1. TREATMENT OF ACANTHAMOEBA KERATITIS IN MEXICO.
Asociación para Evitar la Ceguera en México
Hospital Dr. Luís Sánchez Bulnes, MEXICO
TREATMENT OF ACANTHAMOEBA KERATITIS IN MEXICO.
Ana Lilia Pérez - Balbuena MD
Virginia Vanzzini Zago QFB..
Lorena López Quezada MD
Antonio Sierra- Acevedo MD
Ramón Naranjo Tackman MD.
Authors have no financial interest in the subject matter of this poster.

2. Design : A. restrospective, interventional case series.
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,
2.-Tasanee S. Predisposing factors and etiologic dagnosis Cornea ;27:283
Fig |. Trophozoit of Acanthamoeba poliphaga

3. 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.

4. 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.

5. RESULTS Clinical Features % Ring infíltrate 100% Anterior Uveitis
Ciliar Inyection
Ephitelial defect
83.3%
Satellite Lesion
50%
Hypopyon
Nodular Scleritis
16.6%
Corneal Neovascularizacion
Neurokeratitis
Case days tratment with oral Itraconazol
Case 6. Immunological ring

6. 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 mg b.i.d.
Tobramicin fortificate every hour
Final BCVA 20/ /12 evolution

7. RESULTS Causal agent A/S Risk factor Previous treatment
Before our evaluation
days
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
Corticosteroid, topical chloranphenicol
180 4
44/F
HCL
Polimixin, ketoconazol 5
17/F
Prednisolone, cromoglicic acid 45
A. castellanii 6
24/M
Dexamethasone, polymyxin B, neomycin. 18
Spp
(on study)
N=case number. A/S= age/sex. A=Acanthamoeba. H.C.L.= hard contact lenses SCL= soft contact lenses

8. Treatment in Cornea Service of our Hospital
RESULTS N
Treatment in Cornea Service of our Hospital
Evolution
Days
Surgical treatment 1
Oral Itraconazole 100 mg b.i.d.
Tobramicin fortificate every hour 45
Conjunctival Flap 2
Tobramicin fortificate every hour 35 PK 3 28
None 4
Topical Propamidine Isethionate and Poliexametil-Biguanide. 60 5
Oral Itraconazole 100 mg b.i.d. Tobramicin fortificate every hour 40 6
Oral Itraconazole 100 mg and topical fluorometholone b.i.d.Topical Netilmicin and Fluconazol fortificate 2% every two hours

9. RESULTS N Initial BCVA Final BCVA 1 LP 20/50 2 HM 20/100 3 CF 2m 20/604
20/200 5
20/400 6
20/20

10. Case 5 90 days evolution, vascularized leucoma. Final VA 20/50
Initial examination. Central round ulcer, and immunological ring
40 days evolution.Neovascularization. Stromal Infiltrate.
90 days evolution, vascularized leucoma. Final VA 20/50

11. 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

12. CONCLUSION References
We 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. 
References
Martinez AJ: Free-living amoeba: pathogenic aspect, a review, Protozoal Abst 7:293,1983.
Nagington, J. et al. : Amoebic infection of the eye. Lancet 2:1537,1974.
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):