A 39-year-old male contact lens wearer presented with a painful red right eye, cloudy vision, and photophobia that had been worsening over three weeks despite topical antibiotic therapy. 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 scraping revealed double-walled cyst structures. Based on these findings, a provisional diagnosis of Acanthamoeba keratitis was made. Differential diagnoses included bacterial, herpetic, and fungal keratitis. The patient was started on intensive topical therapy with aminoglycosides, aromatic
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.
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
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
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
31. 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
Cycloplegia for comfort with Cyclopentolate 1% BID or
Atropine QD
Epithelial debridement
Steroid 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)