A unique feature of Epistemonikos is that it connects systematic reviews and their included studies. This allows clustering systematic reviews based on the primary studies they have in common. The concept of 'systematic reviews sharing included studies' is a proxy of 'systematic reviews answering a similar question'.
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<b>PURPOSE: </b>To analyse predictors of clinical outcome in fungal keratitis.<b>METHODS: </b>Data was collected during a prospective, randomized, controlled, double-masked clinical trial of treatment for fungal keratitis. Clinical features at presentation and demographics were collected at the enrollment visit for all patients. Pre-specified clinical outcomes included 3-month visual acuity and infiltrate/scar size, time to re-epithelialization, and corneal perforation. A separate multivariable model with each outcome as the dependent variable included all predictor variables.<b>RESULTS: </b>Predictors for worse 3-month visual acuity include older age (P=0.024), worse presentation visual acuity (P<0.001), larger infiltrate size at presentation (P<0.001), and pigmented ulcer (P=0.030). Larger infiltrate size at presentation was a significant predictor of worse 3-month infiltrate/scar size (P<0.001). Larger epithelial defect size was a significant predictor of perforation (P=0.0013). Predictors of longer time to re-epithelialization include infiltrate size at presentation (P<0.001) and older age (P=0.025).<b>CONCLUSION: </b>Ulcer severity at presentation is highly predictive of worse outcomes. Presentation of clinical characteristics such as baseline acuity and infiltrate scar can provide important information to clinicians about prognosis, and may help guide management and treatment decisions. Prevention of corneal ulcer remains important, as it is difficult to change the course of the ulcer once it has begun.
AIM: The management of suppurative keratitis due to filamentous fungi presents severe problems in tropical countries. The aim was to demonstrate the efficacy of chlorhexidine 0.2% drops as an inexpensive antimicrobial agent, which could be widely distributed for fungal keratitis.
METHODS: Successive patients presenting to the Chittagong Eye Institute and Training Complex with corneal ulcers were admitted to the trial when fungal hyphae had been seen on microscopy. They were randomised to drop treatment with chlorhexidine gluconate 0.2% or the standard local treatment natamycin 2.5%. The diameters, depths, and other features of the ulcers were measured and photographed at regular intervals. The outcome measures were healing at 21 days and presence or absence of toxicity. If there was not a favourable response at 5 days, "treatment failure" was recorded and the treatment was changed to one or more of three options, which included econazole 1% in the latter part of the trial.
RESULTS: 71 patients were recruited to the trial, of which 35 were randomised to chlorhexidine and 36 to natamycin. One allocated to natamycin grew bacteria and therefore was excluded from the analysis. None of the severe ulcers was fully healed at 21 days of treatment, but three of those allocated to chlorhexidine eventually healed in times up to 60 days. Of the nonsevere ulcers, 66.7% were healed at 21 days with chlorhexidine and 36.0% with natamycin, a relative efficacy (RE) of 1.85 (CL 1.01-3.39, p = 0.04). If those ulcers were excluded where fungi were seen in the scraping but did not grow on culture, the estimated efficacy ratio does not change but becomes less precise because of smaller numbers. Equal numbers of Aspergillus (22) and Fusarium (22) were grown. The Aspergillus were the most resistant to either primary treatment.
CONCLUSIONS: Chlorhexidine may have potential as an inexpensive topical agent for fungal keratitis and warrants further assessment as a first line treatment in situations where microbiological facilities and a range of antifungal agents are not available.
AIMS: Suppurative corneal ulcers due to filamentous fungi are a serious and intractable problem in many tropical developing countries. In vitro studies and a small pilot study have shown that chlorhexidine gluconate is effective. The aim was to establish the optimum concentration which would be appropriate to use in a larger randomized clinical trial.
METHODS: A masked randomized clinical trial of three concentrations of chlorhexidine compared with natamycin 5% was carried out in consecutive patients with established corneal ulcers shown by microscopy to contain fungal hyphae and later proven to be culture positive. Topical treatments were applied 1/2-hourly to 2-hourly for up to 5 days, with reduced frequency thereafter, and all patients were re-assessed at 21 days.
RESULTS: Of 60 patients entered in the trial, 2 were lost to follow-up, and 12 were classified as 'severe' with little prospect of recovery. At 5 days the response was related to the concentration of chlorhexidine, with 0.2% giving the best results. Compared with the response to natamycin as the referent, the relative efficacy was 1.17 with chlorhexidine 0.05%, 1.43 with 0.1%, and 2.00 with 0.2%. The superiority of 0.2% chlorhexidine over natamycin was statistically significant (relative efficacy 2.20, p = 0.043) in patients not having had prior antifungal treatment.
CONCLUSIONS: This preliminary study justifies further trials of chlorhexidine as a primary treatment for fungal corneal ulcers in circumstances where specific antifungal agents are not available.
AIM: To compare 2% econazole and 5% natamycin in the management of fungal keratitis.
