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Purpose : To report our experience with oral miltefosine (MLT) as an adjunct treatment for progressive Acanthamoeba keratitis (AK). Methods : Retrospective case series of all patients who underwent treatment with oral MLT for AK at Bascom Palmer Eye Institute from 2017 to 2020. Results : Six females from 16 to 55 years old, with a microbiologic diagnosis of Acanthamoeba , were treated with MLT and standard medical treatment. Four of the six cases deteriorated after initiating treatment and three required a therapeutic keratoplasty. Two patients improved after 1 week of MLT and optical penetrating keratoplasty was performed after clinical resolution. Microbiologic culture of corneal buttons was negative in all cases. All corneal grafts remain clear at last follow-up with best-corrected visual acuity of 20/40 or better. Conclusion : Oral MLT may be a viable adjunctive therapy for recalcitrant AK; however, its use may be associated with a severe inflammatory reaction. Further studies are needed to evaluate its efficacy and variable clinical response.

Purposes: A literature review to describe the current diagnosis and management of Acanthamoeba keratitis., Results: Acanthamoeba is a ubiquitous protozoan: 8 species, 5 genotypic classes have been reported to cause keratitis. It is potentially a sight-threatening infection, and there is often a poor prognosis because of a significant delay in diagnosis and frequently a lack of effective medical management. Main risk factors are contact lens wear, poor hygiene, and contact with contaminated water. Current methods of diagnosis include corneal scrapings for histopathologic analysis, tissue culture, confocal microscopy, and polymerase chain reaction (PCR), each are reviewed in turn. Treatment options include medical (biguanides, diamidines, and corticosteroids) and surgical (epithelial debridement, amniotic membrane transplant, and penetrating keratoplasty)., Conclusions: Early diagnosis and treatment are required to effectively manage this condition.

Purpose: To review the clinical presentations, risk factors, medical and surgical management, and outcomes of patients with Acanthamoeba keratitis (AK)., Methods: Retrospective review of laboratory and medical records of all patients suspected of having AK from January 1999 through May 2008 at Cole Eye Institute., Results: Twenty-nine eyes of 26 patients were identified as having either culture- or tissue-proven AK or presumed AK based on clinical examination and complete response to full course of treatment. The most common risk factors identified for AK were history of contact lens wear (89.7%) and exposure to contaminated water (27.6%). Clinical presentations included early AK (superficial disease) in 37.9% of eyes or late AK (deep stromal disease with or without epithelial disease) in 62.1% of eyes. All early AK cases had best-corrected visual acuity of 20/30 or better at last follow-up, whereas only 55.6% of late AK cases achieved 20/30 or better. Eight eyes underwent penetrating keratoplasty. One patient demonstrated viable-appearing cysts in the corneal button, despite 15 months of maximum medical treatment and 5 months off all medical treatments. Over the nearly 10-year period, there was no significant increase in the number of cases seen each year., Conclusions: The most common risk factor for AK continues to be contact lens wear. AK requires prolonged and intense treatment, although good final visual acuity can be achieved. Potentially viable Acanthamoeba cysts can still persist in a noninflamed cornea after extensive medical therapy, supporting the practice that corneal transplantation after presumably resolved cases of AK should be followed with vigilance to detect the earliest signs of recurrent disease.

Purpose: To report the use of topical voriconazole 1% (Vfend; Pfizer Inc, New York, New York, USA) ophthalmic solution for Acanthamoeba keratitis (AK) resistant to treatment with chlorhexidine (PerioChip; Dexel Pharma Technologies, Jerusalem, Israel)., Design: Retrospective case series., Methods: Three eyes of 2 patients with culture-proven AK were treated at a tertiary care institution, and their charts were reviewed. Topical voriconazole 1% was instituted as second-line treatment for AK unresponsive to standard treatment with chlorhexidine and hexamidine. Treatment with voriconazole 1% was started at 1-hour intervals. Improvement was assessed and defined by absence of clinical signs of active infection and visual improvement., Results: One patient with unilateral AK and 1 patient with bilateral AK who remained culture-positive for Acanthamoeba despite ongoing treatment with chlorhexidine and hexamidine were treated with voriconazole 1% topical solution as an adjuvant. Both patients were contact lens wearers. Of 3 eyes additionally treated with voriconazole, 2 eyes had clinical resolution of disease. One eye demonstrated recurrent disease after penetrating keratoplasty that resolved after intrastromal injection of voriconazole., Conclusions: We report the use of topical and intrastromal voriconazole in successfully treating AK in cases of chlorhexidine- and hexamidine-resistant Acanthamoeba. Voriconazole may be a promising adjuvant agent in treating AK., (Copyright 2010 Elsevier Inc. All rights reserved.)

