Acanthamoebakeratitis: a comprehensive photographic reference of common and uncommon signs

Novel Drug Delivery Systems to Improve the Treatment of Keratitis

Keratitis is a disease characterized by inflammation of the cornea caused by different pathogens. It can cause serious visual morbidity if not treated quickly. Depending on the pathogen causing keratitis, eye drops containing antibacterial, antifungal, or antiviral agents such as besiloxacin, moxifloxacin, ofloxacin, voriconazol, econazole, fluconazole, and acyclovir are used, and these drops need to be applied frequently due to their low bioavailability. Studies are carried out on formulations with extended residence time in the cornea and increased permeability. These formulations include various new drug delivery systems such as inserts, nanoparticles, liposomes, niosomes, cubosomes, microemulsions, in situ gels, contact lenses, nanostructured lipid carriers, carbon quantum dots, and microneedles. Ex vivo and in vivo studies with these formulations have shown that the residence time of the active substances in the cornea is prolonged, and their ocular bioavailability is increased. In addition, in vivo studies have shown that these formulations successfully treat keratitis. However, it has been observed that fluoroquinolones are used in most of the studies; similar drug delivery systems are generally preferred for antifungal drugs, and studies for viral and acanthameba keratitis are limited. There is a need for new studies on different types of keratitis and different drug active substances. At the same time, proving the efficacy of drug delivery systems, which give promising results in in vivo animal models, with clinical studies is of great importance for progress in the treatment of keratitis.

Contact lenses coated with hybrid multifunctional ternary nanocoatings (Phytomolecule-coated ZnO nanoparticles:Gallic Acid:Tobramycin) for the treatment of bacterial and fungal keratitis

Contact lenses are widely used for visual corrections. However, while wearing contact lenses, eyes typically face discomforts (itching, irritation, burning, etc.) due to foreign object sensation, lack of oxygen permeability, and tear film disruption as opposed to a lack of wetting agents. Eyes are also prone to ocular infections such as bacterial keratitis (BK) and fungal keratitis (FK) and inflammatory events such as contact lens-related acute red eye (CLARE), contact lens peripheral ulcer (CLPU), and infiltrative keratitis (IK) caused by pathogenic bacterial and fungal strains that contaminate contact lenses. Therefore, a good design of contact lenses should adequately address the need for wetting, the supply of antioxidants, and antifouling and antimicrobial efficacy. Here, we developed multifunctional gallic acid (GA), phytomolecules-coated zinc oxide nanoparticles (ZN), and phytomolecules-coated zinc oxide nanoparticles + gallic acid + tobramycin (ZGT)-coated contact lenses using a sonochemical technique. The coated contact lenses exhibited significant antibacterial (>log₁₀ 5.60), antifungal, and antibiofilm performance against BK-causing multidrug resistant bacteria (Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia. coli) and FK-related pathogenic fungal strains (Candida albicans, Aspergillus fumigatus, and Fusarium solani). The gallic acid, tobramycin, and phytomolecules-coated zinc oxide nanoparticles have different functionalities (-OH, -NH₂, -COOH, -COH, etc.) that enhanced wettability of the coated contact lenses as compared to that of uncoated ones and further enabled them to exhibit remarkable antifouling property by prohibiting adhesion of platelets and proteins. The coated contact lenses also showed significant antioxidant activity by scavenging DPPH and good cytocompatibility to human corneal epithelial cells and keratinocytes cell lines. STATEMENT OF SIGNIFICANCE: • Multifunctional coated lenses were developed with an efficient sonochemical approach. • Lens surface was modified with nanocoatings of ZnO nanoparticles, gallic acid, and tobramycin. • This synergistic combination endowed the lenses with remarkable antimicrobial activity. • Coated lenses also showed noteworthy antifouling and biofilm inhibition activities. • Coated lenses showed good antioxidant, biocompatibility, and wettability characteristics.

Challenges in Acanthamoeba Keratitis: A Review

To review challenges in the diagnosis and management of Acanthamoeba keratitis (AK), along with prognostic factors, in order to help ophthalmologists avoid misdiagnosis, protracted treatment periods, and long-term negative sequelae, with an overarching goal of improving patient outcomes and quality of life, we examined AK studies published between January 1998 and December 2019. All manuscripts describing clinical manifestations, diagnosis, treatment, prognosis, and challenges in short- and long-term management were included. The diagnosis of AK is often challenging. An increased time between symptom onset and the initiation of appropriate therapy is associated with poorer visual outcomes. The timely initiation of standardized antiamoebic therapies improves visual outcomes, decreases the duration of treatment, and reduces the chances of needing surgical intervention. In clinical practice, AK diagnosis is often missed or delayed, leading to poorer final visual outcomes and a negative impact on patient morbidity and quality of life.

