes include 3-month best spectacle-corrected visual acuity (BSCVA), 3-month infiltrate and/or scar size, and rate of re-epithelialization. RESULTS Patients who tested positive at their 6-day culture had twice the hazard of experiencing a corneal perforation or the need for therapeutic penetrating keratoplasty (P = .002) than those who tested negative, even after controlling for baseline ulcer characteristics. These patients also had on average 0.26 logMAR lines worse BSCVA at 3 months (P = .001). Culture positivity at day 6 was not a statistically significant predictor of 3-month infiltrate/scar-size (-0.24 mm1; P = .45) or time to re-epithelialization (hazard ratio = .81; P = .31). CONCLUSIONS Here we identify a uniquely valuable clinical tool, day 6 culture results, for the treatment of severe fungal keratitis. Risk stratification based on repeat culture positivity is an objective way to assess response to medical therapy and identify patients who are at high risk of a poor clinical outcome. This establishes a new standard of care for severe fungal keratitis management.
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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
| | | | | | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, and Coimbatore, India
| | | | | | - Stephen D McLeod
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California
| | | | - Nisha R Acharya
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California; UCSF Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Thomas M Lietman
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California; UCSF Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, San Francisco, California; UCSF Department of Ophthalmology, University of California San Francisco, San Francisco, California.
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22
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Lum F, Feder RS, McLeod SD, Parke DW. The Preferred Practice Pattern Guidelines in Ophthalmology. Ophthalmology 2017; 123:928-9. [PMID: 27107351 DOI: 10.1016/j.ophtha.2016.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/16/2016] [Accepted: 01/19/2016] [Indexed: 11/18/2022] Open
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23
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Shah R, Srinivasan M, Das M, Ray KJ, Oldenburg CE, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J. Predictors of Corneal Perforation or Need for Therapeutic Keratoplasty in Severe Fungal Keratitis: A Secondary Analysis of the Mycotic Ulcer Treatment Trial II. JAMA Ophthalmol 2017; 135:987-991. [PMID: 28817744 DOI: 10.1001/jamaophthalmol.2017.2914] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Identifying patients with infectious keratitis who are at risk of experiencing a poor outcome may be useful to allocate resources toward high-risk patients, particularly in resource-poor settings. Objective To determine baseline patient and ulcer characteristics that predict a high risk of developing corneal perforation and/or the need to undergo therapeutic penetrating keratoplasty (TPK). Design, Setting, and Participants This is a secondary analysis of Mycotic Ulcer Treatment Trial II, a multicenter, double-masked, placebo-controlled randomized clinical trial that enrolled 240 patients with smear-positive filamentous fungal corneal ulcers who enrolled between May 2010 and August 2015. Participants had a baseline visual acuity of 20/400 or worse and were randomized to receive oral voriconazole or a placebo (all participants received topical voriconazole, 1%). After 39 participants (16.3%) were enrolled, topical natamycin, 5%, was also added. Main Outcomes and Measures The primary outcome of this secondary analysis was the rate of corneal perforation or the need to undergo TPK. Results The mean (SD) age at enrollment was 49 (13) years, 104 participants (43.3%) were women, and all were of Southeast Asian descent. The presence of hypopyon at baseline indicated 2.28 times the odds of the patient developing corneal perforation and/or needing TPK (95% CI, 1.18-4.40; P = .01). Study participants whose infiltrate involved the posterior one-third had a 71.4% risk of developing corneal perforation and/or needing TPK. For each 1-mm increase in the geometric mean of the infiltrate, there was 1.37 (95% CI, 1.12-1.67; P = .002) increased odds of developing perforation and/or needing TPK. Other clinical features such as visual acuity, baseline culture positivity, type of filamentous fungal organism and duration of symptoms, and demographic characteristics, such as sex and occupation, were not significant predictors in the multivariable regression analysis. Conclusions and Relevance These results suggest that risk stratification from baseline ulcer characteristics can identify those at highest risk for developing corneal perforation and/or needing TPK. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | | | | | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli and Coimbatore, India
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco
| | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco.,Department of Ophthalmology, University of California-San Francisco, San Francisco
| | | | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco.,Department of Ophthalmology, University of California-San Francisco, San Francisco.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco.,Department of Ophthalmology, University of California-San Francisco, San Francisco.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California-San Francisco, San Francisco.,Department of Ophthalmology, University of California-San Francisco, San Francisco
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Shah R, Srinivasan M, Devi L, Das M, Ray KJ, O'Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Acharya NR, Lietman TM, Rose-Nussbaumer J. Adjunctive Oral Voriconazole Treatment of Fusarium Keratitis: A Secondary Analysis From the Mycotic Ulcer Treatment Trial II. JAMA Ophthalmol 2017; 135:520-525. [PMID: 28426856 DOI: 10.1001/jamaophthalmol.2017.0616] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Importance Fusarium keratitis is common and often results in poor outcomes. No new treatments since natamycin have become available. Objective To explore the role of adjuvant oral voriconazole on clinical outcomes in Fusarium keratitis. Design, Setting, and Participants In this prespecified subgroup analysis of a multicenter, double-masked, placebo-controlled randomized clinical trial, 240 patients from the Aravind Eye Care System in India, the Lumbini Eye Hospital and Bharatpur Eye Hospital in Nepal, and the University of California, San Francisco, who had culture-positive fungal ulcer and baseline visual acuity of 20/400 or worse were randomized to receive oral voriconazole vs placebo. Enrollment started May 24, 2010, and the last patient study visit was November 23, 2015. All patients received topical voriconazole, 1%, and after the results of the Mycotic Ulcer Treatment Trial (MUTT) II became available, topical natamycin, 5%, was added for all patients. Data analysis was performed from September 2 to October 28, 2016. Main Outcomes and Measures The primary outcome of the trial was the rate of corneal perforation or the need for therapeutic penetrating keratoplasty. Secondary outcomes included rate of reepithelialization, best spectacle-corrected visual acuity, and infiltrate or scar size at 3 months. Results Of the 240 study participants, 72 (30.4%) were culture positive for Fusarium species (41 [56.9%] male and 31 [43.1%] female; median [interquartile range] age, 50 [45-57] years). Of these, 33 (45.8%) were randomized to oral voriconazole and 39 (54.2%) to placebo. Fusarium ulcers randomized to oral voriconazole had a 0.43-fold decreased hazard of perforation or therapeutic penetrating keratoplasty compared with placebo after controlling for baseline infiltrate depth (95% CI, 0.22-fold to 0.84-fold; P = .01). Multiple linear regression revealed a 1.89-mm decreased infiltrate and/or scar size at 3 weeks (95% CI, -2.69 to -1.09 mm; P < .001) and a 0.83-mm decreased infiltrate and/or scar size at 3 months after correcting for baseline values (95% CI, -1.33 to -0.32 mm; P = .001) in eyes randomized to oral voriconazole vs placebo. Eyes treated with oral voriconazole also had a mean 0.29 decreased logMAR (improved) (Snellen equivalent 20/40) visual acuity at 3 months after controlling for baseline visual acuity, although this finding was not statistically significant (95% CI, -0.57 to 0.002; P = .052). Conclusions and Relevance Although MUTT II could not find a benefit for all corneal ulcers, Fusarium keratitis may benefit from the addition of oral voriconazole to topical natamycin, and physicians should consider prescribing oral voriconazole in these cases. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | | | | | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Lumbini Devi
