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Catherine Sun, Namperumalsamy Prajna, Tiruvengada Krishnan, Muthiah Srinivasan, Kathryn Ray, Stephen McLeod, Travis Porco, Nisha Acharya, Thomas Lietman, Mycotic Ulcer Treatment Trial (MUTT) Group; Predictors of outcome in fungal keratitis using data from the Mycotic Ulcer Treatment Trial I. Invest. Ophthalmol. Vis. Sci. 2013;54(15):2900. doi: https://doi.org/.
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To determine baseline factors that are predictive of outcome in fungal keratitis using data collected in the Mycotic Ulcer Treatment Trial 1 (MUTT I).
MUTT I was a multicenter, randomized, double-masked, NEI-funded clinical trial comparing clinical outcomes in 323 patients with fungal keratitis receiving 5% topical natamycin or 1% topical voriconazole. Demographics, ocular medical history and clinical characteristics were collected at the enrollment visit for all patients, and were used as predictors in our analysis. Pre-specified outcomes included best spectacle-corrected visual acuity (BSCVA) at 3 months, infiltrate/scar size at 3 months, corneal perforation or transplant and re-epithelialization time. Separate univariate and multivariable analyses were performed for all predictors with each of the above four outcome variables. We adjusted for multiple comparisons using the Bonferroni correction.
In our multivariable model, significant predictors of worse 3-month visual acuity were worse presentation visual acuity (P<0.001), larger epithelial defect size at presentation (P<0.001) and randomization to voriconazole instead of natamycin in the trial (P=0.007). For 3-month infiltrate/scar size, significant predictors at presentation include larger infiltrate size (P<0.001), larger epithelial defect size (P<0.001), worse presentation visual acuity (P=0.003) and use of topical antifungals prior to trial enrollment (P<0.001). Worse presentation visual acuity (P<0.001), older age (P=0.011) and randomization to voriconazole instead of natamycin (P=0.008) were predictive of perforation. Epithelial defect size (P=0.001) and presentation ulcer depth (P=0.012) were significant predictors of longer time to re-epithelialization.
Ulcer severity at presentation is highly predictive of worse outcomes. In our analysis, we found that clinical characteristics at presentation, such as epithelial defect size and visual acuity, seem to provide more information about prognosis than patient demographics or ocular medical history. Although our findings suggest that it is difficult to change the course of an ulcer even with proper treatment, better understanding of predictive factors may help guide future management and treatment decisions. Nevertheless, prevention of corneal ulcers still remains highly important.
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