FROM OPACITY TO CLARITY: SURGICAL RESCUE WITH PENETRATING KERATOPLASTY IN BILATERAL ACANTHAMOEBA KERATITIS

To present a rare bilateral case of Acanthamoeba keratitis in a contact lens wearer that achieved excellent visual and anatomical recovery following prolonged medical treatment and a carefully timed penetrating keratoplasty.

The patient was followed and treated at Istanbul University - Cerrahpaşa Faculty of Medicine, İstanbul, Turkey, between 2022-2025.

A 22-year-old female contact lens user presented in 2022 with complaints of burning and pain in both eyes. On examination, best-corrected visual acuity (BCVA) was 1/10 in the right eye and hand-motion in the left. Bilateral epithelial defects, stromal haze, and ring-shaped infiltrates were observed. Confocal microscopy revealed Acanthamoeba cysts, confirming the diagnosis.
The patient was started on intensive anti-amoebic therapy, including topical polyhexamethylene biguanide (Brolene), chlorhexidine, and antifungal agents. Despite treatment, stromal infiltrates persisted, and BCVA regressed to hand-motion in both eyes. Amniotic membrane transplantation was performed bilaterally in July 2022 to promote epithelial healing and control inflammation. Following prolonged medical therapy and careful monitoring, inflammation was brought under control. However, a dense full-thickness corneal scar and mature cataract developed in the left eye, necessitating surgical intervention.
In April 2025, after confirming disease inactivity, the patient underwent penetrating keratoplasty combined with cataract extraction in the left eye. The postoperative course was uneventful, and the corneal graft remained clear throughout follow-up. At six months, the left eye achieved a BCVA of 20/25, with no signs of recurrence or graft rejection. The right eye remained stable with mild stromal haze but no progression.

Bilateral Acanthamoeba keratitis is an uncommon but severe condition that poses significant diagnostic and therapeutic challenges. Early recognition and aggressive medical therapy are vital to preventing irreversible stromal damage. When advanced scarring develops despite medical management, penetrating keratoplasty can serve both therapeutic and tectonic purposes.
This case emphasizes the importance of a multidisciplinary approach, patient compliance, and especially precise surgical timing. Long-term follow-up is essential to monitor for recurrence and ensure graft survival. With appropriate treatment planning, even severe bilateral cases can achieve excellent visual outcomes, as demonstrated by this patient’s recovery to 20/25 vision after penetrating keratoplasty.