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Madurai, Pondicherry, Tirunelveli, and Coimbatore, India
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco
| | | | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, University of California, San Francisco
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Prajna NV, Krishnan T, Rajaraman R, Patel S, Srinivasan M, Das M, Ray KJ, O'Brien KS, Oldenburg CE, McLeod SD, Zegans ME, Porco TC, Acharya NR, Lietman TM, Rose-Nussbaumer J. Effect of Oral Voriconazole on Fungal Keratitis in the Mycotic Ulcer Treatment Trial II (MUTT II): A Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:1365-1372. [PMID: 27787540 DOI: 10.1001/jamaophthalmol.2016.4096] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective To compare oral voriconazole with placebo in addition to topical antifungals in the treatment of filamentous fungal keratitis. Design, Setting, and Participants The Mycotic Ulcer Treatment Trial II (MUTT II), a multicenter, double-masked, placebo-controlled, randomized clinical trial, was conducted in India and Nepal, with 2133 individuals screened for inclusion. Patients with smear-positive filamentous fungal ulcers and visual acuity of 20/400 (logMAR 1.3) or worse were randomized to receive oral voriconazole vs oral placebo; all participants received topical antifungal eyedrops. The study was conducted from May 24, 2010, to November 23, 2015. All trial end points were analyzed on an intent-to-treat basis. Interventions Study participants were randomized to receive oral voriconazole vs oral placebo; a voriconazole loading dose of 400 mg was administered twice daily for 24 hours, followed by a maintenance dose of 200 mg twice daily for 20 days, with dosing altered to weight based during the trial. All participants received topical voriconazole, 1%, and natamycin, 5%. Main Outcomes and Measures The primary outcome of the trial was rate of corneal perforation or the need for therapeutic penetrating keratoplasty (TPK) within 3 months. Secondary outcomes included microbiologic cure at 6 days, rate of re-epithelialization, best-corrected visual acuity and infiltrate and/or scar size at 3 weeks and 3 months, and complication rates associated with voriconazole use. Results A total of 2133 patients in India and Nepal with smear-positive ulcers were screened; of the 787 who were eligible, 240 (30.5%) were enrolled. Of the 119 patients (49.6%) in the oral voriconazole treatment group, 65 were male (54.6%), and the median age was 54 years (interquartile range, 42-62 years). Overall, no difference in the rate of corneal perforation or the need for TPK was determined for oral voriconazole vs placebo (hazard ratio, 0.82; 95% CI, 0.57-1.18; P = .29). In prespecified subgroup analyses comparing treatment effects among organism subgroups, there was some suggestion that Fusarium species might have a decreased rate of perforation or TPK in the oral voriconazole-treated arm; however, this was not a statistically significant finding after Holms-Šidák correction for multiple comparisons (effect coefficient, 0.49; 95% CI, 0.26-0.92; P = .03). Patients receiving oral voriconazole experienced a total of 58 adverse events (48.7%) compared with 28 adverse events (23.1%) in the placebo group (P < .001 after Holms-Šidák correction for multiple comparisons). Conclusions and Relevance There appears to be no benefit to adding oral voriconazole to topical antifungal agents in the treatment of severe filamentous fungal ulcers. All patients in this study were enrolled in India and Nepal; therefore, it is possible that organisms in this region may exhibit characteristics different from those in other regions of the world. Trial Registration clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- N Venkatesh Prajna
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Tiruvengada Krishnan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | | | - Muthiah Srinivasan
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Manoranjan Das
- Aravind Eye Care System, Tirunelveli, Madurai, Pondicherry and Coimbatore, India
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Stephen D McLeod
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | | | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco.,Department of Ophthalmology, University of California, San Francisco
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Deiner MS, Lietman TM, McLeod SD, Chodosh J, Porco TC. Surveillance Tools Emerging From Search Engines and Social Media Data for Determining Eye Disease Patterns. JAMA Ophthalmol 2017; 134:1024-30. [PMID: 27416554 DOI: 10.1001/jamaophthalmol.2016.2267] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Internet-based search engine and social media data may provide a novel complementary source for better understanding the epidemiologic factors of infectious eye diseases, which could better inform eye health care and disease prevention. OBJECTIVE To assess whether data from internet-based social media and search engines are associated with objective clinic-based diagnoses of conjunctivitis. DESIGN, SETTING, AND PARTICIPANTS Data from encounters of 4143 patients diagnosed with conjunctivitis from June 3, 2012, to April 26, 2014, at the University of California San Francisco (UCSF) Medical Center, were analyzed using Spearman rank correlation of each weekly observation to compare demographics and seasonality of nonallergic conjunctivitis with allergic conjunctivitis. Data for patient encounters with diagnoses for glaucoma and influenza were also obtained for the same period and compared with conjunctivitis. Temporal patterns of Twitter and Google web search data, geolocated to the United States and associated with these clinical diagnoses, were compared with the clinical encounters. The a priori hypothesis was that weekly internet-based searches and social media posts about conjunctivitis may reflect the true weekly clinical occurrence of conjunctivitis. MAIN OUTCOMES AND MEASURES Weekly total clinical diagnoses at UCSF of nonallergic conjunctivitis, allergic conjunctivitis, glaucoma, and influenza were compared using Spearman rank correlation with equivalent weekly data on Tweets related to disease or disease-related keyword searches obtained from Google Trends. RESULTS Seasonality of clinical diagnoses of nonallergic conjunctivitis among the 4143 patients (2364 females [57.1%] and 1776 males [42.9%]) with 5816 conjunctivitis encounters at UCSF correlated strongly with results of Google searches in the United States for the term pink eye (ρ, 0.68 [95% CI, 0.52 to 0.78]; P < .001) and correlated moderately with Twitter results about pink eye (ρ, 0.38 [95% CI, 0.16 to 0.56]; P < .001) and with clinical diagnosis of influenza (ρ, 0.33 [95% CI, 0.12 to 0.49]; P < .001), but did not significantly correlate with seasonality of clinical diagnoses of allergic conjunctivitis diagnosis at UCSF (ρ, 0.21 [95% CI, -0.02 to 0.42]; P = .06) or with results of Google searches in the United States for the term eye allergy (ρ, 0.13 [95% CI, -0.06 to 0.32]; P = .19). Seasonality of clinical diagnoses of allergic conjunctivitis at UCSF correlated strongly with results of Google searches in the United States for the term eye allergy (ρ, 0.44 [95% CI, 0.24 to 0.60]; P < .001) and eye drops (ρ, 0.47 [95% CI, 0.27 to 0.62]; P < .001). CONCLUSIONS AND RELEVANCE Internet-based search engine and social media data may reflect the occurrence of clinically diagnosed conjunctivitis, suggesting that these data sources can be leveraged to better understand the epidemiologic factors of conjunctivitis.
