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感染染性角膜炎治疗的最新进展 Update on the Management of Infectious Keratitis

Austin, A., Lietman, T., Rose-Nussbaumer, J.





摘要:感染染性角膜炎是全球视力损害和失明的主要原因,常常影响边缘化人群。正确诊断致病微生物是至关重要的,尽管培养仍然是主要的诊断工具,但最新技术,例如共聚焦显微镜,有助于诊断真菌和棘阿米巴。即使对于难以用传统方法培养的有机物,新一代测序也具有早期准确诊断潜力。局部抗生素仍然是细菌性角膜炎的最佳治疗方法,最近的一项综述发现,所有常用的局部用抗生素都是同样有效的。然而,角膜溶解,疤痕和穿孔的继发预后仍然不佳。旨在减少与角膜炎相关的免疫应答的辅助疗法包括局部皮质类固醇。大型随机对照类固醇激素治疗角膜溃疡试验发现,尽管类固醇总体上没有明显的改善,但对中央,深部或巨大非诺卡氏菌或经典的侵入性铜绿假单胞菌溃疡,基线视力低患者,抗生素开始后早期患者似乎有益。由于20世纪60年代引入那他霉素局部治疗后没有新的治疗方法,真菌性溃疡的临床预后往往比细菌性溃疡更差。随机对照霉菌性溃疡治疗试验(MUTTI显示局部那他霉素治疗真菌性溃疡优于局部伏立康唑,特别是对于镰刀菌引起的溃疡。 MUTT II显示口服伏立康唑并不能改善整体预后,尽管对镰刀菌溃疡可能有一些作用。鉴于非严重不良事件增加,作者认为上述患者不推荐口服伏立康唑。病毒性角膜炎与细菌和真菌病例的不同之处在于它是经常发生并且在发达国家是常见的。疱疹性眼病研究(HEDSI显示局部皮质类固醇和口服阿昔洛韦治疗基质性角膜炎明显有益。 HEDS II显示口服阿昔洛韦可降低任何类型的单纯疱疹病毒性角膜炎的复发率约一半。未来降低感染性角膜炎发病率的策略可能是多方面的,辅助疗法旨在改变对感染的免疫应答,以改善临床预后。

Infectious keratitis is a major global cause of visual impairment and blindness, often affecting marginalized populations. Proper diagnosis of the causative organism is critical, and although culture remains the prevailing diagnostic tool, newer techniques such as invivo confocal microscopy are helpful for diagnosing fungus and Acanthamoeba. Next-generation sequencing holds the potential for early and accurate diagnosis even for organisms that are difficult to culture by conventional methods. Topical antibiotics remain the best treatment for bacterial keratitis, and a recent review found all commonly prescribed topical antibiotics to be equally effective. However, outcomes remain poor secondary to corneal melting, scarring, and perforation. Adjuvant therapies aimed at reducing the immune response associated with keratitis include topical corticosteroids. The large, randomized, controlled Steroids for Corneal Ulcers Trial found that although steroids provided no significant improvement overall, they did seem beneficial for ulcers that were central, deep or large, non-Nocardia, or classically invasive Pseudomonas aeruginosa; for patients with low baseline vision; and when started early after the initiation of antibiotics. Fungal ulcers often have worse clinical outcomes than bacterial ulcers, with no new treatments since the 1960s when topical natamycin was introduced. The randomized controlled Mycotic Ulcer Treatment Trial (MUTT) I showed a benefit of topical natamycin over topical voriconazole for fungal ulcers, particularly among those caused by Fusarium. MUTT II showed that oral voriconazole did not improve outcomes overall, although there may have been some effect among Fusarium ulcers. Given an increase in nonserious adverse events, the authors concluded that they could not recommend oral voriconazole. Viral keratitis differs from bacterial and fungal cases in that it is often recurrent and is common in developed countries. The Herpetic Eye Disease Study (HEDS) I showed a significant benefit of topical corticosteroids and oral acyclovir for stromal keratitis. HEDS II showed that oral acyclovir decreased the recurrence of any type of herpes simplex virus keratitis by approximately half. Future strategies to reduce the morbidity associated with infectious keratitis are likely to be multidimensional, with adjuvant therapies aimed at modifying the immune response to infection holding the greatest potential to improve clinical outcomes.


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