부산대학교 도서관

To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1016/j.ajo.2018.05.007 Byline: Julie Cho (b), N. Venkatesh Prajna (a), Prajna Lalitha (a), Revathi Rajaraman (a), Tiruvengada Krishnan (a), Yijie (Brittany) Lin (b,c), Kathryn J. Ray (b), Thomas M. Lietman (b,c,d), Jennifer Rose-Nussbaumer [jennifer.rose@ucsf.edu] (b,c,*), N. Venkatesh Prajna, Prajna Lalitha, Jeena Mascarenhas, Muthiah Srinivasan, Manoranjan Das, Rajarathinam Karpagam, Malaiyandi Rajkumar, S.R. Sumithra, C. Sundar, Revathi Rajaraman, Anita Raghavan, P. Manikandan, K.Tiruvengada Krishnan, N. Shivananda, R. Meenakshi, J. Bharathi, E. Raja, Byanju Raghunandan, Kamal Bahadur Khadka, Ranjeet Shah, Anju Ligal, Thomas M. Lietman, Nisha R. Acharya, Stephen D. McLeod, Jennifer Rose-Nussbaumer, John P. Whitcher, Travis C. Porco, Salena Lee, Vicky Cevallos, Brett L. Shapiro, Catherine E. Oldenburg, Kieran S. O'Brien, Kevin C. Hong, Sushila Patel, Salma K.C. Rai, Bel Bahadur Thapa, Binita Bhattarai, Ramesh C. Giri, Abhijeet Sarkar, Santosh Ghimire, Krishna Kunwar, Roji Yadav, Srijana S. Gautam, Sandeep Bashyal, Rojina Begam, Amar Gautam, Marian Fisher, Anthony Aldave, Donald Everett, Jacqueline Glover, K. Ananda Kannan, Steven Kymes, Ivan Schwab, Thomas M. Lietman, Nisha R. Acharya, Stephen D. McLeod, Jennifer Rose-Nussbaumer, John P. Whitcher, Travis C. Porco, David Glidden, Salena Lee, Kathryn Ray, Vicky Cevallos, Brett L. Shapiro, Catherine E. Oldenburg, Kieran S. O'Brien, Kevin C. Hong, Donald Everett, Michael E. Zegans, Christine M. Kidd Objective To compare oral voriconazole vs placebo in addition to topical antifungals in the treatment of filamentous fungal keratitis. Design Non-prespecified, secondary case-control analysis from a multicenter, double-masked, randomized placebo-controlled clinical trial. Methods Study Participants: Patients with smear-positive filamentous fungal ulcers and visual acuity of 20/400 or worse who eventuated to therapeutic penetrating keratoplasty (TPK). Intervention: Study participants were randomized to oral voriconazole vs oral placebo; all received topical antifungal drops. Main Outcome Measures: TPK button culture positivity. Results A total of 95 of 194 (49.5%) study participants enrolled at Madurai, Coimbatore, or Pondicherry, India eventuated to TPK in an average of 20.9 days (standard deviation 15.2 days, range 2-71 days). TPK button cultures were available for 67 of 95 (71%) of the TPKs performed and were positive for filamentous fungus in 45 of 67 (67%) cases. For each 1-day increase in the time to TPK there was 0.94-fold decreased odds of fungal culture positivity (95% confidence interval [CI] 0.90--0.98, P = .005). Those randomized to oral voriconazole had 1.26-fold increased odds of TPK button culture positivity after controlling for time to TPK and baseline organism, but this was not statistically significant (95% CI 0.32--4.87; P = .74). Those who underwent TPK for lack of response to medical therapy were 10.64-fold more likely to be culture positive than if the indication for surgery was perforation and this was statistically significant (95% CI 2.16--51.70; P = .003). Conclusions There appears to be no benefit to adding oral voriconazole to topical antifungal agents in the treatment of severe filamentous fungal ulcers. Infection rather than inflammation appears to be the reason for the worsening clinical picture in many of these patients. Author Affiliation: (a) Aravind Eye Care System, Madurai, Pondicherry, India (b) Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, USA (c) Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA (d) Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA * Inquiries to Jennifer Rose-Nussbaumer, Assistant Professor, UCSF/Proctor Foundation, 513 Parnassus S334, San Francisco, CA 94122, USA Article History: Accepted 4 May 2018 (footnote) Supplemental Material available at AJO.com(http://AJO.com).