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Affiliation(s)
- Michael S Deiner
- Department of Ophthalmology, University of California San Francisco
| | - Thomas M Lietman
- Department of Ophthalmology, University of California San Francisco2F. I. Proctor Foundation, University of California San Francisco3Department of Epidemiology and Biostatistics, University of California San Francisco4Global Health Sciences, University of California San Francisco
| | - Stephen D McLeod
- Department of Ophthalmology, University of California San Francisco2F. I. Proctor Foundation, University of California San Francisco
| | - James Chodosh
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston
| | - Travis C Porco
- Department of Ophthalmology, University of California San Francisco2F. I. Proctor Foundation, University of California San Francisco3Department of Epidemiology and Biostatistics, University of California San Francisco
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Prajna NV, Lalitha P, Rajaraman R, Krishnan T, Raghavan A, Srinivasan M, O'Brien KS, Zegans M, McLeod SD, Acharya NR, Keenan JD, Lietman TM, Rose-Nussbaumer J. Changing Azole Resistance: A Secondary Analysis of the MUTT I Randomized Clinical Trial. JAMA Ophthalmol 2017; 134:693-6. [PMID: 27054515 DOI: 10.1001/jamaophthalmol.2016.0530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The development of multiple triazole resistance in pathogenic filamentous fungi has become an increasing clinical concern and has been shown to increase the risk for treatment failure. OBJECTIVE To determine whether antifungal resistance increased during the Mycotic Ulcer Treatment Trial I (MUTT I), as measured by minimum inhibitory concentrations (MICs) in baseline cultures. DESIGN, SETTING, AND PARTICIPANTS This secondary analysis of a double-masked, multicenter, randomized clinical trial included patients with culture- or smear-positive filamentous fungal corneal ulcer and a baseline visual acuity of 20/40 to 20/400. Culture-positive samples with susceptibility testing were included in this analysis. The patients were treated at multiple locations of the Aravind Eye Care Hospital system in South India. Data were collected from April 3, 2010, to December 31, 2011, and analyzed from July 15 to September 1, 2015. INTERVENTIONS Corneal smears and cultures were obtained from all study participants at baseline. Susceptibility testing was performed for each culture-positive specimen. MAIN OUTCOMES AND MEASURES Minimum inhibitory concentration of voriconazole and natamycin in baseline cultures. RESULTS Of 323 participants with smear-positive specimens (183 men [56.7%]; 140 women [43.3%]; median [interquartile range] age, 47 [38-56] years), fungal-positive cultures were obtained for 256 (79.3%). The MIC data were available for 221 of 323 participants (68.4%), because 35 samples had no growth during susceptibility testing. A 2.14-fold increase per year (95% CI, 1.13-4.56; P = .02) in voriconazole MICs after controlling for the infectious organism was found. This association was not found when looking at natamycin MICs of baseline cultures after controlling for the infectious organism (1.26; 95% CI, 0.13-12.55; P = .85). CONCLUSIONS AND RELEVANCE Susceptibility to voriconazole appeared to decrease during the relatively short enrollment period of the clinical trial. This decrease may be more related to increased resistance of environmental fungi rather than previous treatment with azoles, because presenting with azole treatment was not a risk factor for resistance. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
| | - Prajna Lalitha
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | | | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry, and Coimbatore, India
| | | | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Michael Zegans
- Department of Ophthalmology, Dartmouth Medical School, Hanover, New Hampshire
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco5Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco4Department of Ophthalmology, University of California, San Francisco6Department of Optometry, University of California, Berkeley
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Parke DW, Lum F, McLeod SD. Stem Cell Treatment: Think Twice If They Ask for Payment. Ophthalmology 2016; 123:S62-S63. [PMID: 27664287 DOI: 10.1016/j.ophtha.2016.07.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/20/2016] [Indexed: 10/21/2022] Open
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Sun CQ, Prajna NV, Krishnan T, Rajaraman R, Srinivasan M, Raghavan A, O'Brien KS, McLeod SD, Acharya NR, Rose-Nussbaumer J. Effect of pretreatment with antifungal agents on clinical outcomes in fungal keratitis. Clin Exp Ophthalmol 2016; 44:763-767. [PMID: 27329780 DOI: 10.1111/ceo.12794] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 06/12/2016] [Accepted: 06/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND To determine if pretreatment with antifungal agents is predictive of worse clinical outcome in a fungal keratitis clinical trial. DESIGN Non-pre-specified subgroup analysis of a randomized controlled trial in a tertiary hospital. PARTICIPANTS Three hundred twenty-three fungal ulcer cases with an enrolment visual acuity of 20/40 to 20/400. METHODS The Mycotic Ulcer Treatment Trial I was a randomized, double-masked trial to determine the optimal treatment for filamentous fungal keratitis at the Aravind Eye Care System, India. Enrolled cases were randomized to receive topical natamycin or voriconazole. Prior antifungal medication use, dose and duration were collected at enrolment. A subgroup analysis was performed to determine if patients using natamycin or azoles at presentation have worse clinical outcomes compared with those who were not pretreated. MAIN OUTCOME MEASURES Three-month visual acuity (primary), 3-month infiltrate or scar size, corneal perforation and/or transplant and re-epithelialization time. RESULTS Of the 323 patients enrolled, 44% presented on an antifungal agent. Pretreated patients had larger mean baseline infiltrate size (P < 0.001) and epithelial defect size (P = 0.02). Multivariate regression analysis demonstrated that pretreatment was associated with significantly worse 3-month visual acuity (P = 0.006), larger 3-month scar size (P < 0.001) and increased odds of corneal perforation and/or transplant (P = 0.001). CONCLUSIONS Fungal keratitis that is smear-positive despite being pretreated with appropriate antifungal agents appears to be a risk factor for worse outcomes, likely a result of initial ulcer severity and treatment failure. These patients may benefit from more aggressive multimodal therapy at a tertiary centre.
