H Nayak, A Patel, S Gudsoorkar, V Kumar University Hospital Wales Cardiff University

1. H Nayak, A Patel, S Gudsoorkar, V Kumar University Hospital Wales Cardiff University None of the authors have any financial interests with regards to this poster

2. The management of Acanthamoeba keratitis remains a challenge requiring combination amoebicidal drugs for a prolonged duration. Traditionally performed therapeutic penetrating keratoplasty for unresponsive cases are at high risk for endothelial rejection1. Recently deep lamellar keratoplasty has been described as an alternative2,3. We present two cases, successfully managed with deep lamellar keratoplasty (DLK) with good visual rehabilitation….

3. A 51 yr male contact lens wearer was referred to the corneal clinic with suspected right acanthamoeba keratitis. Prior to referral he was treated for suspected herpetic keratitis with lubricants, topical steroids and topical antivirals. After 2 weeks he developed a ring infiltrate and was then switched to Chlorhexidine 0.02%2 hrly, propamidine isethionate 0.1% 2 hrly, cyclopentolate 1% twice daily. Ring infiltrate in right eye

4. Case 1 Continued After initial improvement he deteriorated with worsening infiltrate and development of hypopyon. A corneal biopsy sample grew acanthamoeba polyphaga. Addition of topical clotrimazole 1% did not improve the condition. He then underwent a DLK by modified Melles technique, 7 weeks after commencement on amoebicidal drops with primary aim of disease eradication. The corneal button showed acanthamoeba cysts on histopathology and grew acanthamoeba polyphaga on culture. Right eye infiltrate with small hypopyon

5. Case 1 Continued Immediate postoperatively his vision improved from HM to 6/24(6/12 with pin hole) and eye gradually settled down. He was continued on propamidine isethionate 0.1%, clotrimazole 1% along with topical ofloxacin and dexamethasone 0.1%. 2 months after the initial graft he had a recurrence of the infection. Recurrence of infection in the graft

6. A redo deep lamellar keratoplasty was performed with replacement of the infected anterior lamellar graft. The corneal button obtained again showing acanthamoeba cysts. Post-operatively topical Chlorhexidine 0.02%, clotrimazole 1%, chloramphenicol 0.5% and dexamethasone 0.1% were continued. Treatment was gradually tapered and stopped after 6 months. At last visit (8 months after the second DLK), the cornea was clear with vision of 6/9 unaided improving to 6/6 with pinhole. 2 months post redo deep lamellar keratoplasty

7. A 52 year old male contact lens wearer was diagnosed with right eye subepithelial keratitis and treated with topical antibiotics, steroids and antivirals. A corneal scrape was positive only for Herpes Simplex Type 2. When referred to the cornea clinic, he had intense scleritis, large corneal epithelial defect with superficial keratitis and few endothelial keratitic precipitates. Repeat corneal scrapes and biopsy were negative and antiviral and antibiotic treatment was continued. His corneal ulcer worsened with development of hypopyon, faint ring infiltrate and suspected perineural infiltrates.

8. He was also commenced on topical polyhexamethylene biguanide 0.02% and clotrimazole 1% 2 hourly. He responded well with gradual resolution of the epithelial defect and hypopyon, with regression of infiltrates. His drops were gradually tapered over 3 months. In the following 5 months he had 2 recurrences, each time requiring increasing intensity of the drops with gradual taper. The patient was concerned by the recurrences and poor vision. After discussion surgical intervention in a hot eye was planned with the aim of disease eradication and visual rehabilitation.

9. He underwent a deep lamellar keratoplasty (DLK) by a modified Melles technique, 8 months after initial presentation. The corneal button on histopathology showed numerous acanthamoeba cysts and culture grew acanthamoeba polyphaga. Right eye 2 years after DLK

10. At 3 months his vision was 6/18 unaided improving to 6/6 with pin hole. His drops were tapered and stopped 6 months after the DLK. He gradually developed a cataract for which he had a successful cataract extraction with intraocular lens implantation. At last visit (34 months after DLK), his corneal graft was clear with unaided visual acuity of 6/9 improving to 6/6+ with a pin hole. Right eye 2 years after DLK

11. Therapeutic DLK can be used to remove infected tissue in acanthamoeba keratitis after an initial period of topical amoebicidal drops • Recurrence can also be effectively treated with repeat procedures which are easier to perform • Avoiding penetrating keratoplasty decreases complications including graft rejection, graft failure and intraocular spread of infection • Good visual rehabilitation both in the immediate and late postoperative periods can be achieved

12. Ficker LA, Kirkness C, Wright P. Prognosis for keratoplasty in Acanthamoeba keratitis. Ophthalmology. 1993;100:105–110. • Cremona G, Carrasco MA, Tytiun A, et al. Treatment of advanced acanthamoeba keratitis with deep lamellar keratectomy and conjunctival flap. Cornea 2002;21:705–708. • Parthasarathy A, Tan DTH. Deep lamellar keratoplasty for Acanthamoeba keratitis. Cornea 2007;26:1021-1023