Iris Atrophy, Rapidly Progressive White Cataract, And Secondary Glaucoma During Treatment For Severe Acanthamoeba Keratitis Following Laser Assisted In Situ Keratomileusis (Lasik).

Acanthamoeba keratitis is a severe infectious disease that has seen an increasing incidence over the last two decades. Contact lens wear and exposure to contaminated water sources remain the most significant risk factors. Complications include corneal melting and scarring, severe secondary glaucoma, and chronic anterior segment inflammation. Antiprotozoal agents are typically effective and occasionally may cause allergic conjunctivitis or toxic corneal epithelial erosions, which are usually mild and reversible. However, very rare cases have also been described, such as the one we present of rapidly progressive white cataract with non-reactive midriasis and iris atrophy.

Son Llàtzer University Hospital, Palma de Mallorca, Spain.

We present the case of a 37-year-old patient who developed Acanthamoeba keratitis in her right eye eight months after Laser Assisted in Situ Keratomileusis (LASIK) surgery. Two weeks into treatment, she presented with difficult-to-control ocular hypertension with topical hypotensives and areflexive midriasis, raising suspicion of trabeculitis. Throughout follow-up, the patient showed a persistent epithelial defect refractory to multiple treatments, including insulin, platelet-rich plasma (PRP), autologous serum (AS) eye drops, umbilical cord blood, and multiple amniotic membrane transplants. During this period, a rapidly progressive pearly white cataract appeared. Given the stagnant evolution, risk of perforation, and lack of response to treatments, she underwent penetrating keratoplasty and phacoemulsification surgery with open-sky intraocular lens implantation without immediate complications. One month post-surgery, she developed refractory secondary glaucoma despite complete medical treatment, needing filtering surgery. A Baerveldt valve implant in the posterior chamber was chosen to avoid compromising the integrity of the keratoplasty.

The development of white cataracts, along with iris atrophy and secondary glaucoma, are rare complications described following infectious keratitis during amoebicidal treatment, primarily chlorhexidine. These uncommon cases have been reported shortly after the onset of scleritis or iridocyclitis, and in some instances in association with corneal thinning or wound leak after topical agent use for several weeks or months. These complications necessitate combined surgical management, which will be complex due to the high risk of rejection, limited visibility, and alteration of conjunctival and uveal tissues. Therefore, we underscore the importance of thorough assessment and close monitoring of these patients with the presentation of this case.