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O regon M. Eric Y, Vanzzini Z. Virginia, Sierra A. Antonio, Zand H. Igal M, Moreno A. Gilberto, Naranjo T. Ramón Cornea & Refractive Surgery department,

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Presentation on theme: "O regon M. Eric Y, Vanzzini Z. Virginia, Sierra A. Antonio, Zand H. Igal M, Moreno A. Gilberto, Naranjo T. Ramón Cornea & Refractive Surgery department,"— Presentation transcript:

1 O regon M. Eric Y, Vanzzini Z. Virginia, Sierra A. Antonio, Zand H. Igal M, Moreno A. Gilberto, Naranjo T. Ramón Cornea & Refractive Surgery department, Asociación para evitar la ceguera en México A.P.E.C. Universidad Nacional Autónoma de México U.N.A.M. The first author of this poster received travel expense reimbursement by SIFI laboratories México. Off label use of topical netilmicine for Acanthamoeba keratitis. N ETILMICINE AS A TREATMENT FOR A CANTHAMOEBA KERATITIS : THREE CASES

2 I NTRODUCTION The standard treatment for Acanthamoeba keratitis includes clorhexidine and/or propamidine Isethionate and aminoglucosides such as Neomicyn. Together with oral Itraconazole and topical antifungals. However none of this treatments have proven total efficiency and Acanthamoeba keratitis is still a serious corneal disease. John Thomas, Lin J, Sahm DF. Ann Ophthalmol 1990; 22:20-23 Ishibashi Y, Matsumoto J, Katata T et al. Am Jour Ophthalmol 1990; 109: (2) Bang S, Edell E, Eghrari AO, Gottsch JD. Treatment with voriconazole in 3 eyes with resistant Acanthamoeba keratitis. Am J Ophthalmol Jan;149(1):66-9. Epub 2009 Oct 28

3 P URPOSE To report 3 cases of Acanthamoeba keratitis succesfully treated with a combination of topical Netilmicine (Netira- SIFI Lab. Sicilly Italy), Polimixin, Neomycin and Gramicidin ( Polixin- Grin Mexico city) with oral Itraconazole (Isox -Senosiain Mexico). Pre- treatment End of follow up

4 M ATERIAL & M ETHODS  Corneal samples were taken and cultured in NN agar with a lived Enterobacter cloacae layer.  The cultures were positive for Acanthamoeba castellani.  Photographs were taken on their 1st visit and 3 months final follow up.  Susceptibility by dilution method to Netilmicine (Netromycin) was done.

5 Case 1: Case 1: 19 year old female Bilateral ocular pain She wore her contact lenses during the previous 24 hrs. Visual acuity OD 20/400, OS 20/800. Conjunctival hyperemia, cornea on the right eye with diffuse edema.Cornea on the left eye with a ring and perineural infiltrates. Initial diagnosis: herpetic keratitis vs Acanthamoeba keratitis. Initial treatment: Aciclovir 400 mg 5 times a day and moxifloxacin t.i.d. with no improvement within 72 hrs. Topical netilmicine q.i.d. is added. 1 week later visual acuity 20/200 both eyes, less pain, less perineural infiltrate. Clinical diagnosis: Acanthamoeba keratitis. Cultures: Acanthamoeba castellani on both corneal samples. Final treatment: Topical Netilmicine every 2 hours, polimixin B/neomycin/gramicidin every 3 hours and oral itraconazole 200 mg b.i.d. 6 weeks later: no pain, visual acuity 20/25 OD and 20/50 OS, perineural infiltrate on left eyes continues but is dissapearing. 3 months later: best corrected visual acuity 20/20 on both eyes, faint haze (this are the images on 2nd slide).

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7 Case 2: Case 2: 30 year old female comes with ocular pain, low visual acuity and photophobia. She wore her contact lenses during the previous 72 hrs. Visual acuity 20/100. Palpebral edema, conjunctival hyperemia, ciliary reaction, cornea with a ring like, white infiltrate and edema. Celullarity on anterior chamber +++. Initial treatment: Topical tobramicyn b.i.d, homatropine 3 times a day and Itraconazole 100 mg b.i.d. 1 week later she comes with a visual acuity of hand movement. Clinical diagnosis: Acanthamoeba keratitis. Final treatment: Topical Netilmicine every 2 hours, topical fluconazole every 2 hours and oral itraconazole 200 mg b.i.d. 2 weeks later: no pain, visual acuity 20/50, the corneal ring infiltrate is dissapearing. 3 months later: visual acuity 20/20, corneal ring infiltrate less than 50%, happy patient.

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9 Case 3: Case 3: 54 year old femenine comes with ocular pain on her right eye 2 weeks ago, she was originally diagnosed as having corneal desepitelization by other ophthalmologist. Visual acuity 20/400. Cornea: 90% opacification with an ulcer that stained with fluorescein. Cultures (5 days later): Acanthamoeba castellani on corneal sample and therapeutical contact lens. Initial treatment: Therapeutical contact lens, autologous serum q.i.d., netilmicine q.i.d. and sodium hyaluronate every hour. Post cultures treatment: Itraconazole 200 mg b.i.d. Topical polimixin B, gramicidin, neomycin q.i.d. / Netilmicine every 2 hours. 2 weeks later, less pain, less corneal peripheral edema, it only stains 30% on the center. 3 months later: No staining, diffuse corneal leucoma, visual acuity 20/80

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11 D ISCUSSION We believe that the early diagnosis of Acanthamoeba keratitis is crucial for the prognosis of the disease in our cases and other reported on the literature. Netilmicine was amoebostatic for Acanthamoeba castellani as showed on the graphic; we have no knowledge of any other report of this fact. No surgical intervention was needed in any case, no side effects were found on any patient.

12 C ONCLUSIONS A combined treatment of antifungal (oral itraconazole) and the aminoglucoside Netilmicine, seems to be a great option for the quick and sustained improvement of our patients.


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