Acanthamoeba keratitis and contact lens wear

Acanthamoeba keratitis is a rare but serious complication of contact lens wear that may cause severe visual loss. The clinical picture is usually characterised by severe pain, sometimes disproportionate to the signs, with an early superficial keratitis that is often misdiagnosed as herpes simplex virus (HSV) keratitis. Advanced stages of the infection are usually characterised by central corneal epithelial loss and marked stromal opacification with subsequent loss of vision. In this paper, six cases of contact lens-related Acanthamoeba keratitis that occurred in Australia and New Zealand over a three-year period are described. Three of the patients were disposable soft lens wearers, two were hybrid lens wearers and one was a rigid gas permeable lens wearer. For all six cases, the risk factors for Acanthamoeba keratitis were contact lens wear with inappropriate or ineffective lens maintenance and exposure of the contact lenses to tap or other sources of water. All six patients responded well to medical therapy that involved topical use of appropriate therapeutic agents, most commonly polyhexamethylene biguanide and propamidine isethionate, although two of the patients also subsequently underwent deep lamellar keratoplasty due to residual corneal surface irregularity and stromal scarring. Despite the significant advances that have been made in the medical therapy of Acanthamoeba keratitis over the past 10 years, prevention remains the best treatment and patients who wear contact lenses must be thoroughly educated about the proper use and care of the lenses. In particular, exposure of the contact lenses to tap water or other sources of water should be avoided.

Evaluation of loop-mediated isothermal amplification assay for rapid diagnosis of Acanthamoeba keratitis

BACKGROUND

The clinical features of Acanthamoeba keratitis (AK) are non-specific and closely resemble bacterial, viral and fungal keratitis.

MATERIALS AND METHODS

We compared loop-mediated isothermal amplification (LAMP) with microscopy, non-nutrient agar (NNA) culture and polymerase chain reaction (PCR) in clinical suspects of AK.

RESULTS

Of 52 clinical samples (42 AK suspects and 10 proven bacterial, viral or fungal keratitis), 3 were positive by direct microscopy (sensitivity 60%, confidence interval [CI]: 17%-92.7%), and 5 by NNA culture, 18S rDNA PCR and LAMP (sensitivity 100%, CI: 46.3%-100%). The limit of detection of Acanthamoeba DNA was 1 pg/μl by both LAMP and PCR.

CONCLUSION

PCR and LAMP assays targeting 18S rDNA gene were found particularly suitable for a rapid and accurate diagnosis of AK. LAMP assay takes 2-3 h lesser than PCR, and thus offers a rapid, highly sensitive and specific, simple and affordable diagnostic modality for patients suspected of AK, especially in resource limited settings.

[Diagnosis of Acanthamoeba keratitis]

The Acanthamoeba keratitis is a relatively rare, but dangerous disease of the cornea. Its development is thought to be associated with contact lens wearing as well as corneal microwounds contaminated with soil or water. The disease has no evident distinctive clinical features and is, therefore, difficult to be distinguished from herpetic or fungal keratitis. Nevertheless, Acanthamoeba infection can be suspected judging from anamnestic data (i.e. contact lens use and corneal injury with subsequent contamination of the wound), inadequately strong pain syndrome, ring-shaped infiltration of the cornea and ineffectiveness of conventional therapy. Also helpful may be such measures as isolating the bacteria using the method of biocultures, morphological examination of corneal biopsy material (using light and luminescent microscopy), genetic testing, and in vivo confocal microscopy of the cornea. Other promising methods are also listed in this article. A widely accepted diagnostic technique is yet, however, missing.

Advances in the diagnosis and treatment of acanthamoeba keratitis

This paper aims to review the recent literature describing Acanthamoeba keratitis and outline current thoughts on pathogenesis, diagnosis, and treatment as well as currently emerging diagnostic and treatment modalities.

Importance of nonenteric protozoan infections in immunocompromised people

There are many neglected nonenteric protozoa able to cause serious morbidity and mortality in humans, particularly in the developing world. Diseases caused by certain protozoa are often more severe in the presence of HIV. While information regarding neglected tropical diseases caused by trypanosomatids and Plasmodium is abundant, these protozoa are often not a first consideration in Western countries where they are not endemic. As such, diagnostics may not be available in these regions. Due to global travel and immigration, this has become an increasing problem. Inversely, in certain parts of the world (particularly sub-Saharan Africa), the HIV problem is so severe that diseases like microsporidiosis and toxoplasmosis are common. In Western countries, due to the availability of highly active antiretroviral therapy (HAART), these diseases are infrequently encountered. While free-living amoebae are rarely encountered in a clinical setting, when infections do occur, they are often fatal. Rapid diagnosis and treatment are essential to the survival of patients infected with these organisms. This paper reviews information on the diagnosis and treatment of nonenteric protozoal diseases in immunocompromised people, with a focus on patients infected with HIV. The nonenteric microsporidia, some trypanosomatids, Toxoplasma spp., Neospora spp., some free-living amoebae, Plasmodium spp., and Babesia spp. are discussed.

