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RE-EMERGING ACANTHAMOEBA KERATITIS (AK): SHIFT IN DIAGNOSTIC TRENDS AND OUTCOMES GLASGOW EXPERIENCE U AGRAVAL, K RAMAESH, D ANIJEET TENNENT INSTITUTE OF.

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Presentation on theme: "RE-EMERGING ACANTHAMOEBA KERATITIS (AK): SHIFT IN DIAGNOSTIC TRENDS AND OUTCOMES GLASGOW EXPERIENCE U AGRAVAL, K RAMAESH, D ANIJEET TENNENT INSTITUTE OF."— Presentation transcript:

1 RE-EMERGING ACANTHAMOEBA KERATITIS (AK): SHIFT IN DIAGNOSTIC TRENDS AND OUTCOMES GLASGOW EXPERIENCE U AGRAVAL, K RAMAESH, D ANIJEET TENNENT INSTITUTE OF OPHTHALMOLOGY, GLASGOW THE AUTHORS HAVE NO FINANCIAL INTEREST TO DISCLOSE

2 PURPOSE Acanthamoeba keratitis (AK) appears to be re-emerging and remains a diagnostic challenge  1973: First Case of Acanthamoeba Keratitis  1989: US 1.36 per million contact len (CL) wearers  1999: Netherlands 3.06 per million CL wearers  1999: West of Scotland 149 per million CL wearers  2002: England/Wales 21 per million CL wearers INCIDENCE Diagnostic methods such as polymerase chain reaction (PCR) have made early diagnosis possible in high risk patients We report the diagnosis, management and outcomes of patient with AK

3 METHODS Retrospective study of 22 patients diagnosed with contact lens related AK at Gartnavel General Hospital, Glasgow Between January 2009 to July 2014 D emographics Type of contact lens Signs and symptoms on presentation Clinical features: early or late Initial visual acuity Initial diagnosis Delay in AK diagnosis Diagnosis method Treatment Visual outcome Additional procedures Recurrence rate Follow up DATA COLLECTION

4 NHS GLASGOW AND CLYDE: NO. OF CASES RESULTS 22 patients: 7 M, 15 F Age: mean 35.8, range 18-59 * No. of cases up to July 2014 – total of 17 cases of AK diagnosed in 2014 Left eyes: 13 Right eyes: 7 Bilateral: 2

5 RESULTS Rigid Gas Permeable: 9% Soft monthly disposable: 40% Soft daily disposable: 31% Cosmetic: 4% Unknown: 14% Pain: 95% Photophobia: 763% Foreign Body Sensation: 9% Tearing: 9% Decreased Corneal Sensation: 36% Signs and Symptoms Type of Contact Lens Poor hygiene: 2 Extended wear/ Slept in CL: 3 Use during swimming: 2 Additional History

6 RESULTS 55% Epitheliopathy Punctate Keratopathy Pseudo/True Dendrties Perineural Infiltrates Radial Keratopathy EARLY FEATURES CL Related Keratitis: 75% Corneal Abrasion: 8% HSV Keratitis: 8% Fungal: 8% Misdiagnosis Range: 0-10 weeks Mean: 2.5 weeks Delay in Diagnosis Initial: Range 6/6 to 6/36 Visual outcome: Range 6/5 to 6/12 -6/5 – 6/6: 82% -6/9 - 6/12: 18% -25% still on treatment Visual Acuity Discharged: 25% 5-12 months Local follow up: 16% Range: 5-16 months Follow-up Additional Procedures - None

7 RESULTS LATE FEATURES 45% Stromal infiltrates (Ring) Ulceration Anterior Uveitis HSV Keratitis: 50% CL Related Keratitis: 40% Corneal Abrasion: 10% Misdiagnosis Range: 2-16 weeks Mean: 5.8 weeks Delay in Diagnosis Initial: Range 1/60-POL Visual outcome: Range: 6/5 to HM -6/5-6/9: 30% -6/12-6/36: 30% -6/60 or less: 40% -30% still on treatment Visual Acuity Discharged: 30% 12-33 months Range: 14-60 months Follow-up AMG: 50% PK: 40% Evisceration: 10% Additional Procedures