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Affiliation(s)
- Catherine Q Sun
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - N Venkatesh Prajna
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | | | - Revathi Rajaraman
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Muthiah Srinivasan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore, Madurai, India
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Stephen D McLeod
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Nisha R Acharya
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Rose-Nussbaumer
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Optometry, University of California Berkeley, Berkeley, California, USA
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Affiliation(s)
- Stephen D. McLeod
- Department of Ophthalmology and the Francis I. Proctor Foundation, University of California, San Francisco
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Rose-Nussbaumer J, Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Srinivasan M, Raghavan A, Oldenburg CE, O'Brien KS, Ray KJ, Porco TC, McLeod SD, Acharya NR, Keenan JD, Lietman TM. Risk factors for low vision related functioning in the Mycotic Ulcer Treatment Trial: a randomised trial comparing natamycin with voriconazole. Br J Ophthalmol 2015; 100:929-932. [PMID: 26531051 DOI: 10.1136/bjophthalmol-2015-306828] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 09/04/2015] [Accepted: 10/03/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS The Mycotic Ulcer Treatment Trial I (MUTT I) was a double-masked, multicentre, randomised controlled trial, which found that topical natamycin is superior to voriconazole for the treatment of filamentous fungal corneal ulcers. In this study, we determine risk factors for low vision-related quality of life in patients with fungal keratitis. METHODS The Indian visual function questionnaire (IND-VFQ) was administered to MUTT I study participants at 3 months. Associations between patient and ulcer characteristics and IND-VFQ subscale score were assessed using generalised estimating equations. RESULTS 323 patients were enrolled in the trial, and 292 (90.4%) completed the IND-VFQ at 3 months. Out of a total possible score of 100, the average VFQ score for all participants was 81.3 (range 0-100, SD 23.6). After correcting for treatment arm, each logMAR line of worse baseline visual acuity in the affected eye resulted in an average 1.2 points decrease on VFQ at 3 months (95% CI -1.8 to 0.6, p<0.001). Those who required therapeutic penetrating keratoplasty had an average of 25.2 points decrease on VFQ after correcting for treatment arm (95% CI -31.8 to -18.5, p<0.001). Study participants who were unemployed had on average 28.5 points decrease on VFQ (95% CI -46.9 to -10.2, p=0.002) after correcting for treatment arm. CONCLUSIONS Monocular vision loss from corneal opacity due to fungal keratitis reduced vision-related quality of life. Given the relatively high worldwide burden of corneal opacity, improving treatment outcomes of corneal infections should be a public health priority. TRIAL REGISTRATION NUMBER Clinicaltrials.gov Identifier: NCT00996736.
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Affiliation(s)
- Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Department of Optometry, University of California Berkeley
| | | | | | | | | | | | - Anita Raghavan
- Aravind Eye Care System at Madurai, Pondicherry and Coimbatore
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA
| | - Travis C Porco
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Stephen D McLeod
- Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA.,Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.,Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Rose-Nussbaumer J, Prajna NV, Krishnan KT, Mascarenhas J, Rajaraman R, Srinivasan M, Raghavan A, Oldenburg CE, O'Brien KS, Ray KJ, McLeod SD, Porco TC, Lietman TM, Acharya NR, Keenan JD. Vision-Related Quality-of-Life Outcomes in the Mycotic Ulcer Treatment Trial I: A Randomized Clinical Trial. JAMA Ophthalmol 2015; 133:642-6. [PMID: 25764482 DOI: 10.1001/jamaophthalmol.2015.0319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Given the limitations in health care resources, quality-of-life measures for interventions have gained importance. OBJECTIVE To determine whether vision-related quality-of-life outcomes were different between the natamycin and voriconazole treatment arms in the Mycotic Ulcer Treatment Trial I, as measured by an Indian Vision Function Questionnaire. DESIGN, SETTING, AND PARTICIPANTS Secondary analysis (performed October 11-25, 2014) of a double-masked, multicenter, randomized, active comparator-controlled, clinical trial at multiple locations of the Aravind Eye Care System in South India that enrolled patients with culture- or smear-positive filamentous fungal corneal ulcers who had a baseline visual acuity of 20/40 to 20/400 (logMAR of 0.3-1.3). INTERVENTIONS Study participants were randomly assigned to topical voriconazole, 1%, or topical natamycin, 5%. MAIN OUTCOMES AND MEASURES Subscale score on the Indian Vision Function Questionnaire from each of the 4 subscales (mobility, activity limitation, psychosocial impact, and visual function) at 3 months. RESULTS A total of 323 patients were enrolled in the trial, and 292 (90.4%) completed the Indian Vision Function Questionnaire at 3 months. The majority of study participants had subscale scores consistent with excellent function. After adjusting for baseline visual acuity and organism, we found that study participants in the natamycin-treated group scored, on average, 4.3 points (95% CI, 0.1-8.5) higher than study participants in the voriconazole-treated group (P = .046). In subgroup analyses looking at ulcers caused by Fusarium species and adjusting for baseline best spectacle-corrected visual acuity, the natamycin-treated group scored 8.4 points (95% CI, 1.9-14.9) higher than the voriconazole-treated group (P = .01). Differences in quality of life were not detected for patients with Aspergillus or other non-Fusarium species as the causative organism (1.5 points [95% CI, -3.9 to 6.9]; P = .52). CONCLUSIONS AND RELEVANCE We found evidence of improvement in vision-related quality of life among patients with fungal ulcers who were randomly assigned to natamycin compared with those randomly assigned to voriconazole, and especially among patients with Fusarium species as the causative organism. Incorporation of quality-of-life measures in clinical trials is important to fully evaluate the effect of the studied interventions. TRIAL REGISTRATION clinicaltrials.gov Identifier:NCT00996736.
