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PHOTO ESSAY
Year : 2020  |  Volume : 68  |  Issue : 3  |  Page : 515-516

Management of severe Acanthamoeba keratitis and complicated cataract following laser in situ keratomileusis


1 Tej Kohli Cornea Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
2 Jhaveri Microbiology Centre, L V Prasad Eye Institute, Hyderabad, Telangana, India
3 Kanupriya Dalmia Ophthalmic Pathology Laboratory Services, L.V. Prasad Eye Institute, Bhubaneswar, Odisha, India

Date of Submission13-Mar-2019
Date of Acceptance12-Sep-2019
Date of Web Publication14-Feb-2020

Correspondence Address:
Dr. Bhupesh Bagga
Tej Kohli Cornea Institute, L V Prasad Eye Institute, L V Prasad Marg, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_492_19

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Keywords: Acanthamoeba keratitis, complicated cataract, post-LASIK infection


How to cite this article:
Annapurna N V, Bagga B, Garg P, Joseph J, Sharma S, Kalra P, Mittal R. Management of severe Acanthamoeba keratitis and complicated cataract following laser in situ keratomileusis. Indian J Ophthalmol 2020;68:515-6

How to cite this URL:
Annapurna N V, Bagga B, Garg P, Joseph J, Sharma S, Kalra P, Mittal R. Management of severe Acanthamoeba keratitis and complicated cataract following laser in situ keratomileusis. Indian J Ophthalmol [serial online] 2020 [cited 2020 Feb 22];68:515-6. Available from: http://www.ijo.in/text.asp?2020/68/3/515/278364



According to previous studies, the incidence of postoperative laser in situ keratomileusis (LASIK) infections are rare, as such 1 in 2919 cases have been reported with Mycobacteria and Staphylococci[1],[2],[3] being the most common organisms implicated. In the present study, we are reporting a challenging case of Acanthamoeba keratitis, a rare infection following LASIK, managed medically as well as surgically with flap amputation. On subsequent follow-up, the development of complicated cataract was observed which was well-managed, leading to good anatomical and functional outcome.

A 24-year-old lady, who underwent microkeratome-assisted LASIK elsewhere, 3 months ago for myopia (-4DS), presented with a painful decrease of vision in the left eye. At presentation, the visual acuity was counting fingers close to face, while on examination, cornea [Figure 1]a showed diffuse anterior to mid-stromal infiltrate with overlying necrotic flap. On microbiological examination, smears made from the stromal bed after lifting and later amputating the unsalvageable flap, revealed Acanthamoeba cysts [Figure 2] and [Figure 3]. Postoperatively, [Figure 1]b both topical 0.02% polyhexamethylene biguanide with 0.02% chlorhexidine were started hourly. After observing the signs of resolving infection with deep vessels [Figure 1]c, topical 1% prednisolone acetate was added every 3 hours along with gradual tapering of biguanides and steroids. Keratitis was completely resolved in 6 months leading to scar (CCT-392μ) and regression of vessels [Figure 1]d. Complicated cataract observed during follow up was managed with intraocular lens implantation as calculated with SRK-T formula, resulting into visual acuity of 20/20 (p) with +2.0/-2.5@180.
Figure 1: (a) At the presentation to our institute with diffuse stromal infiltration (8.2 mm vertically and 6.4 mm horizontally) (b) After the flap amputation (c) After 1 month of treatment, when steroids were added since deep vessels were noticed (d) Final follow-up after cataract surgery

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Figure 2: Gram stain (a) of the corneal scraping showing hexagonal double-walled cyst of Acanthamoeba (100×) and 10% KOH + 1% CFW STAIN (b) of the corneal scraping showing multiple fluorescent Acanthamoeba cysts (40×)

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Figure 3: Excised LASIK flap shows double-walled cysts of Acanthamoeba (H and E stain (a), GMS (b); 40×)

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  Discussion Top


This case emphasizes the importance of precise microbiological diagnosis and need of long-term treatment (average 3–4 months) along with timely tapering of medications to avoid toxicity and judicious use of topical steroids in post-Lasik Acanthamoeba keratitis. Flap amputation may be considered therapeutic as reported in the literature.[4] Although visual acuity improved in our case study, use of ASCRS calculator[5] for IOL power, would have enhanced better uncorrected visual acuity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Garg P, Chaurasia S, Vaddavalli PK, Muralidhar R, Mittal V, Gopinathan U. Microbial keratitis after LASIK. J Refract Surg 2010;26:209-16.  Back to cited text no. 1
    
2.
Sharma DP, Sharma S, Wilkins MR. Microbial keratitis after corneal laser refractive surgery. Future Microbiol 2011;6:819-31.  Back to cited text no. 2
    
3.
Solomon R, Donnenfeld ED, Azar DT, Holland EJ, Palmon FR, Pflugfelder SC, et al. Infectious keratitis after laser in situ keratomileusis: Results of an ASCRS survey. J Cataract Refract Surg 2003;29:2001-6.  Back to cited text no. 3
    
4.
Au J, Plesec T, Rocha K, Dupps W Jr., Krueger R. Early post-LASIK flap amputation in the treatment of aggressive, branching keratitis: A case report. Arq Bras Oftalmol 2016;79:50-2.  Back to cited text no. 4
    
5.
Yang R, Yeh A, George MR, Rahman M, Boerman H, Wang M. Comparison of intraocular lens power calculation methods after myopic laser refractive surgery without previous refractive surgery data. J Cataract Refract Surg 2013;39:1327-35.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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