H Nayak, A Patel, S Gudsoorkar,

1

• H Nayak, A Patel, S Gudsoorkar,
• V Kumar
• University Hospital Wales
• Cardiff University

None of the authors have any financial interests
with regards to this poster
2

• The management of Acanthamoeba keratitis remains
  a challenge requiring combination amoebicidal
  drugs for a prolonged duration.
• Traditionally performed therapeutic penetrating
  keratoplasty for unresponsive cases are at high
  risk for endothelial rejection1. Recently deep
  lamellar keratoplasty has been described as an
  alternative2,3.
• We present two cases, successfully managed with
  deep lamellar keratoplasty (DLK) with good visual
  rehabilitation.

3

• A 51 yr male contact lens wearer was referred
  to the corneal clinic with suspected right
  acanthamoeba keratitis.
• Prior to referral he was treated for suspected
  herpetic keratitis with lubricants, topical
  steroids and topical antivirals.
• After 2 weeks he developed a ring infiltrate and
  was then switched to Chlorhexidine 0.022 hrly,
  propamidine isethionate 0.1 2 hrly,
  cyclopentolate 1 twice daily.

Ring infiltrate in right eye
4
Case 1 Continued

• After initial improvement he deteriorated with
  worsening infiltrate and development of hypopyon.
  
• A corneal biopsy sample grew acanthamoeba
  polyphaga.
• Addition of topical clotrimazole 1 did not
  improve the condition.
• He then underwent a DLK by modified Melles
  technique, 7 weeks after commencement on
  amoebicidal drops with primary aim of disease
  eradication.
• The corneal button showed acanthamoeba cysts on
  histopathology and grew acanthamoeba polyphaga
  on culture.

Right eye infiltrate with small hypopyon
5
Case 1 Continued

• Immediate postoperatively his vision improved
  from HM to 6/24(6/12 with pin hole) and eye
  gradually settled down.
• He was continued on propamidine isethionate
  0.1, clotrimazole 1 along with topical
  ofloxacin and dexamethasone 0.1.
• 2 months after the initial graft he had a
  recurrence of the infection.

Recurrence of infection in the graft
6

• A redo deep lamellar keratoplasty was performed
  with replacement of the infected anterior
  lamellar graft. The corneal button obtained again
  showing acanthamoeba cysts.
• Post-operatively topical Chlorhexidine 0.02,
  clotrimazole 1, chloramphenicol 0.5 and
  dexamethasone 0.1 were continued.
• Treatment was gradually tapered and stopped
  after 6 months.
• At last visit (8 months after the second DLK),
  the cornea was clear with vision of 6/9 unaided
  improving to 6/6 with pinhole.

2 months post redo deep lamellar keratoplasty
7

• A 52 year old male contact lens wearer was
  diagnosed with right eye subepithelial keratitis
  and treated with topical antibiotics, steroids
  and antivirals.
• A corneal scrape was positive only for Herpes
  Simplex Type 2.
• When referred to the cornea clinic, he had
  intense scleritis, large corneal epithelial
  defect with superficial keratitis and few
  endothelial keratitic precipitates.
• Repeat corneal scrapes and biopsy were negative
  and antiviral and antibiotic treatment was
  continued.
• His corneal ulcer worsened with development of
  hypopyon, faint ring infiltrate and suspected
  perineural infiltrates.

8

• He was also commenced on topical
  polyhexamethylene biguanide 0.02 and
  clotrimazole 1 2 hourly.
• He responded well with gradual resolution of
  the epithelial defect and hypopyon, with
  regression of infiltrates. His drops were
  gradually tapered over 3 months.
• In the following 5 months he had 2
  recurrences, each time requiring increasing
  intensity of the drops with gradual taper. The
  patient was concerned by the recurrences and poor
  vision.
• After discussion surgical intervention in a hot
  eye was planned with the aim of disease
  eradication and visual rehabilitation.

9

• He underwent a deep lamellar keratoplasty (DLK)
  by a modified Melles technique, 8 months after
  initial presentation.
• The corneal button on histopathology showed
  numerous acanthamoeba cysts and culture grew
  acanthamoeba polyphaga.

Right eye 2 years after DLK
10

• At 3 months his vision was 6/18 unaided
  improving to 6/6 with pin hole.
• His drops were tapered and stopped 6 months
  after the DLK.
• He gradually developed a cataract for which he
  had a successful cataract extraction with
  intraocular lens implantation.
• At last visit (34 months after DLK), his
  corneal graft was clear with unaided visual
  acuity of 6/9 improving to 6/6 with a pin hole.

Right eye 2 years after DLK
11

• Therapeutic DLK can be used to remove infected
  tissue in acanthamoeba keratitis after an initial
  period of topical amoebicidal drops
• Recurrence can also be effectively treated with
  repeat procedures which are easier to perform
• Avoiding penetrating keratoplasty decreases
  complications including graft rejection, graft
  failure and intraocular spread of infection
• Good visual rehabilitation both in the immediate
  and late postoperative periods can be achieved

12

1. Ficker LA, Kirkness C, Wright P. Prognosis for
   keratoplasty in Acanthamoeba keratitis.
   Ophthalmology. 1993100105110.
2. Cremona G, Carrasco MA, Tytiun A, et al.
   Treatment of advanced acanthamoeba keratitis with
   deep lamellar keratectomy and conjunctival flap.
   Cornea 200221705708.
3. Parthasarathy A, Tan DTH. Deep lamellar
   keratoplasty for Acanthamoeba keratitis. Cornea
   2007261021-1023