3014 EXPERIMENTAL AND THERAPEUTIC MEDICINE 12: 3014-3020, 2016 Excisional keratectomy combined with focal cryotherapy and amniotic membrane inlay for recalcitrant filamentary fungal keratitis: A retrospective comparative clinical data analysis YINGXIN CHEN1, MINGHONG GAO1, JOSHUA K. DUNCAN2, DI RAN3, DENISE J. ROE3, MICHAEL W. BELIN2 and MINGWU WANG2 1Department of Ophthalmology, The General Hospital of Shenyang Military Command, Shenyang, Liaoning 110016, P.R. China; 2Department of Ophthalmology and Visual Science, College of Medicine, The University of Arizona, Tucson, AZ 85711; 3Epidemiology and Biostatistics Division, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ 85724, USA Received August 20, 2015; Accepted July 21, 2016 DOI: 10.3892/etm.2016.3699 Abstract. The aim of the present study was to investigate Introduction the efficacy of a novel surgical intervention, excisional keratectomy combined with focal cryotherapy and amniotic Fungal keratitis has an prominently increasing morbidity, membrane inlay (EKCAI), for the treatment of recalcitrant accounting for 46.7% of purulent corneal infection in filamentary fungal keratitis. A retrospective analysis was China (1). It has been reported that filamentary fungi are performed of patients who underwent excisional kera- the most prevalent pathogens in China, wherein the genus tectomy combined with conjunctival flap inlay (EKCFI), Fusarium is the most common cause (77.6%) followed by EKCAI or therapeutic penetrating keratoplasty (TPK) from Aspergillus (10.8%) (2). A well-known contributing factor January 2006 to January 2011. Recalcitrance was determined for the development of fungal keratitis is ocular trauma, as being unresponsive to standard medical antifungal therapy specifically contamination of corneal lesions by soil and other for at ≥1 week. Outcome measures among the three interven- vegetative material (3). Notably, the majority of the patients tion modalities were compared. A total of 128 patients had suffering from fungal keratitis in China are farmers in whom a follow‑up of ≥1 year after the primary intervention. The early diagnosis is easily missed, and whose residences are success rates of interventions at 1-year follow-up were 58.33% commonly distant from well-equipped eye care facilities. in the EKCFI group, 88.37% in the EKCAI group and 93.44% Delays in diagnosis and the initiation of prompt antifungal in the TPK group (P<0.0002). The preoperative visual acuity medical therapy are the major reasons that many patients from of the three groups were similar (P=0.6458), while the post- rural areas present with advanced corneal infection (4). Since operative best-corrected visual acuity (BCVA) of patients approximately one-third of cases of fungal keratitis result in without recurrence was significantly different among the three either medical treatment failures or corneal perforations (5), it groups 3 months after surgery. The best postoperative BCVA has become a serious disease in China. When fungal corneal was found in the TPK group, while the worst was in the EKCFI infections become unresponsive to medical therapy, surgical group. In conclusion, EKCAI does not require donor cornea, intervention offers a second chance for eradicating the infec- is straightforward surgically, and has a favorable success rate tion and maintaining the globe integrity. compared with EKCFI. Although therapeutic penetrating keratoplasty (TPK) and lamellar keratoplasty (LK) have been shown to be effective in the management of recalcitrant fungal keratitis (6-9), the lack of donor corneas in China has forced ophthalmologists to investigate other treatment strategies. Given the massive rejection reaction and high graft failure rates associated with keratoplasty in the treatment of recalcitrant fungal keratitis, any Correspondence to: Dr Minghong Gao, Department of modality that avoids the requirement for a donor cornea would Ophthalmology, The General Hospital of Shenyang Military be of significant value in countries such as China (1,10,11). Area Command, 83 Wenhua Road, Shenyang, Liaoning 110016, P. R. Ch i na Historically, debulking the organism and necrotic mate- E-mail: [email protected] rial by daily debridement at the slit lamp was the mainstay of therapy for fungal keratitis. The removal of active infection and Key words: refractory fungal keratitis, cryotherapy, conjunctival devitalized tissue was conducted with the aim of enhancing flap, amniotic membrane inlay, therapeutic keratoplasty the penetration of topical antifungal medications. However, removal of the necrotic corneal tissue combined with conjunc- tival flap excisional keratectomy combined with conjunctival CHEN et al: EKCAI FOR RECALCITRANT FILAMENTARY FUNGAL KERATITIS 3015 flap inlay (EKCFI) is now becoming widely used in many failure, cases with corneal ulcers with the depth >70% of the tertiary eye care facilities in China (12). Additionally, cryo- corneal stroma were also preferentially treated with TPK if therapy combined with antifungal agents and/or corneoscleral donor corneas were available. Therefore, relatively severe grafting has been used successfully in cases of fungal scle- cases in the clinic tended to be treated with TPK. For cases ritis and keratoscleritis (13,14). Several groups have reported involving perforation as a result of medical treatment failure promising results using human amniotic membrane as an that did not receive TPK, the assignment of either EKCFI or adjunct for the treatment of active microbial keratitis (15-17). EKCAI was not randomized either, with more EKCAI proce- In a study conducted by Chen et al in 2006, human amniotic dures performed in later phase of the reviewed time frame. membrane was successfully used in active cases of fungal keratitis, even in some cases in which perforation had previ- Surgical procedures and postoperative treatment. All surgical ously occurred (18). These earlier reports demonstrate that interventions were performed under general or local retrobulbar non-keratoplasty modalities may be effective alternatives for anesthesia with 2.5 ml 2% lidocaine. Intraoperatively, 2 mg/ml the treatment of recalcitrant fungal keratitis. fluconazole solution was used to irrigate the corneal ulcers for In 2006, the present authors began employing human subconjunctival injection. The operated eyes were bandaged amniotic membrane and cryotherapy as adjuncts to surgical for 12 h postoperatively prior to the initiation of treatment. The interventions in the management of fungal keratitis using postoperative medical antifungal regimen was the same in all excisional keratectomy combined with focal cryotherapy and three treatment groups and consisted of 5% natamycin drops amniotic membrane inlay (EKCAI). The present study is a topically 6 times daily for the first week, 4 times daily for the retrospective analysis of all confirmed cases of filamentary second week, and twice daily for the following 2 additional fungal keratitis at a single institution, in which biostatistical weeks during waking hours. In addition, 1% atropine sulfate analysis was attempted to evaluate the efficacy of EKCAI ointment (1%; Alcon; Novartis International AG) was applied compared with that of conventional surgical therapies for once daily. recalcitrant fungal keratitis. EKCFI procedure. Details of the EKCFI procedure have been Materials and methods described previously by Sun et al (12). Briefly, the necrotic corneal tissue was removed with sharp dissection and two Patient enrolment and ethics. The charts of all patients 5-mm bulbar conjunctival incisions were made perpendicular with a diagnosis of fungal keratitis who were enrolled in the to the limbus at the 3:00 and 9:00 o'clock positions, respectively. General Hospital of Shenyang Military Command (Shenyang, The incisions were extended circumferentially along the limbus China) in-patient ophthalmology service from January 2006 to create superior and inferior conjunctival flaps, and then to January 2011, were reviewed and the cases that received undermined to the fornices. Two conjunctival flaps were then surgical intervention were retrieved from the records. Inclusion pulled centripetally onto the corneal surface and sutured in an criteria in this analysis were as follows: i) Filamentary keratitis interrupted manner to cover the debrided stromal ulcer bed. confirmed by corneal scrape culture or potassium hydroxide staining; ii) any cases of urgent surgical intervention due to EKCAI procedure. In the EKCFI procedure, after the ulcer bed corneal perforation either at presentation or within the first was debrided and dried with a surgical sponge, the entire area week of admission; iii) cases deemed as medical treatment of the ulcer was treated with a 3-mm cryoprobe, with involve- failure, defined as documentation of progression of corneal ment of the junctional region 1 mm beyond the edge of the ulcers after at least 1 week of appropriate medical treatment; ulcer. The duration of each treatment was 10 sec once the probe iv) patients who underwent surgical interventions and had reached‑70˚C. Dry amniotic membrane (Ruiji Biotechnology ≥1 year of follow‑up after surgery. Co. Ltd., Jiangxi, China) was first hydrated for 10 min in Medical treatment was standardized to topical 5% nata- balanced salt solution (BSS) solution. Multilayers of the amni- mycin eye drops (5%; Alcon; Novartis International AG, otic membrane were placed as inlays to cover the ulcer bed and Basel, Switzerland) every 2 h and 150 mg intravenous