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Invited Commentary
December 2016

Evidence-Based Treatment of Fungal Keratitis

Author Affiliations
  • 1Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Ophthalmol. 2016;134(12):1372-1373. doi:10.1001/jamaophthalmol.2016.4167

Although, compared with bacterial or viral keratitis, fungal keratitis is rare in the United States, it is much more likely to be associated with loss of vision. This is due to a combination of the pathogenicity of the organism, a delay in diagnosis, and uncertainty regarding an optimal treatment strategy. In the United States, there is a long history of physicians migrating to the newest therapeutic options, even in the absence of evidence of superiority. In the field of ophthalmology, this is certainly the case in the choice of topical antibiotics. For example, the last 2 decades have witnessed several successive waves of new topical fluoroquinolone antibiotics. Each of these received the approval of the US Food and Drug Administration, based on the reduction in bacterial counts in adult patients treated for conjunctivitis, and then largely supplanted the use of older and less expensive options in a wide range of treatment and prophylaxis settings. Yet, we have had no randomized clinical trials comparing one topical antibiotic with another for the relatively common condition of bacterial keratitis since 1995, when no difference in outcome was found between patients treated with ofloxacin and patients treated with fortified cefazolin and tobramycin.1 Ironically, and thanks almost entirely to our colleagues in Southeast Asia, we now have more compelling, evidence-based knowledge regarding treatment choices for fungal keratitis than we have for bacterial keratitis.

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