Recent progress and strategies to develop antimicrobial contact lenses and lens cases for different types of microbial keratitis

Although contact lenses are widely used for vision correction, they are also the primary cause of a number of ocular diseases such as microbial keratitis (MK), etc. and inflammatory events such as infiltrative keratitis (IK), contact lens acute red eye (CLARE), contact lens-induced peripheral ulcer (CLPU), etc. These diseases and infiltrative events often result from microbial contamination of lens care solutions and lens cases that can be exacerbated by unsanitary lens care and extended lens wear. The treatment of microbial biofilms (MBs) on lens cases and contact lenses are complicated and challenging due to their resistance to conventional antimicrobial lens care solutions. More importantly, MK caused by MBs can lead to acute visual damage or even vision impairment. Therefore, the development of lens cases, lens care solutions, and contact lenses with effective antimicrobial performance against MK will contribute to the safe use of contact lenses. This review article summarizes and discusses different chemical approaches for the development of antimicrobial contact lenses and lens cases employing passive surface modifications, antimicrobial peptides, free-radical fabricating agents, quorum sensing quenchers, antibiotics, antifungal drugs and various metals and coatings with antimicrobial nanomaterials. The benefits and shortcomings of these approaches are assessed, and alternative solutions for future developments are discussed.

Corneal Endotheliitis as a Presentation of Acanthamoeba Keratitis

OBJECTIVE

To report 2 cases of Acanthamoeba keratitis (AK) presenting with corneal endotheliitis.

METHODS

Case report.

RESULTS

Two contact lens wearers, who had been diagnosed with herpes simplex virus (HSV) keratitis, predominantly manifested corneal endotheliitis composed of corneal edema, keratic precipitates, and anterior chamber reaction at referral. AK was confirmed using cultures or through polymerase chain reaction testing. The patients were started on polyhexamethylene biguanide and responded favorably to regain satisfactory visual acuity.

CONCLUSIONS

Corneal endotheliitis, although uncommon, may be a manifestation of AK. We must have high-index suspicion for AK in all contact lens users, particularly before making a diagnosis of HSV keratitis. Accurate diagnosis and prompt treatment can result in a favorable prognosis for AK.

High fluence PACK-CXL as adjuvant treatment for advanced Acanthamoeba keratitis

Purpose

To describe the outcome of adjuvant high fluence photoactivated chromophore for infectious keratitis cross-linking (PACK-CXL) used to treat an advanced form of refractory Acanthamoeba keratitis (AK) diagnosed several months after initial presentation.

Observations

An otherwise healthy 24-year old female presented with a severe unilateral keratitis. The diagnosis eluded clinicians for several months and when finally confirmed as AK, anti-amoebic therapy was instated and only appeared to be effective after addition of high fluence PACK-CXL.

Conclusion and importance

In this case of advanced AK, high fluence PACK-CXL treatment given adjuvant to pharmacologic anti-amoebic therapy resulted in lasting pain relief, re-epithelization and eradication of the Acanthamoeba parasite. Given adjuvant to anti-amoebic pharmacotherapy, high fluence PACK-CXL might be a useful method for treating typically refractory advanced AK.

Acanthamoeba keratitis - Clinical signs, differential diagnosis and treatment

PURPOSE

To summarize actual literature data on clinical signs, differential diagnosis, and treatment of acanthamoeba keratitis.

METHODS

Review of literature.

RESULTS

Clinical signs of acanthamoeba keratitis are in early stages grey-dirty epithelium, pseudodendritiformic epitheliopathy, perineuritis, multifocal stromal infiltrates, ring infiltrate and in later stages scleritis, iris atrophy, anterior synechiae, secondary glaucoma, mature cataract, and chorioretinitis. As conservative treatment, we use up to one year triple-topical therapy (polyhexamethylene-biguanide, propamidine-isethionate, neomycin). In therapy resistant cases, surgical treatment options such as corneal cryotherapy, amniotic membrane transplantation, riboflavin-UVA cross-linking, and penetrating keratoplasty are applied.

CONCLUSION

With early diagnosis and conservative or surgical treatment, acanthamoeba keratitis heals in most cases.

[The German Acanthamoeba keratitis register: Initial results of a multicenter study]

BACKGROUND AND PURPOSE

In September 2011 the cornea section of the German Ophthalmological Society (DOG) established the first German Acanthamoeba keratitis registry. The data of this multicenter survey are being collected, compiled and evaluated at the Department of Ophthalmology at the Saarland University. The aim of this article is to present an intermediate report.

