title: Corneal Cross-linking as an Adjuvant Therapy in the Management of Recalcitrant Deep Stromal Fungal Keratitis: A Randomized Trial.
abstract: OBJECTIVE
  To assess the efficacy of corneal cross-linking (CXL) as an adjuvant to appropriate antifungal therapy in nonresolving deep stromal fungal keratitis.
  
  
  METHODS
  Randomized clinical trial.
  
  
  METHODS
  Eyes with culture-positive deep stromal fungal keratitis not responding to appropriate medical therapy for a period of 2 weeks were randomized to receive either adjuvant CXL or no additional treatment. Antifungal medical therapy was continued in both groups. The prespecified primary outcome was treatment failure at 6 weeks after enrollment, defined as perforation and/or increase in ulcer size by ≥2 mm.
  
  
  RESULTS
  The trial was stopped before full enrollment because of a marked difference in the rate of perforation between the 2 groups. Of the 13 cases enrolled in the study, 6 were randomized to the CXL group and 7 to the non-CXL group. Five eyes in the CXL group and 3 eyes in the non-CXL group experienced treatment failure by 6 weeks (P = .56). In a secondary analysis, the CXL group experienced more perforations than the non-CXL group (4 vs 0, respectively; P = .02).
  
  
  CONCLUSIONS
  CXL used as adjuvant therapy for recalcitrant deep stromal fungal keratitis did not improve outcomes.
authors.affiliation: Aravind Eye Hospital, Madurai, Tamilnadu, India.
authors.forename: Madhu
authors.initials: M
authors.lastname: Uddaraju
authors.affiliation: Aravind Eye Hospital, Madurai, Tamilnadu, India.
authors.forename: Jeena
authors.initials: J
authors.lastname: Mascarenhas
authors.affiliation: Aravind Eye Hospital, Madurai, Tamilnadu, India.
authors.forename: Mano Ranjan
authors.initials: MR
authors.lastname: Das
authors.affiliation: Aravind Eye Hospital, Madurai, Tamilnadu, India.
authors.forename: Naveen
authors.initials: N
authors.lastname: Radhakrishnan
authors.affiliation: Francis I. Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, California.
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Keenan
authors.affiliation: Aravind Eye Hospital, Madurai, Tamilnadu, India.
authors.forename: Lalitha
authors.initials: L
authors.lastname: Prajna
authors.affiliation: Aravind Eye Hospital, Madurai, Tamilnadu, India. Electronic address: prajna@aravind.org.
authors.forename: Venkatesh N
authors.initials: VN
authors.lastname: Prajna
mesh_terms: D000287:Administration, Topical; D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use*; D003094:Collagen / Q000378:metabolism*; D003131:Combined Modality Therapy; D003315:Cornea / Q000378:metabolism* / Q000382:microbiology; D057112:Corneal Perforation / Q000209:etiology / Q000601:surgery; D003320:Corneal Ulcer / Q000188:drug therapy* / Q000382:microbiology; D003432:Cross-Linking Reagents / Q000009:adverse effects; D015821:Eye Infections, Fungal / Q000188:drug therapy* / Q000382:microbiology; D005260:Female; D005658:Fungi / Q000302:isolation & purification*; D006801:Humans; D008297:Male; D018613:Microscopy, Confocal; D008875:Middle Aged; D010866:Natamycin / Q000627:therapeutic use; D009883:Ophthalmic Solutions; D017319:Photosensitizing Agents / Q000627:therapeutic use; D012256:Riboflavin / Q000627:therapeutic use; D014466:Ultraviolet Rays; D065819:Voriconazole / Q000627:therapeutic use
chemical_list: D000935:Antifungal Agents; D003432:Cross-Linking Reagents; D009883:Ophthalmic Solutions; D017319:Photosensitizing Agents; D010866:Natamycin; D003094:Collagen; D065819:Voriconazole; D012256:Riboflavin