Surgery and Medicine Go Eye to Eye

Ah, the time old conflict of a surgeon and a medical doctor. Do we treat an ailment with drugs or scalpels? If we choose drugs, are we just culling the weak and leaving the strong pathogens? If we choose to operate, are we putting patients through excessive procedures and how do we know we have gotten everything?

One of the recent battles in this war was fought over moderate cases of Fusarium keratitis by researchers at the Chang Gung University College of Medicine (CCUCM).

 

Early Keratectomy in the Treatment of Moderate Fusarium Keratitis

 

Keratitis is an inflammation of the cornea. While it has a number of causes ranging from over exposure to light (such as during snow blindness) to herpes virus infection, Fusarium keratitis is dealing fungal infection. Actually, as the name implies it is dealing with fungi from the Fusarium genus. And keratitis caused by these fungi can present quite the treatment ordeal. For starters they are filamentous: which means they grow a nice cottony mycelial blanket in/ on the eye. Unfortunately by the time this is visible you have already moved past the initial stages of the infection. It takes up to a few weeks after the germ tube starts for full infiltration and inflammation to become apparent. Up to that point you just sit there with individual feathery hyphae, poking and prodding their way across your cornea.

Progress of Fusarium keratitis

With minor cases the simplest solution is just medical treatment, but as it becomes more advanced surgical intervention is often needed. But what about those moderate cases in the middle? The ones where it may go away with treatment, but then again maybe it won’t. That range of infection is the focus of the CCUCM teams study.

The researchers investigated 38 cases of moderate Fusarium keratitis between January 2004 and December 2010. Of those patients 13 got keratectomies within a week of entering the hospital and twenty were only treated medically.  Out of the patients, five of them didn’t have follow up records and were thus discarded from the research conclusions. There were no major differences between these two groups in regards to age, sex, or severity of eye infection; however it was noted that the medicated group did average a significantly worse baseline vision than the surgery group.

While reviewing all records the group contrasted costs, hospitalization days, disease duration, and perforation progress between the contrasting treatments. Eye photographs were documented weekly and any progress or negative response led to a reculture for Fusarium after a 24 hour break of topical antibiotics.
The results seem to be a straight up win for the surgeons. The group receiving keratectomies had a much shorter duration of the disease, with an average of 29 days vs. 54 days; and of those days the surgery group was only in the hospital 11 days, compared to the medical groups average 31 day stay. Of course the longer stay for those receiving medication also caused a severe jump in cost, having a range centering around 20,000 New Taiwan Dollars higher. And addressing the largest physical end comparison, the degree of corneal perforation following the procedures: in this study group 20% of those treated with medicine only developed perforations, while absolutely none of the patients that went through surgery did. The Scalpel jockeys seem to have sliced out a victory here.

That being said the research team did acknowledge that this was just a retrospective study and with treatments based on the preferences of the physicians, which allowed for potential biases.

Now for the real purpose of this post:


Awesome researchers:
Hsin-Chiung Lin, Ja-Liang Lin, Dan-Tzu Lin-Tan, Hui-Kang Ma, & Hung-Chi Chen (2012). Early Keratectomy in the Treatment of Moderate Fusarium Keratitis PLOS One DOI: 10.1371/journal.pone.0042126