 Hopefully most of you were able to see our patient this morning, and I'm going to be presenting her case of the canthamoeba keratitis 36 year old female Where and she presented on July 27th with a group in a red eye or right eye She also was having some light sensitivity pains. She described pressure through the whole eye She'd been seen two weeks prior as instant care and and Was given a prescription for top-blend biotics a Week after that she hasn't been getting better. And so she was given a prescription for a pred forte four times day at the answer care And then one day prior to her presentation. She was started on POA cycle beer She reported good contact lens hygiene and she was replacing her bi-weekly lenses every 10 days She denied any swimming or showering in her lenses, and she was not using tap water for cleaning She also had not and didn't have a history of swimming in a fresh water bodies So that there are medications. She didn't have other medical problems or only other medication was a normal contraceptive She did have the history of contact lens using no ocular surgery in the past and she had a history of possible viral keratitis in the past She had a family ocular history of a sister who'd been diagnosed with multi focal coriditis So this is her exam on presentation. She was 2200 and holding the 2040 Uncorrected in her right eye with a mild myocardic refraction Correcting 2070 left eye on corrected was 2025 Her the exam number left. I was normal and her right eye. She had diffuse injection She had a central epithelial defect in the cornea with some scattered areas of haze and And a large number of pump data with the little erosion It's a mild peripheral elevation in the cornea with superficial neobascularization Extending from the limbis. She didn't have a hypobe on and the rest of her anterior segment exam is normal She had a pressure that was slightly lower in the right eye and 22 in the left eye Normal dilated exam on both sides So the initial differential was suspected infectious keratitis with possible atypical bacterial or fungal keratitis given the extended time course since her initial presentation of the instacare Was also consideration for a canthamoeba especially given her contact lens use Given her history of possible viral keratitis There was a thought that this could be corneal scarring with the recurrence of viral keratitis or HSP keratitis So our initial changes to her therapy were to stop the steroids We started her on a cyclotelgic and continued her on an appropriate dose-based cycle period for HSP keratitis And then we added a added back a topical antibiotic drop And performed a culture for virus bacteria and fungus and told her to refrain from contact lens use So here's here's her clinical course a couple days after her presentation her vision decreased to hand motion And she had an increase in the amount of pain She was having she was seen in clinic and started on fortified vancomycin and tobromycin every hour around the clock She came back a couple days later And had a 7.5 by 7 millimeter central epithelial defect that was round with peripheral haze you can see You can see the pictures on the bottom right showing her exam on that day with kind of diffuse haze and You can see her The field It's hard to see but she had her for only a vascularization coming in from Olympus And we perform confocal microscopy because we were concerned about it can't be but here's here are her pictures from You can see there's some areas that we're concerning for a can't be the cysts here Although all those clinical pictures are from one day or time those are those are all from August 1st Okay, I just wanted to show an example of a normal confocal microscopy So the the relevant pictures here are especially C and D Those are the anterior and posterior stroma and a normal cornea Compared to our patient on the bottom Possible cysts that are highlighted there So she she came back for a couple other visits over the next two weeks her epithelial defect on August 17th That improved significantly from 7.5 by 7 to 4 and a half by 3 and a half Her vision had improved from hand motion to count fingers So then these are pictures on the 24th on the right side and you can see the Epithelial defect in this picture if you look compared to over here appears to be improving She has a little bit of Clearing and the periphery of the cornea of the stroma infiltrate She was on the 24th. We Decreased the the pH and being chlorhexidine that have been started Just over two weeks prior to every three hours six times a day each And we decreased her for fighting antibiotics to once daily and told her when they run out that she can change to an oral floor or a topical floor quinolone At this point all of her final cultures including the viral anacanthomy cultures have been negative So This morning that she had her epithelial defect to continue to decrease It was about three and a half by three and a half this morning And she has pretty significant clearing of the stroma infiltrate and the periphery looks fairly clear now provision still count fingers So this is a summary of our case Current there being bottom here, but she's improved pretty significantly so far So I just wanted to go over some Basics about risk factors and features and medical and surgical management for a can't meet the care tightest so then the number one risk factor is contact lens use and Other risk factors are related to contact lens use multi-purpose cleaning solution, which is not effective against the can't the meal assists Swimming and showering and contact lenses as well as fresh water swimming So clinical features are pain that's disproportionate to the clinical exam. There's a large percentage of patients That have been demonstrated have co-infection with HSB or other bacteria there Some of the typical features on exam or an epithelial Epithelial here will take care of top feet which our patient had on her initial presentation there you can see pseudo dendrites and Especially perineural infiltrates. Here's a good picture of the perineural infiltrates and Can't me but feeds on the coronal nerves which results in the Disproportionate pain Then there's the classic ring infiltrate Which you can see in this bottom picture, but that's only present in about 50% of patients with again the meba perioditis infections and some poor Poor prognostic factors that you can find are also cataract formation if the infection extends So for diagnosis of the can't meba keratitis Culture on non nutrient and activity coli auger It's important to also culture the contact lenses in case if those are available and there are a variety of stains Capifluor white Acridine orange and gram stains that can be used That are helpful in diagnosis confocal microscopy has been shown with experienced graders to have a high specificity and sensitivity around 90% For both for both, but there is the risk of a lot of false positives and negatives with confocal microscopy Especially with with inexperienced confocal microscopists There some newer techniques are DNA PCR But there are there's a lot of expense in technical issues with this and for a better yield that requires some tissue so recommended medical treatment is There are basically two classes medications and these work synergistically It's recommended that usually people use a combination of agents because of the risk of resistance of the I can't me the organism the first class is the bite one eyes, which is pH MB low and low concentration and chlorhexane, which is less toxic to the corneal epithelium And low concentration those those work by disrupting the site classic membrane and amaging cell components then the second class