Acanthamoeba keratitis is a corneal disease associated predominantly with contact lens wear. The occurrence of Acanthamoeba keratitis has been rising since 1990 in correlation to the growing number of contact lens wearers. To date approximately 2000 cases have been published around the world. Due to the complicated diagnostics, the elaborate treatment and the usually bad compliance of the patients, Acanthamoeba keratitis unfortunately very often takes a serious progression, which may lead to serious visual loss and perforating keratoplasty. Today, local treatment with a combination of polyhexamethylene biguanide (PHMB) and propamidine isethionate (Brolene) is considered the first line therapy for Acanthamoeba keratitis. Alternatively also a combination of propamidine and chlorhexidine or neomycine achieves good therapeutic results. However, the complicated mode of application consistently remains a problem. The intensive local treatment, i.e. hourly application of therapeutics during the first three days day and night makes hospitalization inevitable. Moreover, sufficient efficacy can not always be achieved, and also resistance against propamidine has already been observed. Recently propamidine has sometimes been replaced by hexamidine, which seems to have a greater cysticidal activity. A new path might be struck by the application of alkylphosphocholines. These are phosphocholines esterified to aliphatic alcohols. They exhibit in vitro and in vivo antineoplastic activity and have been shown to be cytotoxic against Leishmania donovani, Trypanosoma cruzi, and Entamoeba histolytica. A recent study has demonstrated that particularly hexadecylphosphocholine is highly effective also against various strains of Acanthamoeba.

Purpose: To characterize patients with Acanthamoeba keratitis and to evaluate the safety and efficacy of propamidine isethionate 0.1% ophthalmic solution (Brolene) when administered concomitantly with neomycin-polymyxin B-gramicidin ophthalmic solution (Neotricin) in the treatment of Acanthamoeba keratitis., Design: Prospective, noncomparative case series., Methods: The authors report the clinical characteristics and outcomes of patients who entered this multicentered, open-label, clinical trial. Eighty-three patients with Acanthamoeba keratitis representing 87 infected eyes entered the trial., Results: Sixty (69%) of the 87 eyes enrolled had data analyzed for treatment efficacy and safety. Of these 60 eyes, 50 (83%) experienced treatment success. Thirty (60%) patients successfully treated adhered to treatment protocol guidelines. Patients who broke protocol had disease exacerbation during the maintenance therapy phase. The only eyes lost/enucleated were 7 of 17 in which penetrating keratoplasty was performed before eradication of the infectious agent., Conclusion: Propamidine isethionate and neomycin are an effective treatment for Acanthamoeba keratitis. Penetrating keratoplasty should be performed only for visual rehabilitation and not to "debulk" an active infection. The authors advocate treating patients with topical medications, mainly Brolene, until all organisms are eradicated. There should be no signs of infection for at least 3 months in the patients not receiving antiamebic medications before penetrating keratoplasty is performed.

