CORNEA 38 EWAP JUNE 2023 Dr. Beckman said he does not typically use steroids, though he thinks a lot of other physicians do. Steroid use for corneal ulcers has been debated. The Steroids for Corneal Ulcers Trial found that “adjunctive topical corticosteroid therapy may be associated with improved long-term clinical outcomes in bacterial corneal ulcers not caused by Nocardia species.” 1 “If one is going to use a steroid, you want to see there is clear improvement with antibiotics before you do it. Those signs would be the epithelium healing, the infiltrate consolidating, any inflammation going away, the anterior chamber (if there are cells) resolving, improved redness, improved comfort, and it really helps if you identified the bug on the original cultures,” Dr. Beckman said. Dr. Majmudar also said he likes to see some sort of clinical progress before starting steroids, but he’ll use them after 3–4 days in a compliant patient. EWAP Reference 1. Srinivasan M, et al. The Steroids for Corneal Ulcers Trial (SCUT): secondary 12-month clinical outcomes of a randomized controlled trial. Am J Ophthalmol. 2014;157:327–333. Editors’ note: Dr. Beckman practices at Comprehensive Eyecare of Central Ohio, Westerville, Ohio. Dr. Majmudar is Associate Professor of Ophthalmology, Rush University Medical Center, Chicago, Illinois. Neither declared any relevant financial interests. What about crosslinking? Over the last few years there have been studies and reports of crosslinking as a possible therapy for corneal ulcers caused by fungal infections. While these results have been “generally positive,” Dr. Majmudar said, they’re mixed. And it’s expensive. In the U.S., for example, Dr. Beckman said crosslinking for this indication would not be covered by insurance, and the riboflavin alone costs several thousand dollars. “It also doesn’t seem necessary. For a fungal infection, we have a lot of antifungals out there and they may do well. I’m not convinced from the data that it would be better. It seems like a last resort to potentially avoid a transplant.” On that note, Dr. Majmudar said that he thinks it may play a role in recalcitrant ulcers that would otherwise require a corneal transplant. Yachana Shah, MD Consultant Ophthalmologist, Lions Outback Vision 45 Frederick Street, Broome, Western Australia 6725 yachana.shah@lei.org.au ASIA-PACIFIC PERSPECTIVES Microbial keratitis (MK) is a widespread problem in developing countries, particularly in South Asia, where it has become an epidemic and poses a significant public health risk. The underlying causes of MK vary depending on several predisposing factors such as geographic location, age, gender, contact lens use, occupation, and gross national income. In India and China, fungal infections account for more than 50% of culture-positive MK cases, with filamentary fungi being common in tropical and subtropical regions, while yeast infections are more prevalent in temperate areas.1 In Australia, bacterial infections are the primary cause of MK, but the incidence of fungal MK rises in hotter climates, remote regions, and in individuals with previously compromised corneas. It is crucial for clinicians to be aware of the prevalence patterns specific to their regions to develop effective empirical treatment plans. I concur with Dr. Beckman’s observation that fungal infections may indeed be on the rise. At a major public hospital in Western Australia, we saw a steady influx of patients with fungal keratitis over the last few years. My guiding principle in treating patients with MK is to strive for a good visual outcome when keratitis shows positive response to treatment, and to pursue a diagnosis when the treatment is proving to be ineffective. By pursuing a good outcome, I mean diligently caring for the epithelium and promoting rapid healing that is sometimes achieved by cutting back on the eyedrops or changing over to preservative free options where possible. The use of topical steroids is a controversial subject in this context but there is a role for it when used with caution, under close watch and when the etiology is not fungal. Patients who have develop keratitis while already on topical immunosuppression often deteriorate rapidly on cessation of steroids despite being on targeted therapy. Pursuing a diagnosis in a worsening scenario is just as important as it is at the start of treatment. Even if it may appear late for the current situation, it can still provide valuable insights for early prophylaxis after surgery. Certain presentations can be deceptive, such as Candida keratitis closely resembling bacterial keratitis or a secondary infection in a neurotrophic ulcer can often lead to treatment delays. Repeat testing with more material, considering rare causes, and being mindful of the possibility of mixed etiology can go a long way in formulating treatment plans. If all other approaches prove ineffective, it becomes essential to promptly consider therapeutic keratoplasty, as larger infiltrate size and graft size can have a detrimental effect on graft survival. Reference 1. Ung L, et al. The persistent dilemma of microbial keratitis: Global burden, diagnosis, and antimicrobial resistance. Surv Ophthalmol. 2019 May-Jun;64(3):255-271. doi: 10.1016/j.survophthal.2018.12.003. Epub 2018 Dec 24. PMID: 30590103; PMCID: PMC7021355. Editors’ note: Dr. Shah declared no financial interests related to her comments.
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