acanthamoeba keratitis case

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Case presentation
Mohammad Abdullah Bawtag
Case presentation
Resident of Ophthalmology Assuit University
Hospitals
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History
39-year-old white male contact lens wearer is
complaining of cloudy vision, photophobia, and a
red, painful right eye.
Three weeks prior to presentation , the patient
began to develop cloudy vision, photophobia and
increasingly severe pain in the right eye (OD).
Despite topical antiobiotic therapy at an outside
facility.On Gatifloxacin and Tobramycin drops
every hour and cyclopentolate 1 twice a day, OD.
Despite this therapy, the ulcer in the right eye
persisted and was worsening.
History
There is no history of other system affection.
The patient is a contact lens wearer who has used
disposable soft contact lenses for the past 3
months
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History
The patient had switched to disposable soft
contact lenses 3 months prior to presentation.
History
4
History
History
Mild hypertension and hypercholesterolemia
5
History
No history of trauma. No history of previous
operations.
History
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History
Topical Gatifloxacin and Tobramycin every hour,
OD, as well as cyclopentolate. His systemic
medications included Valsartan and Atorvastatin.
History
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History
Noncontributory
History
Rare social consumption of alcoholic beverages.
Patient is a non-smoker.
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Systemic examination
Examination
130/80 mmHg
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Systemic examination
Examination
80 beats/min with regular rhythm
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Systemic examination
Examination
The patient is afebrile.
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Systemic examination
Examination
No abnormality detected
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Systemic examination
Examination
No abnormality detected
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Ophthalmic examination
VA Count Fingers at 30 cm OD , 6/6 OS
Examination
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Ophthalmic examination
OD There was conjunctival injection a few SPK.
The anterior chamber was deep quiet. The iris
lens were normal.
Examination
OS normal.
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Ophthalmic examination
OD
Examination
OS Normal
Enlarged corneal nerves (radial perineuritis) are
also seen on high magnification. There is
conjunctival injection and the anterior chamber
is filled with 3 cells and 2 flare reaction.
Keratic precipitates line the endothelium
inferior to the ring infiltrate and there is a
0.5mm hypopyon. Small defects in the epithelium
are present over the area of ring infiltrate
4x4 mm stromal ring infiltrate with surrounding
white blood cell (WBC) infiltration.
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Ophthalmic examination
5mm dark and 3mm light, OU with no relative
afferent pupillary defect (RAPD)
Examination
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Ophthalmic examination
Examination
OD Full
OS Full
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Ophthalmic examination
Examination
OD Digitally Normal
OS 18 mmHg
Applanation tonometry
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Ophthalmic examination
Examination
OD decreased OS normal
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Ophthalmic examination
OD Very difficult and hazy posterior view. OS
Normal disc, macula, vessels, and periphery.
Examination
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Laboratory investigations
Lab investigations
Double-walled cyst structures were seen within
the epithelium
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Laboratory investigations
Lab investigations
No secondary organisms grew
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Provisional diagnosis
Acanthamoeba keratitis
Provisional diagnosis
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Differential diagnosis
Herpetic keratitis
Bacterial keratitis
Differential diagnosis
Fungal keratitis
Contact lens overwear and associated ischemia
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Differential diagnosis
Acanthamoeba Keratitis
History Contact lens disproportionate pain
Differential diagnosis
dense infiltrate or classic "ring infiltrate",
perineuritis, intense injection, some with
keratouveitis, with or without epithelial defect
Histopathoalogy
Confocal Microscopy
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Differential diagnosis
Herpetic keratitis
No recurrent attacks
Differential diagnosis
Mild to moderate pain
No skin affection
Morphology of the ulcer
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Differential diagnosis
Bacterial keratitis
History (no improvement on antibiotic)
Differential diagnosis
culture
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Differential diagnosis
Fungal keratitis
History no history of plant trauma
Differential diagnosis
culture
morphology
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Differential diagnosis
Contact lens overwear and associated ischemia
Differential diagnosis
history
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Lines of management(cont)
Followed by around the clock topical therapy
initially, then slowly decreasing therapy with
improvement
Role of IV diamide therapy (pentamidine) in
resistant cases is yet to be determined, but was
adjunctive in this case report

• Usually Biguanide (chlorohexidine 0.02 or
  polyhexamethylene Biguanide (PHMB) 0.02 every
  hour)
• Plus or minus addition of diamide (propamidine
  isethionate (Brolene) 0.1 or hexamidine)

Ongoing treatment Taper the treatment. Relapse is
common. Treatment is prolong (20- 40wks)
Epithelial debridement
Cycloplegia for comfort with Cyclopentolate 1
BID or Atropine QD
Steroid therapy (oral or topical) may help
control inflammation after control of the
infection has been achieved.
Management
Penetrating Keratoplasty (PKP) may be required in
cases of impending perforation or for visual
rehabilitation after scarring Be wary of
recurrence with peripheral limbal cyst
reactivation and infection of the graft. Continue
topical anti-amoebic therapy.
? Oral as an adjuct has been helpful Oral
Itraconazole or Ketoconazole 200-600mg/day
(divided BID)
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Ophthalmic examination
Examination
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THANKS FOR YOUR KIND ATTENTION