PATIENTS AND METHODS

Data from 172 eyes with Acanthamoeba keratitis were collected during the last 10 years. For this interim report we actually evaluated 121 eyes (60.2 % female patients, average age 41.3 years) and collected the following data: date of onset of symptoms, date and method of diagnosis, initial diagnosis, anamnestic data, clinical symptoms and signs at diagnosis and during follow-up, conservative and surgical therapy. Criteria for inclusion in the Acanthamoeba registry was the established diagnosis of an Acanthamoeba keratitis with at least one of the methods described in this article.

RESULTS

Acanthamoeba keratitis could be histologically proven in 55.3 % of the cases, via PCR in 25.6 %, with confocal microscopy in 20.4 % and using in vitro cultivation in 15.5 %. Clinical symptoms and signs in Acanthamoeba keratitis were pain in 67.0 %, ring infiltrates in 53.4 %, pseudodendritiform epitheliopathy in 11.7 % and keratoneuritis in 5.8 %. In 47.6 % of the cases the initial diagnosis was herpes simplex virus keratitis followed by bacterial keratitis in 25.2 % and fungal keratitis in 3.9 %. Acanthamoeba keratitis was the correct initial diagnosis in only 23.2 % of cases. The average time period between first symptoms and diagnosis was 2.8 ± 4.0 months (range 0-23 months). A triple therapy with Brolene® Lavasept® and antibiotic eye drops at least 5 ×/day was used in 54.5 % of eyes (n = 66). Penetrating keratoplasty was performed in 40.4 %, in 18 cases in combination with cryotherapy of the cornea. The mean graft diameter was 7.9 ± 1.1 mm (range 3.5-11.0 mm). The final visual acuity (Snellen visual acuity chart at 5 m) was comparable in the two groups of eyes with (5/40 ± 5/25) and without (5/32 ± 5/25) keratoplasty.

CONCLUSION

Acanthamoeba keratitis is a rare and often very late diagnosed disease and two thirds of the cases were initially misdiagnosed. The early recognition of the typical symptoms is crucial for the prognosis of the disease. All ophthalmological departments in Germany are invited to submit further data of all confirmed cases (berthold.seitz@uks.eu), whether retrospectively or prospectively in order to generate an adequate standardized diagnostic and therapeutic approach for this potentially devastating disease.

Keratoneuritis is not pathognomonic of Acanthamoeba keratitis: a case report of Pseudomonas keratitis

The presence of keratoneuritis in a radial pattern is considered to be a virtually pathognomonic sign of Acanthamoeba keratitis. We report a case of a massive keratoneuritis as a presenting sign in Pseudomonas keratitis in a contact lens wearer, thereby further challenging this concept.

Free living amoebae and human disease

Pathogenic FLA are ubiquitous protozoans and despite frequent human contact remain a rare cause of often devastating infection with poor prognosis. Given changes in climate, human encroachment into the environment, increasing immunosuppression, and improving diagnostic capacity, it is likely we will see increased cases in the future. Early diagnosis is challenging but crucial to achieving a favourable outcome. It is best facilitated by improved awareness of FLA disease, appropriate clinical suspicion and early diagnostic testing.

Presumed late recurrence of Acanthamoeba keratitis exacerbated by exposure to topical corticosteroids

A 28-year-old female with a history of contact lens wear presented with a 1 week history of pain and photophobia in her left eye. In vivo confocal microscopy (IVCM) and corneal scrape confirmed the diagnosis of Acanthamoeba keratitis (AK) which was treated with intensive topical propamidine isethionate (0.1%) and chlorhexidine (0.02%) with tapering dosage over 11 months. Five years after complete resolution of AK and cessation of all contact lens wear, the subject presented to her optometrist with a history of ocular discomfort and mild photophobia. Without further investigation she was prescribed topical corticosteroids. Three weeks later she presented with pain and reduced vision in the left eye. Slit-lamp examination revealed focal, inferior corneal stromal edema. IVCM confirmed widespread Acanthamoeba cysts. Treatment with topical polyhexamethylene biguanide (PHMB) 0.02% and propamidine isethionate 0.1% resulted in resolution of the AK. Despite an initially mild AK, this subject presumably retained viable Acanthamoeba cysts in her cornea 5 years after the initial episode. This report highlights the importance of caution when using corticosteroids in patients with a previous history of AK, even in the relatively distant past. Patients with AK should be warned regarding the risks of recurrence following presumed resolution.

Acanthamoeba keratitis: an emerging disease gathering importance worldwide?

Acanthamoeba keratitis (AK) is increasingly being recognized as a severe sight-threatening ocular infection worldwide. Although contact lens wear is the leading risk factor for AK, Acanthamoeba parasites are also an important cause of keratitis in non-contact lens wearers. Diagnosis of AK is challenging, and the available treatments are lengthy and not fully effective against all strains. The pathogenesis of Acanthamoeba is still under study, and the identification of the key factors involved in this process should be useful for the development of fully effective therapies. This review focuses on recent developments on AK pathogenesis and diagnosis as well as novel strategies for the evaluation of anti-amoebic agents that could be applied in the near future against these pathogens.

