Epi Off Pack-Cxl As Treatment For Acanthamoeba Epitheliopathy

To strengthen the importance of early diagnosis of the rare, but severe infection Acanthamoeba. Early signs are mild and often misdiagnosed: clinical presentation may overlap with other infectious processes, like herpetic or fungal keratitis, and non-infectious processes, like contact lenses overwear and toxicity.

Treatment for epithelial stages of Acanthamoeba keratitis is evolving and still not standardized. The use as an orphan drug, like PHMB, requires authorization both from hospital and producer, delaying early treatment. It is mandatory to start effective treatments as soon as possible, in order to prevent spreading of infection in deeper layers and improving visual outcomes

A 20-year-old patient presented to emergency department with worsening blurred vision, mild photophobia and foreign body sensation. She had an history of bi-weekly soft contact lens wear. These symptoms occurred 10 days before and partially remised with tobramycin-dexamethasone ophthalmic suspension. She reported a recent trip in Egypt.

On presentation, Snellen Visual Acuity was 20/25 in both eyes. At slit lamp examination, she presented in both eyes mild conjunctival hyperemia, tarsal papillae and irregular corneal epithelium, characterized by diffuse limbus sparing vesicle-like epithelial deposits and overlying areas of positive and negative staining. Anterior-segment OCT image showed epithelial hyperplasia (right eye thickness: 120 micron, left eye thickness: 90 micron).

In vivo confocal microscopy revealed solitary and diffused round-ovoid hyperreflective bodies in both central and paracentral areas, apparently just on the epithelium as anterior stroma in the right eye was hardly explorable due to photophobia. Therefore, the diagnosis was bilateral Acanthamoeba epitheliopathy.

Subsequently, scraping with complete removal of affected epithelium was performed. Corneal smear was sent for PCR and culture.

Given the efficacy of antiseptics and corneal cross-linking (CXL), we decided to treat this patient with epi-off CXL (program for infection) and antiseptic, prescribing iodopovidone 5% QID and chlorhexidine QID.

After one week, the in vivo confocal microscopy showed no residual cysts and PCR was negative for parasite infection. At slit lamp examination, epithelium presented mild corneal haze with punctate keratitis. Visual acuity was 20/20 in both eyes. Iodopovidone treatment was interrupted.

After 8 weeks, symptoms were remised, apart from mild photophobia, and there were no signs of recurrence.

The management of epithelial stages in Acanthamoeba keratitis is developing. Cross-linking, supported by confocal microscopy and suggestive medical history, permit a quick diagnosis and a better prognosis. It could be debated whether Acanthamoeba epitheliopathy might be effectively resolved only through epithelial removal enhanced by CXL, without requiring prolonged use of biguanide.

To conclude, the early stage of Acanthamoeba keratitis marks a critical window in clinical management: corneal debridement, CXL and antiseptics provide a valid therapeutic option to eradicate infection confined to epithelium.