8 RESULTS DIAGNOSIS METHOD SHIFT: Corneal Scrape/Biopsy to Confocal/PCR/Diagnosis 2009-2012: Early features: 15% Late features: 85% 2013-2014: Early features: 73% Late features: 27%

9 RESULTS TREATMENT Biguanide – Polyhexamethylene biguanide (PHMB) 0.02% or Chlorhexidine 0.02% Diamidine – Propamidine Isethionate (Brolene) 0.1% or Hexamidine 0.1% Early features: Range: 1-11 months Mean: 7 months Ongoing treatment: 40% Late features: Range: 5-36 months Mean: 14.6 months Ongoing treatment: 30% Duration of Treatment

10 CONCLUSION Early diagnosis of AK has a better visual prognosis, therefore early clinical features should be considered in CL wearers Our study shows there is an emerging trend toward early diagnosis with the use of diagnostic methods such as PCR and confocal microscopy As AK is re-emerging there should be a very low threshold to implement these in high risk patients Contact Lens Wearers Corneal Trauma Exposure To Contaminated Water/Soil Failure To Respond To First Line Treatment for Keratitis High Index of Suspicion

11 REFERENCES KH Cheng, SL Leung, HW Hoekman, et al. Incidence of contact-lens-related microbial keratitis and its related morbidity. Lancet 1999;354:181–5 B Clarke, A Sinha, N Dipak et al. Review Article Advances in the Diagnosis and Treatment of Acanthamoeba Keratitis. Journal of Ophthalmology 2014. JK Dart, VP Saw, S Kilvington. Acanthamoeba keratitis: diagnosis and treatment update 2009. Am J Ophthalmol 2009 148(4): 487-499. K Hiti, J Walochnik, C Faschinger, EM Haller-Schober, and H. Aspöck, “One- and two-step hydrogen peroxide contact lens disinfection solutions against Acanthamoeba: how effective are they?” Eye, vol. 19, no. 12, pp. 1301–1305, 2005 H Jasim, N Knox-Cartwright, S Cook, and D Tole, “Increase in Acanthamoeba keratitis may be associated with use of multipurpose contact lens solution,” British Medical Journal, vol. 344, Article ID e1246, 2012. S Kilvington, T Gray, J Dart, et al. Acanthamoeba Keratitis: The Role of Domestic Tap Water Contamination in the United Kingdom. Investigative Ophthalmology and Visual Science, Jan 2004 (45): 165 – 169 RV Lawande, SN Abraham, I John, and LJ Egler, “Recovery of soil amebas from the nasal passages of children during the dusty harmattan period in Zaria,” American Journal of Clinical Pathology, vol. 71, no. 2, pp. 201–203, 1979. J Naginton, PG Watson, TJ Playfair, J McGill, BR Jones, and AD Steele, “Amoebic infection of the eye,” The Lancet, vol. 2, no. 7896, pp. 1537–1540, 1974.). CF Radford, OJ Lehmann, JKG Dart. Acanthamoeba keratitis:multi-centre survey in England 1992–1996. Br J Ophthalmol 1998;82:1387– 92. CF Radford, DC Minassian, and JKG Dart, “Acanthamoeba keratitis in England and Wales: incidence, outcome, and risk factors,” British Journal of Ophthalmology, vol. 86, no. 5, pp. 536–542, 2002. DV Seal, CM Kirkness, HGB Bennett, et al and Keratitis Study Group. Population-based cohort study of microbial keratitis in Scotland: incidence and features. Contact Lens and Anterior Eye1999;22:49–57.) JK Stehr-Green, TM Bailey, GS Visvesvara. The epidemiology of Acanthamoeba keratitis in the United States. Am J Ophthalmol 1989;107:331–6.


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