RESUMO
PURPOSE: To report clinical outcomes of rose bengal photodynamic antimicrobial therapy (RB-PDAT) as an adjunct treatment for severe, progressive infectious keratitis. DESIGN: Consecutive interventional case series. METHODS: Patients with progressive infectious keratitis unresponsive to standard medical therapy underwent RB-PDAT at the Bascom Palmer Eye Institute from January 2016 through March 2018. RB-PDAT was performed by applying a solution of rose bengal (0.1% or 0.2% RB in balanced salt solution) to the de-epithelialized cornea for 30 minutes, followed by irradiation with a 6 mW/cm2 custom-made green LED source for 15 minutes (5.4 J/cm2). RESULTS: The current study included 18 patients (7 male and 11 female) ranging from 17 to 83 years old. Acanthamoeba was the most frequent microbe (10/17; 59%), followed by Fusarium spp. (4/17; 24%), Pseudomonas aeruginosa (2/17; 12%), and Curvularia spp. (1/17; 6%); 1 patient had no confirmed microbiologic diagnosis. Main clinical risk factor for keratitis included contact lens wear (79%). The average area of epithelial defect prior to first RB-PDAT was 32 ± 27 mm2 and average stromal depth hyperreflectivity measured with anterior segment optical coherence tomography was 269 ± 75 µm. Successful RB-PDAT (avoidance of therapeutic keratoplasty) was achieved in 72% of the cases, with an average time to clinical resolution (decreased pain and inflammation with re-epithelialization and infiltrate resolution) of 46.9 ± 26.4 days after RB-PDAT. Time of follow-up after RB-PDAT was 13.3 ± 5.7 months. CONCLUSION: RB-PDAT can be considered as an adjunct therapy for cases of severe, progressive infectious keratitis before performing a therapeutic keratoplasty.
Assuntos
Anti-Infecciosos/uso terapêutico , Úlcera da Córnea/tratamento farmacológico , Infecções Oculares/tratamento farmacológico , Corantes Fluorescentes/uso terapêutico , Fotoquimioterapia , Rosa Bengala/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Úlcera da Córnea/microbiologia , Úlcera da Córnea/parasitologia , Infecções Oculares/microbiologia , Infecções Oculares/parasitologia , Feminino , Humanos , Ceratoplastia Penetrante , Luz , Masculino , Pessoa de Meia-Idade , Soluções Oftálmicas , Projetos Piloto , Estudos Retrospectivos , Adulto JovemRESUMO
INTRODUCTION: Cornea ulceration and infectious keratitis are leading causes of corneal morbidity and blindness. Infectious causes are among the most frequent and most severe. Management strategies for bacterial corneal ulcers have changed significantly over the last decades, however with a more limited progress in the treatment and management of nonbacterial, infectious ulcers. AREAS COVERED: This paper provides an overview of the current principles, strategies and treatment choices for infectious corneal ulcers in adults. EXPERT OPINION: Topical application with a broad-spectrum antimicrobial remains the preferred method for the pharmacological management of infectious corneal ulcers. Increasing reports of clinical failures and in vitro resistance to antibiotics to treat the most common infectious (bacterial) corneal ulcers are increasing concerns. New approaches for improvement in the pharmacological management of corneal ulcers should focus on strategies for a more rational and evidence-based use of current antimicrobials and development of products to modulate the host immune response and to neutralize microbial toxins and other immune modulators.
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Anti-Infecciosos/uso terapêutico , Úlcera da Córnea/tratamento farmacológico , Infecções Oculares/tratamento farmacológico , Ceratite/tratamento farmacológico , Administração Oftálmica , Corticosteroides/uso terapêutico , Anti-Infecciosos/administração & dosagem , Anti-Infecciosos/efeitos adversos , Anti-Infecciosos/farmacocinética , Úlcera da Córnea/diagnóstico , Úlcera da Córnea/microbiologia , Úlcera da Córnea/parasitologia , Úlcera da Córnea/virologia , Infecções Oculares/diagnóstico , Infecções Oculares/microbiologia , Infecções Oculares/parasitologia , Infecções Oculares/virologia , Infecções Oculares Bacterianas/tratamento farmacológico , Infecções Oculares Bacterianas/microbiologia , Infecções Oculares Fúngicas/tratamento farmacológico , Infecções Oculares Fúngicas/microbiologia , Infecções Oculares Parasitárias/tratamento farmacológico , Infecções Oculares Parasitárias/parasitologia , Infecções Oculares Virais/tratamento farmacológico , Infecções Oculares Virais/virologia , Humanos , Ceratite/diagnóstico , Ceratite/microbiologia , Ceratite/parasitologia , Ceratite/virologia , Testes de Sensibilidade Microbiana , Testes de Sensibilidade Parasitária , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the therapeutic effect of photo-activated riboflavin (PAR) for treating refractory corneal ulcers. METHODS: Seven eyes with infectious keratitis, presented with a gradually deteriorating, vision-threatening, corneal ulcer, despite intense antimicrobial therapy, were treated with PAR. The surgical procedure was deepithelialization of the affected corneas followed by UV-A riboflavin (B2) cross-linking. Local antimicrobial therapy was continued after the procedure. RESULTS: In all cases, the progression of corneal melting was halted after PAR treatment. Emergency keratoplasty was not necessary in any of the 7 eyes presented. More importantly, all the ulcers were healed without significant vascularization. CONCLUSION: PAR is a promising option for treating patients with therapy-refractory infectious keratitis to avoid emergency keratoplasty and should be considered as a potential adjuvant therapeutic tool in such eyes.
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Úlcera da Córnea/tratamento farmacológico , Infecções Oculares/tratamento farmacológico , Fotoquimioterapia , Fármacos Fotossensibilizantes/uso terapêutico , Riboflavina/uso terapêutico , Adolescente , Adulto , Idoso , Anti-Infecciosos/uso terapêutico , Úlcera da Córnea/microbiologia , Úlcera da Córnea/parasitologia , Infecções Oculares/microbiologia , Infecções Oculares/parasitologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Raios Ultravioleta , Acuidade Visual/fisiologiaRESUMO
PURPOSE: To present the first 3 cases of Acanthamoeba keratitis (AK), unresponsive to medical treatment, that were successfully treated with a novel adjunctive therapy using ultraviolet light A (UVA) and riboflavin (B2). DESIGN: Interventional case series. PARTICIPANTS: Two patients with confirmed AK and 1 patient with presumptive AK, which were all refractive to multidrug conventional therapy. INTERVENTION: Two treatment sessions involving topical application of 0.1% B2 solution to the ocular surface combined with 30 minutes of UVA irradiation focused on the corneal ulcer. MAIN OUTCOME MEASURES: Clinical examination by slit lamp, confocal microscopy, and histopathology, when available. RESULTS: All patients in these series showed a rapid reduction in their symptoms and decreased ulcer size after the first treatment session. The progress of the clinical improvement began to slow after 1 to 3 weeks of the first application and was then renewed after the second application. All ancillary signs of inflammation mostly resolved after the second treatment session. The ulcers in all patients continued to decrease and were closed within 3 to 7 weeks of the first application. Two patients developed dense central corneal scars, and penetrating keratoplasty was performed for visual rehabilitation. Histopathologic examination of the excised tissue revealed no Acanthamoeba organisms. The remaining patient had no symptoms or signs of infection, both clinically and by confocal microscopy, and was left with a semitransparent eccentric scar that did not affect visual acuity. CONCLUSIONS: The adjunctive use of UVA and B2 therapy seems to be a possible alternative for selected cases of medication-resistant AK.