Utility of real-time polymerase chain reaction in diagnosing and treating acanthamoeba keratitis

PURPOSE

Using real-time polymerase chain reaction (PCR), we detected Acanthamoeba and monitored the changes in Acanthamoeba DNA copy number over the treatment course in patients suspected of Acanthamoeba keratitis (AK).

METHODS

Subjects were 6 patients (average age, 26.2 years) suspected of AK at the Kinki University Outpatient Clinic. For detection of Acanthamoeba, patients' corneal scrapings were collected for smear analysis, culture, and real-time PCR. After the diagnosis of AK was confirmed, treatment was initiated based on the quantitative result of the real-time PCR.

RESULTS

Both the smear and culture were positive for Acanthamoeba in 4 cases and negative in 2 cases (agreement in 3 cases and disagreement in 2 cases). By real-time PCR, all 6 cases were positive for Acanthamoeba with an average DNA copy number of 4.8 ± 9.1 × 10 copies per sample. We further monitored the variation in the Acanthamoeba DNA copy number over the treatment course and successfully treated all the patients. DNA copy number provided a parallel with other clinical features of AK.

CONCLUSIONS

Real-time PCR can be a useful method for a rapid and precise diagnosis of AK. Moreover, utility of the Acanthamoeba DNA copy number obtained by real-time PCR can help ophthalmologists in making the best treatment decision.

Resurgence of Acanthamoeba keratitis in Auckland, New Zealand: a 7-year review of presentation and outcomes

PURPOSE

To investigate the presentation, clinical characteristics and outcomes of Acanthamoeba keratitis (AK) in Auckland, New Zealand over a 7-year period.

METHODS

Retrospective analysis of all cases of AK treated by the tertiary corneal service at Auckland City Hospital/ University of Auckland Department of Ophthalmology (August 2001 to May 2008). Data were collected regarding age, gender, contact lens history, presenting signs and symptoms, diagnosis at first presentation, time to final diagnosis, identifiable risk factors, presenting and final visual acuity, results of microbiological testing, medical treatment, surgical interventions, recurrence of disease and length of follow up. All photographs and in vivo confocal microscopy images were reviewed.

RESULTS

Twenty-five eyes of 25 patients were identified with a diagnosis of AK (mean age 40 +/- 13 years). Ninety-six per cent were contact lens wearers. Mean time to diagnosis was 41 +/- 49 days (range 0-181 days, median 21 days). Fourteen patients (56%) had been treated with topical corticosteroids prior to the diagnosis. Early diagnosis of AK (<21 days) was associated with significantly better final visual acuity and did not require any surgical intervention compared with those diagnosed at a later stage. Six patients, all in the late diagnosis group, required surgical intervention.

CONCLUSIONS

AK has become significantly more common in New Zealand in the current decade. This study highlights the fundamental importance of early diagnosis and appropriate management in ensuring favourable outcomes. Practitioners should maintain a clinical suspicion of AK, especially as 96% of the subjects in this study were contact lens wearers.

Molecular phylogeny of acanthamoeba

After morphological grouping of Acanthamoeba by Pussard and Pons, phylogeny of the genus has been always a big topic to the researchers. Because of the variability of morphological characteristics, unchangeable and stable characters have been investigated for phylogenic criteria. Isoenzyme and mitochondrial DNA RFLP (Mt DNA RFLP) analyses revealed different patterns among strains assigned to a same species. Therefore, these characteristics would be considered as tools for strain discrimination than species identification. The most recently developed and the most promising method is the sequence analysis of 18s ribosomal RNA coding DNA (18s rDNA). The phylogenic tree based on comparison of 18s rDNA sequences distinguished the 3 morphological groups of Acanthamoeba and divided them into 12 unique sequence types (T1-T12 genotypes). Most clinical and environmental isolates belonged to the morphological group II and the genotype T4. In the Republic of Korea, 2 strains of Acanthamoeba, YM-2 and YM-3, were first isolated from the environment in 1974. However, phylogenic identification of Korean Acanthamoeba isolates from human infections or the environment were tried from the late 1990s. By RFLP analysis or total sequence analysis of 18s rDNA revealed that almost all clinical isolates including the one from a suspicious granulomatous amebic encephalitis patient belonged to the genotype T4. A large number of environmental isolates from contact lens storage cases, tapped water, and ocean sediments also belonged to the genotype T4. Almost identical strain characteristics, such as Mt DNA RFLP pattern of environmental isolates, with the clinical isolates could make a simple conclusion that most environmental isolates might be a potential keratopathogen.