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Affiliation(s)
- Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco3Department of Optometry, University of California, Berkeley
| | - N Venkatesh Prajna
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - K Tiruvengada Krishnan
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - Jeena Mascarenhas
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - Revathi Rajaraman
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - Muthiah Srinivasan
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | - Anita Raghavan
- Aravind Eye Care System, Madurai, India5Aravind Eye Care System, Pondicherry, India6Aravind Eye Care System, Coimbatore, India
| | | | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Stephen D McLeod
- Department of Ophthalmology, University of California, San Francisco
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco7Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco
| | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco2Department of Ophthalmology, University of California, San Francisco
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McLeod SD. October consultation #2. J Cataract Refract Surg 2014; 40:1748; discussion 1751. [PMID: 25263048 DOI: 10.1016/j.jcrs.2014.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ray KJ, Srinivasan M, Mascarenhas J, Rajaraman R, Ravindran M, Glidden DV, Oldenburg CE, Sun CQ, Zegans ME, McLeod SD, Acharya NR, Lietman TM. Early addition of topical corticosteroids in the treatment of bacterial keratitis. JAMA Ophthalmol 2014; 132:737-41. [PMID: 24763755 DOI: 10.1001/jamaophthalmol.2014.292] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Scarring from bacterial keratitis remains a leading cause of visual loss. OBJECTIVE To determine whether topical corticosteroids are beneficial as an adjunctive therapy for bacterial keratitis if given early in the course of infection. DESIGN, SETTING, AND PARTICIPANTS The Steroids for Corneal Ulcers Trial (SCUT) was a randomized, double-masked, placebo-controlled trial that overall found no effect of adding topical corticosteroids to topical moxifloxacin hydrochloride in bacterial keratitis. Here, we assess the timing of administration of corticosteroids in a subgroup analysis of the SCUT. We define earlier administration of corticosteroids (vs placebo) as addition after 2 to 3 days of topical antibiotics and later as addition after 4 or more days of topical antibiotics. MAIN OUTCOMES AND MEASURES We assess the effect of topical corticosteroids (vs placebo) on 3-month best spectacle-corrected visual acuity in patients who received corticosteroids or placebo earlier vs later. Further analyses were performed for subgroups of patients with non-Nocardia keratitis and those with no topical antibiotic use before enrollment. RESULTS Patients treated with topical corticosteroids as adjunctive therapy within 2 to 3 days of antibiotic therapy had approximately 1-line better visual acuity at 3 months than did those given placebo (-0.11 logMAR; 95% CI, -0.20 to -0.02 logMAR; P = .01). In patients who had 4 or more days of antibiotic therapy before corticosteroid treatment, the effect was not significant; patients given corticosteroids had 1-line worse visual acuity at 3 months compared with those in the placebo group (0.10 logMAR; 95% CI, -0.02 to 0.23 logMAR; P = .14). Patients with non-Nocardia keratitis and those having no topical antibiotic use before the SCUT enrollment showed significant improvement in best spectacle-corrected visual acuity at 3 months if corticosteroids were administered earlier rather than later. CONCLUSIONS AND RELEVANCE There may be a benefit with adjunctive topical corticosteroids if application occurs earlier in the course of bacterial corneal ulcers.
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Affiliation(s)
- Kathryn J Ray
- F. I. Proctor Foundation, University of California, San Francisco2Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | | | | | | | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | | | - Catherine Q Sun
- F. I. Proctor Foundation, University of California, San Francisco
| | - Michael E Zegans
- Department of Surgery (Ophthalmology), Dartmouth Medical School, Lebanon, New Hampshire7Department of Microbiology and Immunology, Dartmouth Medical School, Lebanon, New Hampshire
| | - Stephen D McLeod
- F. I. Proctor Foundation, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- F. I. Proctor Foundation, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco
| | - Thomas M Lietman
- F. I. Proctor Foundation, University of California, San Francisco2Department of Epidemiology and Biostatistics, University of California, San Francisco8Department of Ophthalmology, University of California, San Francisco
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Sun CQ, Lalitha P, Prajna NV, Karpagam R, Geetha M, O'Brien KS, Oldenburg CE, Ray KJ, McLeod SD, Acharya NR, Lietman TM. Association between in vitro susceptibility to natamycin and voriconazole and clinical outcomes in fungal keratitis. Ophthalmology 2014; 121:1495-500.e1. [PMID: 24746358 DOI: 10.1016/j.ophtha.2014.03.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 03/01/2014] [Accepted: 03/04/2014] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To assess the association between minimum inhibitory concentration (MIC) and clinical outcomes in a fungal keratitis clinical trial. DESIGN Experimental study using data from a randomized comparative trial. PARTICIPANTS Of the 323 patients enrolled in the trial, we were able to obtain MIC values from 221 patients with monocular fungal keratitis. METHODS The Mycotic Ulcer Treatment Trial I was a randomized, double-masked clinical trial comparing clinical outcomes of monotherapy with topical natamycin versus voriconazole for the treatment of fungal keratitis. Speciation and determination of MIC to natamycin and voriconazole were performed according to Clinical and Laboratory Standards Institute guidelines. The relationship between MIC and clinical outcome was assessed. MAIN OUTCOME MEASURES The primary outcome was 3-month best spectacle-corrected visual acuity. Secondary outcomes included 3-month infiltrate or scar size; corneal perforation and/or therapeutic penetrating keratoplasty; and time to re-epithelialization. RESULTS A 2-fold increase in MIC was associated with a larger 3-month infiltrate or scar size (0.21 mm; 95% confidence interval [CI], 0.10-0.31; P < 0.001) and increased odds of perforation (odds ratio, 1.32; 95% CI, 1.04-1.69; P = 0.02). No correlation was found between MIC and 3-month visual acuity. For natamycin-treated cases, an association was found between higher natamycin MIC with larger 3-month infiltrate or scar size (0.29 mm; 95% CI, 0.15-0.43; P < 0.001) and increased perforations (odds ratio, 2.41; 95% CI, 1.46-3.97; P < 0.001). Among voriconazole-treated cases, the voriconazole MIC did not correlate with any of the measured outcomes in the study. CONCLUSIONS Decreased susceptibility to natamycin was associated with increased infiltrate or scar size and increased odds of perforation. There was no association between susceptibility to voriconazole and outcome.
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Affiliation(s)
- Catherine Q Sun
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | | | | | | | | | - Kieran S O'Brien
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Catherine E Oldenburg
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Kathryn J Ray
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Stephen D McLeod
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Nisha R Acharya
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California
| | - Thomas M Lietman
- F.I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, California.
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Srinivasan M, Mascarenhas J, Rajaraman R, Ravindran M, Lalitha P, O'Brien KS, Glidden DV, Ray KJ, Oldenburg CE, Zegans ME, Whitcher JP, McLeod SD, Porco TC, Lietman TM, Acharya NR. The steroids for corneal ulcers trial (SCUT): secondary 12-month clinical outcomes of a randomized controlled trial. Am J Ophthalmol 2014; 157:327-333.e3. [PMID: 24315294 DOI: 10.1016/j.ajo.2013.09.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 09/24/2013] [Accepted: 09/24/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To determine whether topical corticosteroids as adjunctive therapy for bacterial keratitis improves long-term clinical outcomes. DESIGN Randomized, placebo-controlled, double-masked clinical trial. METHODS This multicenter trial compared 1.0% prednisolone sodium phosphate to placebo in the treatment of bacterial keratitis among 500 patients with culture-positive ulcers receiving 48 hours of moxifloxacin before randomization. The primary endpoint was 3 months from enrollment, and 399 patients were evaluated at 12 months. The outcomes examined were best spectacle-corrected visual acuity (BSCVA) and scar size at 12 months. Based on previous results, regression models with adjustments for baseline status and/or causative organism were used for analysis. RESULTS No significant differences in clinical outcomes by treatment group were seen with the prespecified regression models (BSCVA: -0.04 logMAR, 95% CI, -0.12 to 0.05, P = .39; scar size: 0.03 mm, 95% CI, -0.12 to 0.18, P = .69). A regression model including a Nocardia-treatment arm interaction found corticosteroid use associated with a mean 1-line improvement in BSCVA at 12 months among patients with non-Nocardia ulcers (-0.10 logMAR, 95% CI, -0.19 to -0.02, P = .02). No significant difference was observed in 12-month BSCVA for Nocardia ulcers (0.18 logMAR, 95% CI, -0.04 to 0.41, P = .16). Corticosteroids were associated with larger mean scar size at 12 months among Nocardia ulcers (0.47 mm, 95% CI, 0.06-0.88, P = .02) and no significant difference was identified by treatment for scar size for non-Nocardia ulcers (-0.06 mm, 95% CI, -0.21 to 0.10, P = .46). CONCLUSIONS Adjunctive topical corticosteroid therapy may be associated with improved long-term clinical outcomes in bacterial corneal ulcers not caused by Nocardia species.
