Man presents with red, painful eye after foreign body injury
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A 62-year-old man with no medical or ophthalmic history presented with a red, painful right eye and decreased vision for 10 days after foreign body injury. Upon initial examination in clinic, visual acuity was 20/400 in the right eye and 20/40 in the left eye. Examination of the right eye revealed hyperemic conjunctiva with 3+ diffuse conjunctival injection, a large mid-peripheral ring-shaped corneal epithelial defect with intact but loose central epithelium, mild diffuse stromal edema, no corneal thinning, anterior chamber with 2+ cell and limited view to the posterior pole due to corneal edema. The examination of the left eye was normal. B-scan ultrasonography of the right eye did not reveal any vitritis, posterior masses, or retinal detachments.

Treatment of this patient’s Acanthamoeba sclerokeratitis and bacterial superinfection included topical chlorhexidine, topical polyhexamethylene biguanide, systemic and topical voriconazole, topical cefazolin and topical gatifloxacin. The patient was admitted to the hospital for intravenous treatment with pentamidine, systemic steroids and miltefosine. Upon admission, intravenous methylprednisolone was used to help control inflammation and pain and was later tapered to oral prednisone. Intravenous pentamidine was administered for a 14-day course. Oral miltefosine, granted orphan drug designation for Acanthamoeba, was initiated on hospital day 4 but was stopped earlier than the planned 28-day course on day 22 due to adverse side effects of transaminitis, diabetic ketoacidosis and hypotension.

Clinical improvement was evident on day 4 of treatment, with improved vision and improved pain. The patient was discharged on hospital day 10 with 20/20- near vision in the right eye, 30% hypopyon and overall improved examination pertinent for 1+ diffuse conjunctival injection with ciliary flush, 6 mm by 9 mm central corneal epithelial defect with persistent 360° ring infiltrate and diffuse keratic precipitates.

Three weeks after initiating therapy for Acanthamoeba, confocal microscopy was repeated and revealed clearing of the organisms in the sclera and corneal periphery. Therapeutic PK was successfully performed, and surgical pathology confirmed Acanthamoeba cysts throughout the removed central corneal tissue. More than 1 year later, the patient has not had recurrence of disease, as evidenced by confocal microscopy.