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2019 OMIG Abstract

Evaluation of Serial Cultures for Risk Stratification of Fungal Keratitis in the Mycotic Antimicrobial Localized Injection Trial

Travis Redd, MD, MPH1, Julia Pickel, BA1, Shivananda Narayana, MS2, Tiruvengada Krishnan, DO, DNB2, Seema Ramakrishnan, DO, DNB2, Puja Prativa Samantaray, MS, FICO2, Ariana Austin, MS1,
Travis Porco, PhD1, Tom Lietman, MD1, Jennifer Rose-Nussbaumer, MD1
1Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA; 2Aravind Eye Hospital, Pondicherry, India

Purpose: Fungal keratitis is a major cause of corneal blindness, particularly in the developing world. It remains a significant challenge to diagnose and treat, and refractory cases often require surgical intervention including therapeutic penetrating keratoplasty (TPK). Prior studies have established that repeat culture positivity at day 6 is predictive of worse visual outcomes, increased risk of perforation, and need for TPK. However, given the high likelihood of poor visual outcomes with delayed treatment, earlier identification of high-risk cases is necessary. As a secondary analysis of the Mycotic Antimicrobial Localized Injection (MALIN) trial, we evaluated the utility of repeat cultures at day 3 and day 7 after presentation for predicting outcomes in fungal keratitis.

Methods: As part of the MALIN trial at Aravind Eye Hospital, patients age 18-70 with fungal keratitis and visual acuity worse than 20/70 received topical natamycin and were randomized to intrastromal injection of either voriconazole or placebo. All subjects received corneal cultures at date of presentation, day 3, and day 7. Subjects were followed for 3 months, and outcome measures included visual acuity, scar size, perforation, and need for TPK. Statistical analysis included bivariate comparisons and multivariate logistic regression.

Results: 70 subjects with fungal keratitis were included. 25/69 (36%) remained culture positive at day 3, and 20/62 (32%) were culture positive at day 7. Culture positivity at day 3 conferred an odds ratio of 4.4 for requiring TPK (p=0.01), but was not a statistically significant predictor of perforation, scar size, or final visual acuity. Culture positivity at day 7 had an odds ratio of 12.3 for requiring TPK (p<0.001), and was also a significant predictor of larger scar size (p=0.04) and worse final visual acuity (p=0.006).

Conclusion: While not as predictive as day 7 cultures, persistent culture positivity at day 3 after starting treatment is a significant predictor of need for TPK in patients with fungal keratitis. This has applications for risk stratification, and may facilitate earlier consideration of TPK in high-risk patients.

Disclosure: S.

Supported by the National Eye Institute, National Institutes of Health, Bethesda, Maryland (grant no: K23 EY025025 [J.R.-N.]), and Research to Prevent Blindness, Inc, New York, New York (J.R.-N.).



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