A 39-year-old male contact lens wearer presented with cloudy vision, photophobia, and pain in his right eye for three weeks. On examination, his right eye showed conjunctival injection, a 4x4mm stromal ring infiltrate with surrounding white blood cell infiltration, and a 0.5mm hypopyon. Epithelial scrapings revealed double-walled cyst structures. Acanthamoeba keratitis was provisionally diagnosed based on history and clinical findings. Differential diagnoses included bacterial, herpetic, and fungal keratitis. The patient was started on topical aminoglycosides, aromatic diamides, and biguanides, with epithelial debridement

1. Case presentation
Mohammad Abdullah Bawtag
Resident of Ophthalmology
Assuit University Hospitals

2. The patient is a contact lens
wearer who has used
disposable soft contact lenses
for the past 3 months
39-year-old white male contact lens
wearer is complaining of cloudy
vision, photophobia, and a red,
painful right eye.
History
Presenting
history
Presenting
history
Previous
ocular history
Past medical
history
Trauma &
operations
Therapeutic
history
family &
social history
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.
There is no history of other system
affection.

3. History
Previous
ocular history
Presenting
history
Past medical
history
Trauma &
operations
Therapeutic
history
family &
social history
Previous
ocular history
The patient had switched to disposable
soft contact lenses 3 months prior to
presentation.

4. History
Presenting
history
Mild hypertension and hypercholesterolemia
Previous
ocular history
Past medical
history
Trauma &
operations
Therapeutic
history
family &
social history
Past medical
history

5. History
Presenting
history
No history of trauma.
No history of previous
operations.
Previous
ocular history
Past medical
history
Trauma &
operations
Therapeutic
history
family &
social history
Trauma &
operations

6. History
Presenting
history
Previous
ocular history
Past medical
history
Trauma &
operations
Therapeutic
history
family &
social history
Therapeutic
history
Topical Gatifloxacin and Tobramycin every
hour, OD, as well as cyclopentolate. His
systemic medications included Valsartan and
Atorvastatin.

7. History
Presenting
history
Previous
ocular history
Past medical
history
Trauma &
operations
Therapeutic
history
family &
social history
family &
social history
Rare social consumption of
alcoholic beverages. Patient is a
non-smoker.
Noncontributory

8. Systemic examination
Blood
pressure
Blood
pressure
Pulse
Temperature
Head & neck
Other systemic
exam
130/80 mmHg

9. Systemic examination
Blood
pressure
Pulse
Temperature
Head & neck
Other systemic
exam
80 beats/min with regular rhythm
Pulse

10. Systemic examination
Blood
pressure
Pulse
Temperature
Head & neck
Other systemic
exam
The patient is afebrile.
Temperature

11. Systemic examination
Blood
pressure
Pulse
Temperature
Head & neck
Other systemic
exam
No abnormality detected
Head & neck

12. Systemic examination
Blood
pressure
Pulse
Temperature
Head & neck
Other systemic
exam
No abnormality detected
Other systemic
exam

13. Ophthalmic examination
External exam
VA :Count Fingers at 30 cm OD ,
6/6 OS
Slit lamp ex.
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus exam
Visual acuity

14. Slit lamp ex.
Ophthalmic examination
External exam
OD: There was conjunctival
injection & a few SPK. The
anterior chamber was deep &
quiet. The iris & lens were
normal.
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus exam
OS: normal.
External exam

15. Slit lamp exam
OS: Normal
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
Ophthalmic examination
Ext. exam.
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus exam
OD
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.
4x4 mm stromal ring infiltrate with
surrounding white blood cell (WBC)
infiltration.
Slit lamp exam

16. Ophthalmic examination
External exam
5mm dark and 3mm light, OU with no
relative afferent pupillary defect (RAPD)Slit lamp exam
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus exam
Pupils

17. Ophthalmic examination
External exam
OD : Full
Slit lamp exam
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus exam
Motility OS: Full

18. Ophthalmic examination
External exam
OD: Digitally Normal
Slit lamp exam
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus exam
IOP
OS: 18 mmHg
Applanation tonometry

19. Ophthalmic examination
External exam
OD : decreased; OS : normal
Slit lamp exam
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus exam
Corneal
Sensation

20. Ophthalmic examination
External exam
Slit lamp exam
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus examFundus exam
OD: Very difficult and hazy
posterior view.
OS: Normal disc, macula,
vessels, and periphery.

21. Laboratory investigations
Multiple swab
samples Double-walled cyst structures
were seen within the epithelium
Epithelial
scraping
Epithelial
scraping

22. Laboratory investigations
Multiple swab
samples
No secondary organisms grew
Epithelial
scraping
Multiple swab
samples

23. Provisional diagnosis
Acanthamoeba
keratitis

24. Differential diagnosis
Bacterial keratitis
Herpetic keratitis
Fungal keratitis
Contact lens overwear and associated ischemia

25. Differential diagnosis
Acanthamoeba Keratitis
History
Contact lens;
disproportionate pain
dense infiltrate or classic "ring
infiltrate", perineuritis, intense
injection, some with
keratouveitis, with or without
epithelial defect
Confocal Microscopy
Histopathoalogy

26. Differential diagnosis
Herpetic keratitis
No recurrent attacks
No skin affection
Morphology of the ulcer
Mild to moderate pain

27. Differential diagnosis
Bacterial keratitis
History
(no improvement on antibiotic)
culture

28. Differential diagnosis
Fungal keratitis
History: no history of
plant trauma
morphology
culture

29. Differential diagnosis
Contact lens overwear
and associated ischemia
history

30. Management
Medical surgical
Nonspecific
1-stop contact
lens wear.
2-cycloplegic.
3- Steroid
therapy.
Specific
1-Aminoglycosides
2-Aromatic diamide
3-biguanide
4-imidazoles
Epithelial
debridement
Penetrating
Keratoplasty

31. Lines of management(cont)
Followed by around the clock topical
therapy initially, then slowly decreasing
therapy with improvementRole of IV diamide therapy (pentamidine) in resistant
cases is yet to be determined, but was adjunctive in this
case report
Cycloplegia for comfort with Cyclopentolate 1% BID or
Atropine QD
Epithelial debridementSteroid therapy (oral or topical) may help control
inflammation after control of the infection has been
achieved.
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)
Ongoing treatment
Taper the treatment.
Relapse is common.
Treatment is prolong (20- 40wks)
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)

32. Slit lamp exam
Ophthalmic examination
Ext. exam.
Pupils
Visual acuity
IOP
Corneal
Sensation
Motility
Fundus exam
Slit lamp exam