Case presentation AKERATITIS.pptx0000000

eye

1. Case presentation Acanthamoeba keratitis By DR PARTHVI R UPADHYAY Under the guidance of DR SANGEETA WAGH

2. A 37 year old male patient resident of pune DAILY soft contact lens wearer came to the eye OPD on 11/3/2023 With presenting c/o; Pain in LEFT eye acute since 1 week Redness since 5 days Blurred vision Sensitivity to light Sensation of something in the eye Excessive tear He was referred from the another centre with the presumed diagnosis of conjunctivitis.

3. Past ocular history daily soft contact lens user. Complained of rain water entering to the eye while lens ON. No h/o exposure to contaminated water or vegetative injury. No h/o of any sticky or purulent discharge and colored halos Medical history No h/o HTN ,DM,TB or any systemic disease. No significant family history as well Patient was co-operative and well oriented to time, place and person His vitals; WNL

4. Clinical photo at presentation I nferior crescent like infiltrate T here was dendriform like appearance DEFECT SIZE 3.5X4.5 MM

5. Visual acuity- RE : 6/6 LE: F.C 2 m Digital tention NORMAL IOP RE 15mmhg LE 18mmhg Corneal scrapping were done All were negative Gram – TP CIN – CLUSTERS, pairs present KOH negative Giemsa negative no fungus Acanthamoeba – ve scraping was negative for fungus cysts or bacteria Presumptive diagnosis of viral keratitis was made

6. DIAGNOSIS NECTROTISING KERATITIS WITH HSV KERATITIS PRESUMED PRESCRIBED Gatiquin HS – QID Homide eye drop – TDS Acivir e ye oint – TDS Tab. Valcivir 1gm -TDS Tab wysolone [40mg] OD Tab pan 40 OD

7. Follow up 1 WEEK Redness decreased Pain decreased Visual acuity RE 6/6 LE 6/60 defect size: height:2.5mm width:3.5mm Prescribed Gatiquin HS QID Chloroapp / occupol eye oint 2 hourly Acivir eye oint TDS Tab. Valcivir [1gm] TDS Tab. Wysolone [40mg] od Tab Pan 40 OD

8. Follow up 3 week CLINICAL PRESENTATION ; D/T EVOLUTION OF RING Worsening was noted and CORNEAL scrapping repeated, Stain + ve Gram + ve cocci SUSPECTED FOR ACANTHAMOEBA KERATITIS visual acuity RE:6/6 LE:6/24 defect size LE: 1MMX1.5MM Prescribed ADDED PHMB 2 HOURLY CHLOROHEXIDINE 1 HOURLY Gatiquin HS QID Atropine eye drops BD Chloroapp / occupol eye oint 2 hourly Acivir eye oint TDS Tab. Valcivir [1gm] TDS Tab. Wysolone [40mg] od Tab Pan 40 OD

9. Follow up 4 week Patient had an episode of convulsion discontinued the drops for 3-4 days Came with c/o watering o/e congestion increased defect size stable Visual acuiIty RE 6/6 LE:6/18 PHMB 2 HOURLY CHLOROHEXIDINE 1 HOURLY Gatiquin HS QID Atropine eye drops BD Chloroapp / occupol eye oint 2 hourly Acivir eye oint TDS Tab. Valcivir [1gm] TDS Tab. Wysolone [40mg] od Tab Pan 40 OD

10. Follow up 5 week C/O watering and pricking sensation in left eye o/e Worsening was noted. defect size h 5mm; w 6mm Corneal opacity 331µm VA RE 6/6 LE 6/24 NV LE DECREASED PHMB 2 HOURLY CHLOROHEXIDINE 1 HOURLY Gatiquin HS QID Atropine eye drops BD Chloroapp / occupol eye oint 2 hourly Acivir eye oint TDS Tab. Valcivir [1gm] TDS Tab. Wysolone [40mg] od Tab Pan 40 OD

11. Follow up 6 week Improvement was accompanied by scarring and Further drop in visual acuity CONFOCAL MICROSCOPY was performed by DR NATASHA PAHUJA FINDINGS: Appearance of refractive circular bodies most likely cyst Visual Acuity RE: 6/6 LE: F.C ½ M ;NV N36

12. PENETRATING KERATOPLASTY LEFT EYE WAS DONE 6 th week using optical grade tissue FOLLOW UP AFTER 1 WEEK post PK VA : LE 6/12 RE 6/6 TREAMENT PROTOCOL PHMB QID CHLORHEXIDINE QID PREDFORTE E/D TDS VIGAMOX E/D QID OCCUPOL E/O HS

13. Histopathology showed - cysts and trophizoites in entire stroma Hence even after what looked like complete clinical response , there was persistent existence of infection. PHMB and CHX were continued for two months after surgery along with oral steroids given for 4 weeks after which Topical steroids were started one month postop .

14. Take home message Clinical suspicion of acanthamoeba keratitis in contact lens wearer in smear and culture negative patient should be kept in mind . Despite apparent clinical response , dormant cysts can remain in stroma . Timely surgery can ensure saving the vision. Post-op continuing of anti amoebic drops will prevent recurrences.

15. R eferences Clinical ophthalmology ; systemic approach 7 th edition Jack J Kanski and Brad B owling Ophthalmology 4 th edition M yron Y anoff and Jay S D uker External disease and cornea AAO BASIC AND CLINICAL SCIENCE COURSE SECTION 8 CORNEA 3 RD EDITION JAY H KRACHMER, MARK J MANNIS AND EDWARD J HOLLAND