Table 2

Baseline assessment

Assessment	Details
Visual acuity	Presenting, Pin-Hole and best spectacle corrected visual acuity) will be measured using an ETDRS Tumbling-E logMAR 3 m chart (Good-Lite Inc, USA) mounted on an ESC 2000 ETDRS LED Cabinet, (Good-Lite Inc, USA) by a trial-certified optometrist, for each eye separately
Contrast sensitivity	Measured using the Peek Contrast Sensitivity smartphone application running on Android OS with a Sony Xperia Z3 Compact smartphone (Sony, Japan).26
Clinical photographs	Photographs will be taken separately of both corneas using a Nikon D7500 camera with an AF-S Micro Nikkor 105 mm lens and lens mounted SB-200 flash units (Nikon, Japan). A standardised photography protocol is used to ensure images can be compared between time points. Standardised magnification will be used to allow epithelial defect and stromal infiltrate size measurements to be made.
Slit-lamp examination	Both eyes will be examined using a slit-lamp biomicroscope (standard ophthalmology examination) to assess the anterior segment of the eye. This examination will be performed by an ophthalmic clinician experienced in managing MK. Particular attention will be paid to the following features:
	1. Eyelids: trichiasis, lagophthalmos, facial weakness, Bell’s reflex
	2. Suppuration
	3. Conjunctival inflammation
	4. Corneal sensation
	5. Cornea epithelial defect (measuring the longest dimension and the longest perpendicular) and ulcer depth
	6. Corneal inflammatory infiltrate depth, size, profile, colour, edge pattern, texture, satellites
	7. Anterior chamber inflammatory cells, hypopyon, endothelial plaque
	8. Relative afferent pupillary defect
In vivo confocal microscopy (IVCM)	The Heidelberg Retinal Tomograph 3 IVCM enables the clinician to examine the cornea down to the cellular level. It is able to detect the presence of fungal hyphae.27 28 A sterile, single-use disposable cap covers the objective lens and is changed between patients. Volume scans will be performed which provide a series of 400×400 µm images over a depth range of 80 µm. The resolution of the corneal scanning module is 7.6 µm. IVCM images will be collected in a systematic way, starting at the centre of the ulcer, then at the superior, inferior, nasal and temporal borders of the ulcer. Volume scans will be performed in all of these locations, starting at the level of the corneal epithelium, and ending at the deepest affected aspect of the cornea assessed from IVCM images. Images will be assessed during the examination.
Ocular sample collection	The following samples will be collected from the corneal ulcer of each patient at the baseline assessment:
	1. Corneal scrape specimens for microscopy and microbiological culture. A corneal scrape will be collected from the corneal ulcer after application of preservative free proxymetacaine local anaesthetic eye-drops (Minims). Sterile needles are used to take corneal scrape specimens and then place on to glass slides for immediate Gram stain, KOH and Calcofluor white. Samples will be directly inoculated onto blood, chocolate, Sabouraud agar and broths for culture.
	2. Corneal specimen collection for PCR. Two sterile swabs will be gently swept over the surface of the corneal ulcer and placed into a 2 mL tube. The swabs will be for pathogen detection by PCR, fungal sequencing and assessment of point of care tests for fungal infections. Swabs will be stored dry at −80°C. If swab yields are found to be too low for analysis an additional corneal scrape will be collected for PCR. The analysis of the PCR samples will not form part of the RCT workup and report.
HIV testing	All individuals presenting with MK would be offered counselling and testing services. If this is found to be positive and the patient is unknown to the HIV care services an appropriate referral will be made. HIV testing is performed using HIV Tri-Dot rapid diagnostic test (J. Mitra & Co, India)
Random blood glucose	There is a suggestion that individuals with diabetes may be more susceptible to FK. Participants will be offered a random blood glucose test, on a finger prick sample, analysed using HumaLyzer Primus (HUMAN Gesellschaft für Biochemica und Diagnostica mbH, Germany). If this is above 6.1 mmol/L they will be referred to the hospital physicians for assessment and formal diagnosis of impaired glucose tolerance or diabetes mellitus. This level is considered a suitable cut-off to detect individuals with diabetes and has been validated in a south-Asian population.34
Quality of life questionnaires	For those with confirmed FK and who are enrolled in the trial, there will be several additional baseline assessments to evaluate the impact of FK on quality of life.
	Vision-related quality of life (VRQoL): will be assessed by a vision disease specific tool the WHO/PBD-VF20.35 This tool measures the impact of visual impairment in the person’s life including mental well-being, dependency and social functioning. These have been used in a number of other vision related studies to show a difference in QoL.36 37 This instrument consists of 20 questions divided into three sub-scales: visual symptom, general functioning and psychosocial. It begins by asking the patient ‘Overall, how would you rate your eyesight using both eyes?’; and uses a five point scale answer option such as ‘very good’, ‘good’, ‘moderate’, ‘bad’, ‘very bad’. The test is scored out of 100, with higher scores reflecting a better VRQoL.
	General health-related quality of life: We will use the EQ-5D questionnaire and EQ-Visual Analogue Scale. The EQ-5D is a standardised tool to measure health outcomes.38 Patients will also be assessed using the WHOQOL-BREF.39 This has good applicability in low and middle-income countries as it was developed simultaneously from concept across 18 countries in Africa, Asia and Latin America. It measures 4 domains of health: Physical Health, Psychological Health, Social Relationships, and Environment. It asks respondents 26 questions how much (frequency) they have experienced and/or were able to do things (eg, feel safe, able to concentrate, enjoy life) in the past 4 weeks and how satisfied they are with certain aspects of their lives (eg, sleep, capacity for work). Each question is scored between one and five in a positive direction, with one being attributed for a very low or dissatisfied quality of life, and five being very good or very satisfied with their quality of life (ie, higher scores denote a higher quality of life). Each domain has its own score calculated by calculating the mean of the item scores within each domain. In addition, there are two items that are examined separately: question 1 asks about an individual’s overall perception of quality of life and question 2 asks about an individual’s overall perception of their health. These are scored on the same positive scale from one to five. The mean domain scores can then be multiplied by four in order to make domain scores comparable with the scores used in the WHOQOL-100.39

Assessment performed at baseline with details of how they are made.
AF-S, Autofocus Single; EQ-5D, EuroQol-5 dimensions; ETDRS, Early Treatment Diabetic Retinopathy Study; FK, fungal keratitis; KOH, Potassium Hydroxide; MK, microbial keratitis; RCT, randomised controlled trial.