Riboflavin and ultraviolet light a therapy as an adjuvant treatment for medically refractive Acanthamoeba keratitis: report of 3 cases

PURPOSE

To present the first 3 cases of Acanthamoeba keratitis (AK), unresponsive to medical treatment, that were successfully treated with a novel adjunctive therapy using ultraviolet light A (UVA) and riboflavin (B2).

DESIGN

Interventional case series.

PARTICIPANTS

Two patients with confirmed AK and 1 patient with presumptive AK, which were all refractive to multidrug conventional therapy.

INTERVENTION

Two treatment sessions involving topical application of 0.1% B2 solution to the ocular surface combined with 30 minutes of UVA irradiation focused on the corneal ulcer.

MAIN OUTCOME MEASURES

Clinical examination by slit lamp, confocal microscopy, and histopathology, when available.

RESULTS

All patients in these series showed a rapid reduction in their symptoms and decreased ulcer size after the first treatment session. The progress of the clinical improvement began to slow after 1 to 3 weeks of the first application and was then renewed after the second application. All ancillary signs of inflammation mostly resolved after the second treatment session. The ulcers in all patients continued to decrease and were closed within 3 to 7 weeks of the first application. Two patients developed dense central corneal scars, and penetrating keratoplasty was performed for visual rehabilitation. Histopathologic examination of the excised tissue revealed no Acanthamoeba organisms. The remaining patient had no symptoms or signs of infection, both clinically and by confocal microscopy, and was left with a semitransparent eccentric scar that did not affect visual acuity.

CONCLUSIONS

The adjunctive use of UVA and B2 therapy seems to be a possible alternative for selected cases of medication-resistant AK.

Acanthamoeba keratitis in the south of Sweden

Eight patients with Acanthamoeba keratitis were diagnosed and treated at our clinic between February 1991 and February 1993. Five of these were contact lens wearers, two had suffered recent corneal trauma and one had recently undergone penetrating keratoplasty. The diagnoses were based on both culture and histological examination of biopsy material in three cases, on culture alone in two cases and on histological examination alone in three cases. In all but one primary treatment was Propamidine isethionate and Neomycin/Polymyxin B topically and Ketoconazole orally. Because of poor healing three patients additionally received Paromomycin and Miconazole or Clotrimazol topically; two of these were further treated with Polyhexamethylene biguanide topically. The interval from initial symptoms to accurate diagnoses varied from one to eleven months. In one patient the eye could not be saved; in the remaining patients visual acuity after healing ranged from hand movements to 1.0.

Outbreak of keratitis presumed to be caused by Acanthamoeba

PURPOSE

A sharp increase of Acanthamoeba keratitis from two cases per year to 30 cases per year at our institution prompted this study to determine whether there was a change in the clinical characteristics, basic epidemiology, and outcome of this disease.

METHODS

We reviewed all cases of Acanthamoeba keratitis diagnosed at the University of Iowa Hospitals and Clinics from mid-1993 through 1994.

RESULTS

We screened 217 patients with keratitis by tandem scanning confocal microscopy and suspected Acanthamoeba in 51 patients. Diagnosis was confirmed by cytology in 43 patients (48 eyes). There were no positive cultures. Patients examined within four weeks of onset of symptoms were younger (mean age, 32.6 +/- 15.4 years) and wore contact lenses (11 of 18 patients), and infrequently herpes simplex keratitis (four of 18 patients) was diagnosed. Patients examined after four weeks were older (mean age, 54.0 +/- 19.5 years), infrequently wore contact lenses (six of 25 patients), and often had herpes simplex keratitis (12 of 25 patients).

CONCLUSIONS

Corneal examination with tandem scanning confocal microscopy was associated with a marked increase in the detection of Acanthamoeba, strongly suggesting that the disease is more prevalent than suspected. Acanthamoeba may account for many cases of clinically presumed herpes simplex keratitis, the leading cause of corneal blindness in the United States. Acanthamoeba should be considered in the differential diagnosis of any unexplained keratitis, even those of short duration.

Pathogenesis of acanthamoebic keratitis: hypothesis based on a histological analysis of 30 cases

The results of a histopathological study of 30 cases of Acanthamoeba keratitis are construed as indicating a four stage pathogenetic sequence: (1) initial infection, involving breaching of the surface epithelium; (2) keratocyte depletion by the invading trophozoites; (3) inflammatory response mediated by neutrophil polymorphonuclear leucocytes; (4) stromal necrosis attributable to leucocytic activity.