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.

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;v3,142-246 2.-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.

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 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 Final BCVA 20/50. 6/12 evolution

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

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

RESULTS N Initial BCVA Final BCVA 1 LP 20/50 2 HM 20/100 3 CF 2m 20/60 4 20/200 5 20/400 6 20/20

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

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

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):121-126