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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] [What about the content of this article? (0)] [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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Prajna NV, Srinivasan M, Lalitha P, Krishnan T, Rajaraman R, Ravindran M, Mascarenhas J, Oldenburg CE, Ray KJ, McLeod SD, Acharya NR, Lietman TM. Differences in clinical outcomes in keratitis due to fungus and bacteria. JAMA Ophthalmol 2013; 131:1088-9. [PMID: 23929517 DOI: 10.1001/jamaophthalmol.2013.1612] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Sun CQ, Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Srinivasan M, Raghavan A, O'Brien KS, Ray KJ, McLeod SD, Porco TC, Acharya NR, Lietman TM. Expert prior elicitation and Bayesian analysis of the Mycotic Ulcer Treatment Trial I. Invest Ophthalmol Vis Sci 2013; 54:4167-73. [PMID: 23702779 DOI: 10.1167/iovs.13-11716] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To perform a Bayesian analysis of the Mycotic Ulcer Treatment Trial I (MUTT I) using expert opinion as a prior belief. METHODS MUTT I was a randomized clinical trial comparing topical natamycin or voriconazole for treating filamentous fungal keratitis. A questionnaire elicited expert opinion on the best treatment of fungal keratitis before MUTT I results were available. A Bayesian analysis was performed using the questionnaire data as a prior belief and the MUTT I primary outcome (3-month visual acuity) by frequentist analysis as a likelihood. RESULTS Corneal experts had a 41.1% prior belief that natamycin improved 3-month visual acuity compared with voriconazole. The Bayesian analysis found a 98.4% belief for natamycin treatment compared with voriconazole treatment for filamentous cases as a group (mean improvement 1.1 Snellen lines, 95% credible interval 0.1-2.1). The Bayesian analysis estimated a smaller treatment effect than the MUTT I frequentist analysis result of 1.8-line improvement with natamycin versus voriconazole (95% confidence interval 0.5-3.0, P = 0.006). For Fusarium cases, the posterior demonstrated a 99.7% belief for natamycin treatment, whereas non-Fusarium cases had a 57.3% belief. CONCLUSIONS The Bayesian analysis suggests that natamycin is superior to voriconazole when filamentous cases are analyzed as a group. Subgroup analysis of Fusarium cases found improvement with natamycin compared with voriconazole, whereas there was almost no difference between treatments for non-Fusarium cases. These results were consistent with, though smaller in effect size than, the MUTT I primary outcome by frequentist analysis. The accordance between analyses further validates the trial results. (ClinicalTrials.gov number, NCT00996736.).
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Affiliation(s)
- Catherine Q Sun
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California, USA
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Seider MI, McLeod SD, Porco TC, Schallhorn SC. The effect of procedure room temperature and humidity on LASIK outcomes. Ophthalmology 2013; 120:2204-8. [PMID: 23769199 DOI: 10.1016/j.ophtha.2013.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 03/11/2013] [Accepted: 04/12/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To determine whether procedure room temperature or humidity during LASIK affect refractive outcomes in a large patient sample. DESIGN Retrospective cohort study. PARTICIPANTS A total of 202 394 eyes of 105 712 patients aged 18 to 75 years who underwent LASIK at an Optical Express, Inc., location in their United Kingdom and Ireland centers from January 1, 2008, to June 30, 2011, who met inclusion criteria. METHODS Patient age, gender, flap creation technique, pre- and 1-month post-LASIK manifest refraction, and ambient temperature and humidity during LASIK were recorded. Effect size determination and univariate and multivariate analyses were performed to characterize the relationships between LASIK procedure room temperature and humidity and postoperative refractive outcome. MAIN OUTCOME MEASURES One month post-LASIK manifest refraction. RESULTS No clinically significant effect of procedure room temperature or humidity was found on LASIK refractive outcomes. When considering all eyes in our population, an increase of 1°C during LASIK was associated with a 0.003 diopter (D) more hyperopic refraction 1 month postoperatively, and an increase in 1% humidity was associated with a 0.0004 more myopic refraction. These effect sizes were the same or similar when considering only myopic eyes, only hyperopic eyes, and subgroups of eyes stratified by age and preoperative refractive error. CONCLUSIONS Neither procedure room temperature nor humidity during LASIK were found to have a clinically significant relationship with postoperative manifest refraction in our population.
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Affiliation(s)
- Michael I Seider
- Department of Ophthalmology, University of California, San Francisco, California.
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Oldenburg CE, Lalitha P, Srinivasan M, Rajaraman R, Ravindran M, Mascarenhas J, Borkar DS, Ray KJ, Zegans ME, McLeod SD, Porco TC, Lietman TM, Acharya NR. Emerging moxifloxacin resistance in Pseudomonas aeruginosa keratitis isolates in South India. Ophthalmic Epidemiol 2013; 20:155-8. [PMID: 23662986 PMCID: PMC3746029 DOI: 10.3109/09286586.2013.790978] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To describe temporal trends in Pseudomonas aeruginosa resistance to moxifloxacin in keratitis isolates from South India. METHODS The Steroids for Corneal Ulcers Trial (SCUT) was a randomized, double-masked, placebo-controlled trial assessing outcomes in patients with culture positive bacterial corneal ulcers randomized to receive prednisolone phosphate or placebo. All patients received moxifloxacin, and susceptibility to moxifloxacin was measured at baseline using Etest. We investigated trends in moxifloxacin susceptibility of P. aeruginosa during 2007, 2008, and 2009 isolated in SCUT in South India. RESULTS There were 89 P. aeruginosa isolates during 2007, 2008, and 2009 in SCUT that were eligible for this study. There was an increase in the proportion of resistant isolates from 19% in 2007 to 52% in 2009 (p = 0.02, χ(2) test for trend). Logistic regression showed that there was a 2-fold increase in odds of resistance per 1 year increase during the study period (odds ratio 2.16, 95% confidence interval 1.09-4.26, p = 0.027). CONCLUSIONS We found a sharp increase in the proportion of isolates that were resistant to moxifloxacin from 2007 to 2009. Further work needs to be done to characterize the nature of this increase.
