13.1 Cornea

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HEDS [i,ii]

ACV = PO aciclovir   TFD = topical trifluridine   Steroid = pred. phosphate

Barron, B.A., Gee, L., Hauck, W.W. et al. 1994. Herpetic Eye Disease Study. A controlled trial of oral acyclovir for herpes simplex stromal keratitis. Ophthalmology 101(12) 1871-1882.

Wilhelmus, K.R., Gee, L., Hauck, W.W. et al. 1994. Herpetic Eye Disease Study. A controlled trial of topical corticosteroids for herpes simplex stromal keratitis. Ophthalmology 101(12) 1883-1895; discussion 1895-1886

HEDS Keratitis Add Already on Outcome
1 Epithelial ACV TFD <b>No benefit</b> = add ACV if 1. Stromal Keratitis or 2. Uveitis
2 Stromal Steroid TFD <b>Benefit</b> = 1. Faster resolution 2. Less recurrence 3. Less uveitis
3 Stromal ACV TFD + steroid <b>No benefit</b> in non-necrotising keratitis (but possible benefit in necrotizing stromal disease) NB: HEDS didn’t analyse disciform keratitis as subgroup
4 Uveitis ACV TFD + steroid <b>May have benefit</b> (study stopped because of poor recruitment)
5 Recurrence Prophylaxis ACV Nothing <b>Benefit</b> = reduced recurrence by 50% (if prior stromal keratitis, then 10x ­ risk of future stromal disease)
Triggers No triggers identified (stress, systemic infection, sunlight, menstruation, CL wear, eye injury)

SCUT 1 [iii]

No difference in 3-month BCVA, safety, scar size, re-epithelialisation, corneal perforation with topical steroids given after 48 hours of moxifloxacin for corneal ulcers. Subgroup analysis found benefit for those with BCVA of CF or less or with central 4mm corneal involvement

Srinivasan, M., Mascarenhas, J., Rajaraman, R. et al. 2012. Corticosteroids for bacterial keratitis: the Steroids for Corneal Ulcers Trial (SCUT). Arch Ophthalmol 130(2) 143-150.

SCUT 2 [iv]

No difference in 12-month BCVA or scar. Subgroup analysis found that non-Nocardial infections had 1-line better BCVA and a significantly smaller scar with the early introduction of steroids. Of note, Nocardia is extremely rare in Australia and New Zealand

Srinivasan, M., Mascarenhas, J., Rajaraman, R. et al. 2014. The steroids for corneal ulcers trial (SCUT): secondary 12-month clinical outcomes of a randomized controlled trial. Am J Ophthalmol 157(2) 327-333.e323.

QLD Steroid Study [v]

Cohort of 328 patients of which 50% received high dose steroid within 7 days of infection. Odds ratio of better visual outcomes with high dose steroids was 5.49

Green, M., Hughes, I., Hogden, J. et al. 2019. High-Dose Steroid Treatment of Bacterial Keratitis. Cornea 38(2) 135-140.

MUTT 1 [vi]

Natamycin 5% vs. voriconazole 1% for filamentous fungal keratitis. Natamycin better outcomes (VA and less perforation; particularly for fusarium). Primary outcome VA 3 months

Prajna, N.V., Krishnan, T., Mascarenhas, J. et al. 2013. The mycotic ulcer treatment trial: a randomized trial comparing natamycin vs voriconazole. JAMA Ophthalmol 131(4) 422-429.

MUTT 2 [vii]

Topical antifungals with PO voriconazole or placebo for filamentous fungal keratitis. Primary outcome was corneal perforation at 3 months. No benefit in adding PO voriconazole. Most were fusarium or aspergillus

Prajna, N.V., Krishnan, T., Rajaraman, R. et al. 2016. Effect of Oral Voriconazole on Fungal Keratitis in the Mycotic Ulcer Treatment Trial II (MUTT II): A Randomized Clinical Trial. JAMA Ophthalmol 134(12) 1365-1372.

          

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