Purpose: To review the available treatment modalities for Acanthamoeba keratitis and to assess the most effective regimens., Methods: The efficacy of therapeutic modalities and chemotherapeutic agents used in the treatment of Acanthamoeba keratitis was reviewed. Potential synergistic or additive drug interactions were documented both in vitro and in vivo., Results: Early diagnosis of Acanthamoeba keratitis plays a crucial role in successful medical treatment. The cationic antiseptic agents, chlorhexidine and polyhexamethylene biguanide (PHMB) have the lowest minimal amoebicidal concentrations. Synergistic effects are seen when used with pentamidine, and additive effects are seen with propamidine or neomycin. Penetrating keratoplasty should be deferred if at all possible until a medical cure has been achieved., Conclusion: Early diagnosis and wide epithelial debridement are important elements in the successful treatment of Acanthamoeba keratitis. Recommended therapy would include the cationic antiseptic agents, chlorhexidine or PHMB in combination with propamidine isethionate and neomycin as part of triple therapy. Surgical intervention should be avoided until a medical cure has been achieved.

Objective: This study investigates the clinical outcome of Acanthamoeba keratitis treated with polyhexamethyl biguanide (PHMB) and propamidine isethionate (Brolene)., Design: A retrospective review of all patients treated for Acanthamoeba keratitis between September 1992 and February 1995 was carried out. All patients were treated with PHMB 0.02% and propamidine 0.1% hourly for 3 days, the frequency reduced to four to six times daily according to clinical response., Main Outcome Measures: Age, gender, result of laboratory investigation, duration of disease before diagnosis, visual acuity (VA) pretreatment and post-treatment, need for keratoplasty, and presence of adverse reaction were measured., Results: One hundred eleven cases were identified in 105 patients (60 male, 45 female; mean age, 32). Ninety-two percent of infections were in contact lens wearers. The clinical diagnosis was confirmed by corneal culture or histopathology in 64 cases (57.7%). The diagnosis was made "early" (within 28 days) in 65 cases (58.6%). Twenty-one (18.9%) were "intermediate" (28 days-2 months) and 20 (18%) were "late" (> 2 months) diagnoses. Overall post-treatment VA was 6/12 or better in the majority (88/111, 79.3%) of cases, and 18 (16.2%) had VA of 6/36 or worse. The VA of > or = 6/12 was achieved by 90.8% of the early, 71.4% of the intermediate, and 65% of the late groups. Clinical relapses occurred in 19 patients on reducing the therapy. Treatment toxicity was never serious and consisted only of stinging or superficial punctate keratopathy. Keratoplasty was indicated in only ten patients, and disease activity was controlled adequately in all patients before grafting., Conclusions: Combined treatment with PHMB and propamidine is well tolerated, nontoxic, and effective. Typically, visual outcome is favorable and the requirement for keratoplasty reduced markedly.

Purpose: To describe the outcome of a series of Acanthamoeba keratitis treated with a similar regimen., Methods: All cases diagnosed with Acanthamoeba keratitis in a referral centre from June 1994 through June 1997 were included. Diagnosis of Acanthamoeba keratitis was based in clinical presentation and laboratory results. Positive laboratory identification of Acanthamoeba from corneal scraping or contact lens was required, unless the patient had very characteristic symptoms (severe pain) and signs of the infection, including perineural infiltrates. Initial intensive treatment included topical polyhexamethylene biguanide (PHMB) 0.02%, propamidine isothionate 0.1% and broad-spectrum antibiotics. The treatment was gradually tapered. After documented response to anti-acanthamoeba therapy, topical steroids were introduced; they were discontinued before cessation of the anti-Acanthamoeba regimen., Results: Six males and four females, with a mean age of 30.0 +/- 7.4 years were included in this study. All cases wore contact lenses. On presentation all cases had severe pain, and epitheliopathy was associated with stromal infiltrate in most (seven of ten) cases. Four patients had anterior uveitis. Perineural infiltrates were present in three cases and ring infiltrate in one patient. Anti-amoebic treatment was started 12.7 +/- 7.2 days after beginning of symptoms. The clinical response to therapy was very satisfactory in all patients. Within two to three weeks all patients had remarkable lessening of pain and photophobia, and improvement of clinical signs. At two to three months, visual acuity had improved in all patients. Two patients required penetrating keratoplasty for visual rehabilitation., Conclusion: The use of PHMB and propamidine cured all cases of Acanthamoeba keratitis. Cautious introduction of steroids was associated with expedited resolution of inflammation and provided symptomatic relief.