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Affiliation(s)
| | | | | | | | | | | | - Durga S. Borkar
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | | | - Stephen D. McLeod
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Nisha R. Acharya
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
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Ray KJ, Prajna L, Srinivasan M, Geetha M, Karpagam R, Glidden D, Oldenburg CE, Sun CQ, McLeod SD, Acharya NR, Lietman TM. Fluoroquinolone treatment and susceptibility of isolates from bacterial keratitis. JAMA Ophthalmol 2013; 131:310-3. [PMID: 23307105 DOI: 10.1001/jamaophthalmol.2013.1718] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To analyze the relationship between fluoroquinolone use at presentation and minimum inhibitory concentration in bacterial keratitis. METHODS The Steroids for Corneal Ulcers Trial was a randomized, double-masked, placebo-controlled trial assessing the effect of adjunctive topical corticosteroid treatment on outcomes in bacterial keratitis. After presentation, all patients were treated with moxifloxacin hydrochloride, 0.5%. We compare antibiotic use at presentation with minimum inhibitory concentration against moxifloxacin for all isolates. Separate analyses accounted for organism species and fluoroquinolone generation. RESULTS Topical fluoroquinolone use at presentation was reported in 92 of 480 cases (19.2%). Causative organisms in the 480 cases included Streptococcus pneumoniae (247 cases [51.5%]), Pseudomonas aeruginosa (109 cases [22.7%]), and Nocardia species (55 cases [11.5%]). Isolates from patients who reported fluoroquinolone use at presentation had a 2.01-fold-higher minimum inhibitory concentration (95% CI, 1.39-fold to 2.91-fold; P < .001). Fourth-generation fluoroquinolones were associated with a 3.48-fold-higher minimum inhibitory concentration than those isolates that were not exposed to pretreatment at enrollment (95% CI, 1.99-fold to 6.06-fold; P < .001). CONCLUSION This study provides evidence that prior use of fluoroquinolones is associated with antibiotic resistance. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00324168.
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Affiliation(s)
- Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco, CA 94143-0412, USA
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Borkar DS, Fleiszig SMJ, Leong C, Lalitha P, Srinivasan M, Ghanekar AA, Tam C, Li WY, Zegans ME, McLeod SD, Lietman TM, Acharya NR. Association between cytotoxic and invasive Pseudomonas aeruginosa and clinical outcomes in bacterial keratitis. JAMA Ophthalmol 2013; 131:147-53. [PMID: 23411878 DOI: 10.1001/jamaophthalmol.2013.778] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine whether cytotoxic and invasive Pseudomonas aeruginosa strains differentially influence clinical presentation, outcomes, or therapeutic response in bacterial keratitis. METHODS Pseudomonas aeruginosa isolates from the National Eye Institute-funded Steroids for Corneal Ulcers Trial were subtyped as cytotoxic or invasive strains. The main outcome measure compared between the 2 subtypes was change in visual acuity at 3 months using Huber robust regression, adjusting for topical corticosteroid treatment. RESULTS Of 101 confirmed P aeruginosa isolates from the Steroids for Corneal Ulcers Trial, 74 had a classically cytotoxic or invasive genotype. While corneal ulcers caused by genotypically invasive P aeruginosa strains were associated at presentation with significantly better visual acuity than corneal ulcers caused by genotypically cytotoxic P aeruginosa strains when adjusting for the effect of ulcer location (P= .008), invasive ulcers had improved significantly less than cytotoxic ulcers at 3 months (0.35; 95% CI, 0.04-0.66 logMAR; P= .03 [3.5-line difference]). Compared with topical moxifloxacin alone, adjunctive treatment with topical corticosteroids was associated with significantly more improvement in visual acuity in the invasive subgroup (P= .04) but was associated with less improvement in visual acuity in the cytotoxic subgroup (P= .07). CONCLUSIONS Rational profiling of differentially expressed virulence determinants (eg, cytotoxicity and invasiveness for P aeruginosa) could be used as a tool for decision making in the management of infections to optimize outcomes.
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Affiliation(s)
- Durga S Borkar
- F. I. Proctor Foundation, University of California, San Francisco, San Francisco, CA 94143-0412, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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See CW, Srinivasan M, Saravanan S, Oldenburg CE, Esterberg EJ, Ray KJ, Glaser TS, Tu EY, Zegans ME, McLeod SD, Acharya NR, Lietman TM. Prior elicitation and Bayesian analysis of the Steroids for Corneal Ulcers Trial. Ophthalmic Epidemiol 2013; 19:407-13. [PMID: 23171211 DOI: 10.3109/09286586.2012.735332] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To elicit expert opinion on the use of adjunctive corticosteroid therapy in bacterial corneal ulcers. To perform a Bayesian analysis of the Steroids for Corneal Ulcers Trial (SCUT), using expert opinion as a prior probability. METHODS The SCUT was a placebo-controlled trial assessing visual outcomes in patients receiving topical corticosteroids or placebo as adjunctive therapy for bacterial keratitis. Questionnaires were conducted at scientific meetings in India and North America to gauge expert consensus on the perceived benefit of corticosteroids as adjunct treatment. Bayesian analysis, using the questionnaire data as a prior probability and the primary outcome of SCUT as a likelihood, was performed. For comparison, an additional Bayesian analysis was performed using the results of the SCUT pilot study as a prior distribution. RESULTS Indian respondents believed there to be a 1.21 Snellen line improvement, and North American respondents believed there to be a 1.24 line improvement with corticosteroid therapy. The SCUT primary outcome found a non-significant 0.09 Snellen line benefit with corticosteroid treatment. The results of the Bayesian analysis estimated a slightly greater benefit than did the SCUT primary analysis (0.19 lines verses 0.09 lines). CONCLUSION Indian and North American experts had similar expectations on the effectiveness of corticosteroids in bacterial corneal ulcers; that corticosteroids would markedly improve visual outcomes. Bayesian analysis produced results very similar to those produced by the SCUT primary analysis. The similarity in result is likely due to the large sample size of SCUT and helps validate the results of SCUT.