METHODS: A randomised clinical trial was performed using 2% econazole or 5% natamycin as the two treatment arms on patients presenting with culture positive fungal keratitis to the cornea service at Aravind Eye Care System, Madurai, India.
RESULTS: 116 patients were recruited, and 112 continued in the study. There were no significant differences between the two arms at baseline or for success (defined as a healed or healing ulcer) at final visit (p = 0.79).
CONCLUSIONS: 2% Econazole appears to be as effective as 5% natamycin for the management of fungal keratitis.
OBJECTIVE: To compare the efficacy of topical voriconazole and topical natamycin with that of intrastromal voriconazole and topical natamycin in patients with recalcitrant fungal keratitis.
DESIGN: Randomized clinical trial.
PARTICIPANTS: Forty eyes of 40 patients with fungal keratitis (positive smear or culture results or both) larger than 2 mm, involving up to two thirds of the stromal depth, and not responding to topical natamycin therapy for 2 weeks were recruited.
INTERVENTION: The patients were randomized to receive either topical 1% voriconazole therapy (n = 20) or intrastromal injections of voriconazole 50 μg/0.1 ml (n = 20). The patients in both groups continued topical natamycin 5% every 4 hours until the ulcer healed.
MAIN OUTCOME MEASURES: Primary outcome measure was best spectacle-corrected visual acuity (BSCVA) 3 months after intervention, and secondary outcome measures were time to healing and the size of the scar.
RESULTS: The patients in both groups had comparable baseline parameters. The mean BSCVA after treatment was 1.295 ± 0.5 logarithm of the minimum angle of resolution (logMAR) units in the topical group and 1.692 ± 0.29 logMAR units in the intrastromal group. The visual acuity after treatment was significantly better in the topical voriconazole group (P = 0.008). Nineteen patients receiving topical voriconazole and 16 patients who were given intrastromal voriconazole healed with therapy.
CONCLUSIONS: Topical voriconazole seems to be a useful adjunct to natamycin in fungal keratitis not responding to topical natamycin. Intrastromal injections did not offer any beneficial effect over topical therapy.
PURPOSE: To evaluate the efficacy of topical (1%) and systemic itraconazole against common fungi such as Aspergillus and other filamentous fungi that cause mycotic corneal ulcer.
METHODS: A prospective randomised, controlled study was done in 54 clinically suspected cases of fungal keratitis of which 44 were culture proven. Half the cases (n=27) with superficial involvement were treated with only topical itraconazole (1%) and the other half were treated with both topical and systemic itraconazole.
RESULTS: Aspergillus, Penicillium and Fusarium were the most common fungi isolated. The ulcer resolved in 42 eyes (77%) and 12 eyes (23%) did not respond well to treatment. Four of 12 non-responding eyes were caused by Fusarium species.
CONCLUSION: Itraconazole, given either topically or systemically, is effective in treating mycotic corneal ulcers.
PURPOSE: The aim of the study was to compare the use of combination therapy of topical amphotericin B (0.5 mg/mL) eye drops together with subconjunctival injection of fluconazole (2 mg/mL) with the use of topical amphotericin B (0.5 mg/mL) eye drops alone in dealing with cases of fungal keratitis.
METHODS: The study was performed in the Ophthalmology Department, Zagazig University and included 48 eyes of 48 patients who presented clinically with fungal keratitis. Laboratory investigations were performed, including direct microscopy of corneal smear using gram staining and culture of corneal specimens using Saboraud agar media and bacterial agar media. According to laboratory results, cases were classified into 2 groups: group 1 comprising 24 eyes treated by a combination therapy of topical amphotericin B eye drops (0.5 mg/mL) with subconjunctival injection of fluconazole (2 mg/mL) and group 2 comprising 24 eyes treated by topical amphotericin B eye drops (0.5 mg/mL) alone.
RESULTS: Direct corneal smear for all 48 eyes included in the study revealed 18 eyes (38%) with positive fungal spores, 3 of them (6%) with gram-positive bacterial infection. Fungal culture of corneal specimens revealed positive result in 36 eyes (75%), including the positive corneal smear cases showing Candida in 12 eyes and filamentous fungi in 24 eyes. Treatment by a combination therapy in group 1 revealed statistically significant result (P < 0.05) of healing of corneal ulcers in 20 eyes (83%), with a mean duration of healing of 31 days (standard deviation [SD] +/-3), in comparison to group 2 with monotherapy, which revealed 16 eyes (67%), with a mean duration of healing of 37 days (SD +/-2).
CONCLUSION: Combination therapy of topical amphotericin B eye drops with subconjunctival injection of fluconazole was more efficient (according to the percentage and the duration of healing of the ulcers) than the use of topical amphotericin B eye drops alone in dealing with cases of fungal keratitis--it may be contributed to the broad spectrum of the antifungal agents of the combination therapy than the monotherapy.
100%Randomized controlled trial (RCT)