Asociación para Evitar la Ceguera en México Hospital Dr. Luís Sánchez Bulnes, MEXICO

Ana Lilia Pérez - Balbuena MD

Virginia Vanzzini Zago QFB..Lorena López Quezada MD Antonio Sierra- Acevedo MD

Ramón Naranjo Tackman MD.

TREATMENT OF ACANTHAMOEBA KERATITIS IN MEXICO.

Authors have no financial interest in the subject matter of this poster.

Introduction : Acanthamoeba keratitis is a sight-threatening corneal disease caused

by a pathogenic free-living amoeba, which is ubiquitous (1). In 1974. Nagington and associates and in 1975, Jones, Visvesvara, and

Robinson described Acanthamoeba keratitis for the first time. (2,3). Acanthamoeba keratitis occurs in immunocompetent, healthy young individuals and most of the patients are contact lens wearers.

Acanthamoeba appears in two forms : a) Latent (Cyst) and b) Active (Trophozoites).

Purpose: To evaluate the efficacy of oral Itraconazol, topical fluconazole, analize risk factors, clinical findings, evolution, treatment and results of 6 cases of Acanthamoeba keratitis.

Design : A. restrospective, interventional case series.

1.-Jones D B. Opportunistically pathogenic free-living amebae 1993;v3,142-2462.-Tasanee S. Predisposing factors and etiologic dagnosis Cornea 2008 ;27:283

Fig |. Trophozoit of Acanthamoeba poliphaga

PATIENTS AND METHODS We include 6 eyes of the Cornea Service of the Asociación

para Evitar la Ceguera Hospital in México "Dr. Luis Sánchez Bulnes" in México City in the period from 1998 to 2009 with diagnosis of Acanthamoeba Keratitis.

We reported the following variables: age, gender, risk factors , treatment prior to entry, evolution, clinical picture, treatment, initial and final AV.

     

Stains: Gram, Giemsa, PAS ,calcofluor Laboratory cultures; NNA with Enterobacter aerogenes layer samples: corneal tissue and CL.

RESULTS The clinical findings are characterised by conjunctival

hyperemia, foreign body sensation, photophobia and tearing.  As main feature severe eye pain and decreased visual acuity in 100% of our cases.

 

Case 4. right eye. Initial examination. Central round ulcer, hypopion and immunological ring

Case 4. Five days evolution. Hiperemia, nodular scleritis, corneal edema and central ulcer.

RESULTSClinical Features %

Ring infíltrate 100%Anterior Uveitis 100%Ciliar Inyection 100%Ephitelial defect 83.3%Satellite Lesion 50%Hypopyon 50%Nodular Scleritis 16.6%

Corneal Neovascularizacion

16.6%

Neurokeratitis 16.6%

Case 4. 12 days tratment with oral Itraconazol

Case 6. Immunological ring

Final BCVA 20/50. 6/12 evolution

Case 1

Stromal infíltrate, Satellite Lesion, Hypopyon. Conjunctival flap retraction, deep stromal

infiltrate

1 month after oral Itraconazol 100 mg b.i.d.Tobramicin fortificate every hour

RESULTSN A/S Risk

factorPrevious treatment

Before our evaluationdays Causal

agent

1 31/F Trauma/ foreign body

Corticosteroid, Gentamicin, acyclovir, ketoconazol

60 A. polyphaga

2 18/M SCL Corticosteroid, sulfacetamide 15 A. spp

3 35/M SCL Corticosteroid, topical chloranphenicol

180 A. polyphaga

4 44/F HCL Polimixin, ketoconazol 180 A. polyphaga

5 17/F SCL Prednisolone, cromoglicic acid

45 A. castellanii

6 24/M SCL Dexamethasone, polymyxin B, neomycin.

18 A. Spp(on study)

N=case number. A/S= age/sex. A=Acanthamoeba. H.C.L.= hard contact lenses SCL= soft contact lenses

N Treatment in Cornea Service of our Hospital EvolutionDays

Surgical treatment

1 Oral Itraconazole 100 mg b.i.d.Tobramicin fortificate every hour

45 Conjunctival Flap

2 Oral Itraconazole 100 mg b.i.d.Tobramicin fortificate every hour

35 PK

3 Oral Itraconazole 100 mg b.i.d.Tobramicin fortificate every hour

28 None

4 Oral Itraconazole 100 mg b.i.d.Topical Propamidine Isethionate and Poliexametil-Biguanide.

60 None

5 Oral Itraconazole 100 mg b.i.d. Tobramicin fortificate every hour

40 None

6 Oral Itraconazole 100 mg and topical fluorometholone b.i.d.Topical Netilmicin and Fluconazol fortificate 2% every two hours

45 None

RESULTS

N Initial BCVA Final BCVA

1 LP 20/50

2 HM 20/100

3 CF 2m 20/60

4 HM 20/200

5 20/400 20/50

6 20/100 20/20

RESULTS

Case 5

Initial examination. Central round ulcer, and immunological ring

40 days evolution.Neovascularization. Stromal Infiltrate.

90 days evolution, vascularized leucoma. Final VA 20/50

DISCUSSION Among risk factors for Acanthamoeba keratitis are:the use of contact

lenses and bad hygiene.

The treatment with neomycin, neomycin combined with bacitracin and polymyxin B; paromomycin; propamidine isethionate 0.1%; pentamidine isethionate 0.05% to 0.1%; and oral miconazole, ketoconazole, itraconazole have been reported.

Our choice of treatment with oral itraconazole and topical fluconazole both are triazole with a broad spectrum of activity against many fungal species and microsporum (4,5)

In our cases, because failure of the initial treatment we changed to topical tobramycin and netilmicine recently to prevent bacterial infection and topical fluconazole 2% with oral itraconazole at the usual doses.

The isolates are Acanthamoeba polyfaga and Acanthamoeba castelllanii

Acanthamoeba cysts

CONCLUSIONWe must suspect the diagnosis by Acanthamoeba keratitis

in contact lens users. The early diagnosis leads to a better visual prognosis. The oral Itraconzal combined with a topical fluconazole

2%, and aminoglucoside ( Trobramicine, Netilmicine) is a good alternative treatment.

The conjunctival Flap and Penetrating Keratoplasty are surgical therapeutic options in medical treatment failure. 

 

1. Martinez AJ: Free-living amoeba: pathogenic aspect, a review, Protozoal Abst 7:293,1983.

2. Nagington, J. et al. : Amoebic infection of the eye. Lancet 2:1537,1974.

3. Jones, D.B. et al.: Acanthamoeba polyphaga keratitis and Acanthamoeba uveitis associated with fatal meningoencephalitis. Trans. Ophthalmol. Soc. U.K. 95:221,1975

4.-Van Cutsen, J., et al.: The in vitro and in vivo antifungal activity of itraconazole. In Fromtling, R.A. (ed.): International Telesymposium on Recent Trends in the Discovery, Development and Evaluation of Antifungal Agents. Beerse, belgium, J.R. Prous Science, 1987, p.177

5.-Shibashi, Y., et al.: Oral Itraconzaole and Topical Miconazole with Débridement for Acanthamoeba keratitis. Am J Ophthalmol 1990 (109):121-126

References