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Affiliation(s)
- Craig W See
- FI Proctor Foundation, University of California, San Francisco, CA 94143-0412, USA
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Lalitha P, Srinivasan M, Rajaraman R, Ravindran M, Mascarenhas J, Priya JL, Sy A, Oldenburg CE, Ray KJ, Zegans ME, McLeod SD, Lietman TM, Acharya NR. Nocardia keratitis: clinical course and effect of corticosteroids. Am J Ophthalmol 2012; 154:934-939.e1. [PMID: 22959881 DOI: 10.1016/j.ajo.2012.06.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 06/12/2012] [Accepted: 06/13/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To compare the clinical course of Nocardia species keratitis with keratitis resulting from other bacterial organisms and to assess the effect of corticosteroids as adjunctive therapy using data collected from the Steroids for Corneal Ulcers Trial. DESIGN Subgroup analysis of a randomized controlled trial. METHODS setting: Multicenter randomized controlled trial. study population: Five hundred patients with bacterial keratitis randomized 1:1 to topical corticosteroid or placebo who had received at least 48 hours of topical moxifloxacin. intervention/observation procedure: Topical prednisolone phosphate 1% or placebo and clinical course of Nocardia keratitis. main outcome measures: Best spectacle-corrected visual acuity and infiltrate or scar size at 3 months from enrollment. RESULTS Of 500 patients enrolled in the trial, 55 (11%) had a Nocardia corneal ulcer. Patients with Nocardia ulcers had better presentation visual acuity compared with non-Nocardia ulcers (median Snellen visual acuity, 20/45, compared with 20/145; P < .001) and comparable 3-month visual acuity (median, 20/25, vs 20/40; P = .25). Nocardia ulcers had approximately 2 lines less of improvement in visual acuity compared with non-Nocardia ulcers (0.21 logarithm of the minimal angle of resolution; 95% confidence interval, 0.09 to 0.33 logarithm of the minimal angle of resolution; P = .001). This difference may reflect the better starting visual acuity in patients with Nocardia ulcers. In Nocardia ulcers, corticosteroids were associated with an average 0.4-mm increase in 3-month infiltrate or scar size (95% confidence interval, 0.03 to 0.77 mm; P = .03). CONCLUSIONS Nocardia ulcers responded well to treatment. They showed less overall improvement in visual acuity than non-Nocardia ulcers, but had better presentation acuity. Corticosteroids may be associated with worse outcomes.
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Gilmer W, McLeod SD, Jeng BH. Laboratory model of bursting pressures of femtosecond laser-assisted penetrating keratoplasty wounds using novel pattern designs. Br J Ophthalmol 2012; 96:1273-4. [PMID: 22694963 DOI: 10.1136/bjophthalmol-2012-302037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Srinivasan M, Mascarenhas J, Rajaraman R, Ravindran M, Glidden D, Oldenburg CE, Whitcher JP, Zegans ME, McLeod SD, Lietman TM, Acharya NR, Steroids For Corneal Ulcers Trial Group FT. Subgroup analysis in the steroids for corneal ulcers trial-reply. Arch Ophthalmol 2012; 130:807-808. [PMID: 23753737 PMCID: PMC3845516 DOI: 10.1001/archophthalmol.2012.352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Dalmon C, Porco TC, Lietman TM, Prajna NV, Prajna L, Das MR, Kumar JA, Mascarenhas J, Margolis TP, Whitcher JP, Jeng BH, Keenan JD, Chan MF, McLeod SD, Acharya NR. The clinical differentiation of bacterial and fungal keratitis: a photographic survey. Invest Ophthalmol Vis Sci 2012; 53:1787-91. [PMID: 22395880 DOI: 10.1167/iovs.11-8478] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The purpose of this study was to determine whether clinical signs of infectious keratitis can be used to identify the causative organism. METHODS Eighty photographs of eyes with culture-proven bacterial keratitis or smear-proven fungal keratitis were randomly selected from 2 clinical trials. Fifteen cornea specialists from the F. I. Proctor Foundation and the Aravind Eye Care System assessed the photographs for prespecified clinical signs of keratitis, and they identified the most likely causative organism. RESULTS Clinicians were able to correctly distinguish bacterial from fungal etiology 66% of the time (P < 0.001). The Gram stain, genus, and species were accurately predicted 46%, 25%, and 10% of the time, respectively. The presence of an irregular/feathery border was associated with fungal keratitis, whereas a wreath infiltrate or an epithelial plaque was associated with bacterial keratitis. CONCLUSIONS Cornea specialists correctly differentiated bacterial from fungal keratitis more often than chance, but in fewer than 70% of cases. More specific categorization led to less successful clinical distinction. Although certain clinical signs of infectious keratitis may be associated with a bacterial or fungal etiology, this study highlights the importance of obtaining appropriate microbiological testing during the initial clinical encounter.
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Affiliation(s)
- Cyril Dalmon
- F. I. Proctor Foundation and Department of Ophthalmology, University of California-San Francisco, 513 Parnassus Avenue, San Francisco, CA 94143, USA
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Lalitha P, Srinivasan M, Manikandan P, Bharathi MJ, Rajaraman R, Ravindran M, Cevallos V, Oldenburg CE, Ray KJ, Toutain-Kidd CM, Glidden DV, Zegans ME, McLeod SD, Acharya NR, Lietman TM. Relationship of in vitro susceptibility to moxifloxacin and in vivo clinical outcome in bacterial keratitis. Clin Infect Dis 2012; 54:1381-7. [PMID: 22447793 DOI: 10.1093/cid/cis189] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND For bacterial infections, the susceptibility to antibiotics in vitro has been associated with clinical outcomes in vivo, although the importance of minimum inhibitory concentration (MIC) has been debated. In this study, we analyzed the association of MIC on clinical outcomes in bacterial corneal ulcers, while controlling for organism and severity of disease at presentation. METHODS Data were collected as part of a National Eye Institute-funded, randomized, controlled trial (the Steroids for Corneal Ulcers Trial [SCUT]). All cases enrolled in SCUT had a culture-positive bacterial corneal ulcer and received moxifloxacin. The MIC to moxifloxacin was measured by E test. Outcomes included best spectacle-corrected visual acuity, infiltrate/scar size, time to re-epithelialization, and corneal perforation. RESULTS Five hundred patients with corneal ulcers were enrolled in the trial, and 480 were included in this analysis. The most commonly isolated organisms were Streptococcus pneumoniae and Pseudomonas aeruginosa. A 2-fold increase in MIC was associated with an approximately 0.02 logMAR decrease in visual acuity at 3 weeks, approximately 1 letter of vision loss on a Snellen chart (0.019 logMAR; 95% confidence interval [CI], .0040-.033; P = .01). A 2-fold increase in MIC was associated with an approximately 0.04-mm larger infiltrate/scar size at 3 weeks (0.036 mm; 95% CI, .010-.061; P = .006). After controlling for organism, a higher MIC was associated with slower time to re-epithelialization (hazards ratio, 0.92; 95% CI, .86-.97; P = .005). CONCLUSIONS In bacterial keratitis, a higher MIC to the treating antibiotic is significantly associated with worse clinical outcomes, with approximately 1 line of vision loss per 32-fold increase in MIC. CLINICAL TRIALS REGISTRATION NCT00324168.
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Affiliation(s)
- Prajna Lalitha
- Department of Ocular Microbiology, Aravind Eye Care System, Madurai, India
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