is diameting which can work synergistically with the bite one eyes and That includes bro Brolin and hex hexamidine Those are also affected against both the trophozoids and the cysts So the recommended regimen is every hour Around the clock for the first 48 hours and then decreasing to every hour for a period of days and weeks depending on the clinical response and then Therapy may need to be clean continued for up to six months because of The cysts penetrating into the deep stroma and and how resistant they are and some people recommend even continuing for up to a year So surgical treatment The this has changed a lot and therapeutic PK is no longer recommended And it should only be used in cases where there's perforation That's unresponsive to repeat gluina large perforations that there's no other option and some some Studies have shown that multi-layer and tea can be used prior to to a training career of fasting and There are there are a few case studies now that people are showing use of corneal cross-linking There is conflicting evidence in the future studies showing that Rigor flag and a and you be like maybe amoebicidal But there are other in vitro studies showing that it may not be there are mostly international case studies specifically one in Mexico and one in Spain that were done where they treated active acanthamine balcers with corneal cross-linking and They they did show in those studies that after after the resolution of the infection They did a penetrating care to Plasti and on pathology there was absence of Amoeba site of Amoeba cysts So this may be something in the future that could be a possibility for a treatment of But there aren't any good controlled studies of this yet Any questions? The slides did not indicate whether or not she might have been wearing her contact lenses 24 hours a day for a day or Couple of days are all 10 days before she put in a new lens You know Yeah, she she said that she was not she she said that she was taking contact lenses out every day She was replacing them every 10 days She didn't she didn't admit any risk factors with her contact lens Yes Were you able to culture the case or the solution to find out it's actually becoming a little bit more difficult to do Our lab is like rejecting our ability to culture things like that because they're We had a case earlier this year where it's long discussion with them about it They don't want to sending From the contact lenses because they feel like it drives the clinical course potentially in the wrong way because you're not for sure It's the same bug is what's growing on the eye So I bought that battle with them trying to get them to allow us to do that, but it sounds like they're not letting us Contact lenses or cases at this point. So I think I mean this is a I just want to talk about the culture thing Because I think it's this is a perfect example of the diagnostic. I mean this is actually what we see all the time here and it almost it usually comes down to herpes simplex versus a hemp amoeba after treatment of a bacterial infection presumed bacterial infection with negative cultures and so You know obviously when you're on call, you know Try to get infectious care titus patients to come here. Don't give advice over the phone I mean the cultures are just hugely hugely helpful in early treatment and diagnosis is critical And when you're on call, I would say in a person like this Put a lid spectacular man. Take the patient to the minor room Lay them flat numb the heck out of them and take a belay and to breathe the Wad that all up. If you're suspicious of a hemp amoeba, put that in pages saline You can use aathlon swab. We usually use the viral swab you just take an extra one of those and Put it in the pages saline and send that and I would say that the yield in the early case is pretty high If you're aggressively cultured the diagnosis if you make the diagnosis You can usually Reverse this and if you don't then it's this Holly therapy for a long time because you don't really know what's going on and the confocal sounds great But in practice, it's pretty tough. I mean this was a fairly early case and I think that It's fortunate when you can see that but it's often very difficult and then you know with regard to the contact lens Case and or solution. I would just say You know send a separate culture just e-swab it because that's what the lab wants now And you can even label it cornea to or whatever They will know the difference, but we'll know what it is But I think it is really useful. We've definitely cultured it from contact lens cases before and that's actually made the diagnosis for us And then the other thing to think about you mentioned co-infection but I had a patient who was treated for months now weeks to months and Aggressively scraped her she grew fungus Acanthamoeba and a caram negative bacteria, and I don't think any of them work contaminants And so you really have to think about And that patient actually did well So think about co-infection Worst thing about sitting in the back is you don't make the comments that everybody else said what you were going to say But yeah, what Mark says Sometimes it's difficult to get If you're still really concerned I know it's hard to go in and do a little biopsy of the cornea But sometimes we can actually see the cysts on a biopsy We've got some special stains that can actually make the diagnosis That the second comment I want to make is we really need to work with our colleagues at the Instacare's and dock in the boxes Those guys use steroids way too much. I don't know what they're treating and you obviously everybody with the red eye gets toberdex You know it's a virus. It's an acanthamoeba. They should not be on steroids And I think we need to educate our colleagues that steroid use is dangerous and You know someone who really is not comfortable looking at things and diagnosing things that a sweat lamp should not be using So I just had a question Isn't Yes At low at really low concentrations though, which are compounded for use in acanthamoeba infections It's it's it's the least toxic of the of the type of medications that are used for Thelial cells I can't remember what the percentages 2% or something it's you know orders of magnitude higher Yeah, yeah, I mean we have the reason doctor Warner asks is that Hibicline's or you know for hexadean based cleaners are sometimes an alternative to Prep skin and we had a case too long ago where basically the patient had their feeling cooked Hibicline's NEI was really rinsed very well So if you're really cause long-term damage, but certainly can be toxic in higher concentrations I already call the first day outbreak of acanthamoeba was kind of brought to popular knowledge because of the homemade saline solution I Mean I don't I don't know any specific Studies indicating but I don't think too many people are using that anymore Cleaning with water or just regular saving it's a culprit for I'm just wondering what the utility of like using something like early I don't think it's approved in the u.s. And I can tamper as far as I mean you throw the The armory at the canton Eva So we often most of our patients we try to have them get online and buy these drugs internationally and Usually you can We have a really awful acanthamoeba patient We're like a year in the treatment now. He hasn't lost his eyes so we consider that success, but We had you know, he they found a website and got the pecs and we need drops from France or five bucks or five years So you can't I mean there is more of availability and you know, certainly we try to bring medicines back when we travel I think there's a company in the UK that makes for a Yeah, you can get