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JAMA Ophthalmology Journal Club Slides: Mycotic Ulcer Treatment Trial

JAMA Ophthalmology Journal Club Slides: Mycotic Ulcer Treatment Trial.

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JAMA Ophthalmology Journal Club Slides: Mycotic Ulcer Treatment Trial

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  1. JAMA Ophthalmology Journal Club Slides:Mycotic Ulcer Treatment Trial Prajna NV, Krishnan T, Mascarenhas J, et al; Mycotic Ulcer Treatment Trial Group. The Mycotic Ulcer Treatment Trial: a randomized trial comparing natamycin vs voriconazole. JAMA Ophthalmol. Published online December 10, 2012. doi:10.1001/jamaophthalmol.2013.1497.

  2. Introduction • Infectious keratitis is a leading cause of monocular blindness globally, and fungal keratitis accounts for about 50% of all corneal ulcers. • Fungal keratitis is more difficult to treat than bacterial corneal ulcers and often results in worse outcomes. • Natamycin is the only US Food and Drug Administration–approved antifungal for topical ophthalmic use, but expert opinion and in vitro results indicate that voriconazole may be superior. • Objective: • To compare topical natamycin vs topical voriconazole in the treatment of filamentous fungal keratitis.

  3. Methods • Study Design: Double-masked, multicenter, randomized controlled trial. • Participants: 368 patients with smear-positive filamentous fungal keratitis and visual acuity between 20/40 and 20/400 (inclusive). • Data Analysis: Best spectacle-corrected visual acuity (BSCVA) at 3 months analyzed in a multiple linear regression model with baseline BSCVA and treatment arm as covariates. • Limitations: • Enrolled patients only from South India. • No contact lens wearers enrolled. • Compared only topical monotherapies.

  4. Results • Natamycin-treated cases had significantly better 3-month BSCVA than voriconazole-treated cases (P = .006) • Natamycin-treated cases were less likely to have perforation or require therapeutic penetrating keratoplasty (P = .009). • Fusarium cases fared better with natamycin than with voriconazole for 3-month BSCVA (P < .001) and perforation (P = .001). • Non-Fusarium cases fared similarly for 3-month BSCVA (P = .81) and perforation (P = .86).

  5. Results Table title or figure legend with table or figure Abbreviation: BSCVA, best spectacle-corrected visual acuity.

  6. Results Abbreviation: TPK, therapeutic penetrating keratoplasty.

  7. Comment • Why voriconazole? • Recent survey of cornea specialists indicated that while natamycin was the most commonly used antifungal, voriconazole was largely preferred. • Isolates from fungal keratitis demonstrated good in vitro susceptibility to voriconazole. • The Mycotic Ulcer Topical Treatment Trial I (MUTT I) found that natamycin-treated cases had significantly better clinical and microbiological outcomes compared with voriconazole-treated cases. • Much of the difference was attributable to improvements seen in Fusarium cases.

  8. Contact Information • If you have questions, please contact the corresponding author: • Thomas M. Lietman, MD, Department of Ophthalmology, University of California, San Francisco, 513 Parnassus Ave, Box 0412, San Francisco, CA 94143-0412 (tom.lietman@ucsf.edu). Funding/Support • This work was supported by grants U10 EY018573 (Dr Lietman) and K23 EY017897 (Dr Acharya) from the National Eye Institute and grants from That Man May See, the Harper/Inglis Trust, the South Asia Research Foundation, and Research to Prevent Blindness (Drs Lietman and Acharya). Natamycin and voriconazole were donated by Alcon and Pfizer, respectively. Conflict of Interest Disclosures • None reported.

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