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PHOTO ESSAY
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 255-256

Acanthamoeba sclerokeratitis: Infection or inflammation?


Cornea Services, LV Prasad Eye Institute, Bhubaneswar, Odisha, India

Date of Submission26-May-2021
Date of Acceptance01-Jul-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Sujata Das
L V Prasad Eye Institute, Bhubaneswar, Odisha - 751 024
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1360_21

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How to cite this article:
Alluri H, Soni T, Das S. Acanthamoeba sclerokeratitis: Infection or inflammation?. Indian J Ophthalmol Case Rep 2022;2:255-6

How to cite this URL:
Alluri H, Soni T, Das S. Acanthamoeba sclerokeratitis: Infection or inflammation?. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:255-6. Available from: https://www.ijoreports.in/text.asp?2022/2/1/255/334870



Acanthamoeba sclerokeratitis (ASK) is a rare complication of Acanthamoeba keratitis. We describe the clinical features and management of ASK that presented with infectious nodular scleritis.

A 92-year-old male complained of redness, irritation, and watering following the fall of an insect in the right eye since 2 months; there was no history of any other systemic illness. On examination, his best-corrected visual acuity in the right eye was perception of light. Slit-lamp examination revealed edematous lids, conjunctival hyperemia, 7 × 8 mm epithelial defect, stromal edema, faint grayish infiltrate of size 4 × 5 mm in the center of the cornea, and hypopyon [Figure 1]a, and a normal B-scan ultrasonography. Microbiological examination of corneal scraping revealed double-walled hexagonal cysts suggestive of Acanthamoeba cysts on potassium hydroxide with calcofluor white staining [Figure 1]b. The patient was started on topical polyhexamethylene biguanide (0.02%) eye drops hourly and chlorhexidine (0.02%) eye drops hourly. However, the patient was not compliant with medications, and he presented with increased pain after 1 week. Examination revealed persistent epithelial defect with an increase in stromal infiltrate size and contiguous nodular scleral lesion with an active pus point at 7 O'clock position [Figure 1]c.
Figure 1: (a) Slit-lamp photo under diffuse illumination showing conjunctival hyperemia, central epithelial defect, and faint grayish stromal infiltrate with hypopyon in the right eye during the first visit; (b) microscopy showing double-walled Acanthamoeba cysts on KOH calcofluor staining from smear taken from sclera nodule; (c) slit-lamp photo under diffuse illumination showing persistent epithelial defect with stromal infiltrate and scleral nodule at 7 O' clock position

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Scleral exploration revealed Acanthamoeba cysts on smear examination along with growth on non-nutrient agar with Escherichia coli overlay. He was continued with anti-Acanthamoeba treatment (AAT) and systemic itraconazole (100 mg) twice daily. The patient could not come for follow-up due to nationwide lockdown imposed to curb COVID-19 (coronavirus disease 2019).


  Discussion Top


The pathogenesis of ASK is poorly understood. The underlying process can be either inflammation due to persistence of antigen of Acanthamoeba or active infection that can be established only by the absence or presence of viable cysts, respectively.[1] The reported incidence of ASK is 6% to 18% and the most commonly reported cases are diffuse scleritis with inflammatory etiology.[2],[3] There have been isolated reports of four cases of infectious nodular ASK with poor clinical outcomes and of these two underwent enucleation.[4],[5],[6] We described a case of nodular ASK with viable cysts in sclera, and AAT was continued. The authors suggest that nodular scleral lesion contiguous with keratitis should prompt to rule out active infection. The treatment for ASK is largely guided by a well-defined stepladder approach for diffuse scleritis.[2] The approach to treatment in nodular ASK is affected by a dearth of evidence due to rare occurrences.

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.
Yang YF, Matheson M, Dart JK, Cree IA. Persistence of acanthamoeba antigen following acanthamoeba keratitis. Br J Ophthalmol 2001;85:277-80.  Back to cited text no. 1
    
2.
Iovieno A, Gore DM, Carnt N, Dart JK. Acanthamoeba sclerokeratitis: Epidemiology, clinical features, and treatment outcomes. Ophthalmology 2014;121:2340-7.  Back to cited text no. 2
    
3.
Mannis MJ, Tamaru R, Roth AM, Burns M, Thirkill C. Acanthamoeba sclerokeratitis. Determining diagnostic criteria. Arch Ophthalmol 1986;104:1313-7.  Back to cited text no. 3
    
4.
Arnalich-Montiel F, Jaumandreu L, Leal M, Valladares B, Lorenzo-Morales J. Scleral and intraocular amoebic dissemination in Acanthamoeba keratitis. Cornea 2013;32:1625-7.  Back to cited text no. 4
    
5.
Mammo Z, Almeida DR, Cunningham MA, Chin EK, Mahajan VB. Acanthamoeba endophthalmitis after recurrent keratitis and nodular scleritis. Retin Cases Brief Rep 2017;11:180-2.  Back to cited text no. 5
    
6.
Baker MS, Maltry AC, Syed NA, Allen RC. Orbital implant exposure after Acanthamoeba panophthalmitis. Am J Ophthalmol Case Rep 2018;10:48-50.  Back to cited text no. 6
    


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