EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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54 November 2013 EW CORNEA There's continued from page 53 problem is they are not as broad spectrum and not as effective as the other antifungals." However, they have been successfully used topically in certain fungal infections that have been resistant to the usual medications, he said. The drug caspofungin falls into this category and is one that Dr. Alfonso pointed to as an alternative that has appeared in the last eight to 10 years. Dr. Tu said that there has been some talk of collagen crosslinking for many other corneal infections, but he said this has not proven particularly helpful, specifically for fungal cases. In cases where medical management is ineffective, Dr. Tu swiftly moves on to therapeutic keratoplasty. "I can't emphasize strongly enough that if things are going the wrong way and you can't figure out a medication that is going to stop it, then you need to do the transplant as soon as possible," he said. Dr. Alfonso concurred, citing studies indicating that early corneal transplantation may be better than waiting until the infection doesn't respond to medication and may not be controllable with therapeutic keratoplasty any longer. There is also some thought that when treating this at an earlier stage, perform a Only One System Delivers the Shield of PROTECTION. DuoVisc® Viscoelastic System offers both the endothelial protection of chondroitin sulfate in Viscoat® OVD with the proven mechanical protection and space maintenance found in ProVisc®OVD. One System. No Compromises. Brilliant from Beginning to End.™ Protection you can count on for every phase of cataract surgery. The first and only viscous dispersive, DisCoVisc® OVD provides the flexibility of both cohesive and dispersive properties in a single syringe. DisCoVisc® OVD combines the excellent endothelial protection of chondroitin sulfate with the mechanical protection of superior space maintenance and clarity. To see how DisCoVisc® OVD can help protect your outcomes, visit AlconOVD.com. lamellar rather than a penetrating keratoplasty, he said. "The only difficulty there is that if you misjudge the depth of the infection, when you place the donor cornea you may allow the organisms to stay in the deeper layer and grow," Dr. Alfonso said. "It will recur and be more difficult to treat because now you have a barrier on top of the organism—the new cornea." After performing keratoplasty, Dr. Alfonso advocates continuing antifungal medication, however, he emphasized the need to avoid cortisone drops since these can enhance the growth of fungi. He suggested using both topical and oral antifungal medication to increase the concentration in the eye. To avoid corneal transplant rejection, he recommended using cyclosporine. This was developed as an antifungal drug, and while not as potent as the other medication, it does have some additive effect. "We don't like to use steroids in this disease until we are very sure way down the course of the postoperative care that there is no fungi left behind," he said. Likewise, Dr. Tu doesn't use steroids for the first week or two after corneal transplant and continues antifungal medication postoperatively. If there's no sign of new infection in the area, he then will introduce corticosteroids cautiously after this period. While he agrees that it is reasonable to use cyclosporine early on, he tends to reserve this for cases where there is a lot of inflammation and no other option. Going forward, Dr. Tu thinks that the demand for antifungals is going to increase with numerous studies indicating that fungal keratitis is on the rise in the U.S. and elsewhere. "We only have a handful of drugs," he said, adding that many don't get to the heart of the infection very well. "We need more drugs and we need more studies on how to handle these and identify the flood that is coming around the world," he concluded. EW Editors' note: Dr. Alfonso has financial interests with Bio-Tissue (Miami). Dr. Tu has no financial interests related to this article. Contact information Alfonso: 305-326-6303, ealfonso@med.miami.edu Tu: 312-996-8937, etu@uic.edu Please refer to the important safety information on the adjacent page. © 2013 Novartis 9/13 VIS13035JAD