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Acanthamoeba keratitis.
Patients with Acanthamoeba keratitis typically present with a unilateral, red, painful eye. Initially, there is typically a non-specific epitheliopathy which can progress to ulceration with infiltration. Limbititis occurs as 1-3 the initial finding in 94% of early stage cases and in 84% of late-stage cases. Another common finding is radial keratoneuritis, or perineuritis; this involves irregularly thickened corneal nerves in the anterior to mid-stroma with shaggy borders. Other clinical signs of Acanthamoeba keratitis include irregular epithelial defect, corneal microcysts, punctate keratopathy, bullous keratopathy, disciform stromal keratitis, pseudodendritic keratitis, anterior uveitis and a granulomatous stromal reaction. While Acanthamoeba keratitis has historically been associated with stromal ring infiltrate formation, only 6% of early cases and 1-3 16% of late cases actually present in this manner clinically. About half of patients report significant pain, the rest experience only mild irritation and foreign-body 4,5 sensation. Those who do report pain often present a degree much worse than the clinical appearance suggests. Rarely is Acanthamoeba keratitis correctly diagnosed in the early stage. It typically follows a chronic course that waxes and wanes over weeks to months and never fully heals despite seemingly appropriate therapy. In fact, the diagnosis is often finally made when all other treatments fail.
the presence of bacteria, because Acanthamoeba frequently coexists with bacterial colonies upon which it feeds. Acanthamoeba often accompanies other corneal diseases, and may not be the primary or most active disease process in a combined keratitis.
Management: Treatment of Acanthamoeba keratitis is difficult due to the organism's ability to encyst
with the use of topical medications. Effective medications include topical polyhexamethylene biguanide (PHMB), propamidine isethionate (Brolene), chlorhexidine digluconate 0.02%, polymixin B, neomycin and clortrimazole 1%. In one series of 10 patients, the combination of Brolene and PHMB successfully cured all cases of Acanthamoeba keratitis. Cautious introduction of topical steroids along with anti-amoebic therapy helped resolve the inflammation and provided symptomatic relief.
Clinical Pearls:
Strongly suspect Acanthamoeba keratitis in chronic keratitis that does not respond to treatment. While ring infiltration has historically been associated with Acanthamoeba keratitis, it is a relatively rare finding and typically occurs late in the disease. Non-specific epitheliopathy is typically the presenting feature. As Acanthamoeba feeds upon bacteria, it frequently accompanies bacterial ocular infections. Acanthamoeba play a part in coinfections, sometimes explaining why other corneal infections do not respond to conventional therapy.