Talk which is to be given by professor ajay sinha who is going to talk about not very common but very serious disease infection or cornea with akanthiva and we know that economic heritage can be very very difficult to treat and he’ll highlight all the you know difficulties to be solved in this group of cases dr rajesh thank you sir and as president said that
It’s not a very common condition not a very common keratitis but many times what happens that people in order to you know when you have this concept that it’s not very common then you don’t keep this in mind and many times you miss it as well so you have to keep it in mind although it’s less than one percent of all microbial keratitis you have to clinch the
Diagnosis based on some risk factors as well somebody who’s a contact lens user who slept with contact lens or who did swimming while using contact lens and then coming with some symptoms you have to suspect that it may be keratitis somebody who’s using tap water for cleaning the contact lens uh i mean there was a study in uk on tap water and they found out that
Eighty percent of the samples of tap water had some uh amoeba in it so we can expect definitely that in our country as well so all these factors can help you to think about uh anthropoceratitis as well you have to keep it in mind it is mostly unilateral has severe pain in immunocompetent patients but those who are able to compromise like hiv positive or you know
Established diabetic patients they may have painless academic heritage as well and many times we diagnose as i said when it fails to respond to all the other antimicrobials so as i said the symptoms can be pain redness photophobia and blurring of vision and on examination in the initial part which very uncommonly you get they can be epithelial irregularities or
Dendritic form lesions which can be seen they can be patchy stromal infiltrates or the perineural infiltrates but these are definitely pathognomonic but these are not very often seen the patient comes to you with something like ring infiltrate and you know severe infection something like this when you examine the patient you get a ring infiltrate ask the patient
Whether the patient is using contact lens if it has used contact lens it can this ring infiltrate can be because of two reasons one can be pseudomonas the other one can be a canthame if it is very rapid progressing then it is pseudomonas if it’s not rapid progressing it is slow progressing that it can be a kantha so based on on the initial history itself you can
You know somehow guess that what is it and as i said it’s a slow progressing doesn’t have much vascularization but if there is clearities limb biters then you can have vascularization like this or you can have scleral nodules which can thin out with time and this is one case wherein there was a fleeting type of uh you know scale module that we saw and throughout
360 degrees the patient had no duel and then there was a trophy and then again there was no duel so such a thing can happen and based on history and based on examination you can somehow guess that it may be again amoeba but yes microbiological diagnosis is something which we should always do in all the ulcers we do corner scraping we can do confocal microscopy
And by confocal you can get to see thickened nerves you can get to see these you can see here the thickened nerves will be seen like this and then as you move forward you can see the double-walled cysts and then as you move anteriorly you get to see the refractile trophozoites in the basal epithelium of the cornea and on staining with calculus or white and you
Can get to see this apple green fluorescence uh of the double wall cysts trophozoites are difficult to stain when you send the the the sample for culture you send it in non-nutrient agar with uh live or killed gram-negative bacilli and wherever the kantiva feeds on these these e coli there’s presence of depressions or trails and on serial transfer you actually
Confirm that it is a kantham not macrophages which can also cause pseudotrains and pcr has been shown to be very effective tool in in diagnosing acanthin biba uh apart from other investigations as far as uh treatment is concerned it is definitely a challenge because many times we don’t get these definitive drugs bygonide is the treatment of choice chlorhexidine
Or phmb 0.02 phmb normally is not available uh in the market but there is a company that’s called arch which has a which uh sells phmb in a concentration of twenty percent and that can be bought and that can be made 0.02 diameters again not freely available but if it’s available it can be used and both the drugs can be used as a combination therapy one hourly
For 48 hours and then of course you can reduce depending upon the response systemic therapy with azoles are again useful in these cases and a new drug that is multiposing which has been used in animal studies and also there are a couple of reports one with systemic multifunction and one with topical and they have shown good result but these are just one of case
And maybe with time this is that study that has been published in the american journal of oral multiphosion for refractory again thermoclititis wherein multiposition was given 50 milligram three times a day but this is just one case and we have to know more about it as far as steroid is concerned it is not routinely given but if there is scleritis in that case
We can give system if we can give steroid and undercover of bigonites and sometimes the scleritis doesn’t respond so you have to give a long-term mycophenolate which can be started 500 milligram twice a day increase to 1.5 with time and then later on you can stop it supportive therapy as we all know is very essential because these patients have a lot of pain and
Many times the nsaids don’t help you have to resort to opioid drugs and sometimes these patients do require lignocaine or amitriptyline patch as well in a couple of patients have used them and the patients have you know really benefited and had reduction in pain cxl and ptk there are a couple of just reports not yet established in this and the last thing that
People would like to do is that if it is not responding to any drug then we have to do credoplasty lambda or penetrating lambda of course if it’s not involving the full thickness and trading if if it’s full thickness the key is that the risk of recurrence is high after cryptoplasty so we have to give medical management initially to some extent so that there is
Some limitation of the infective load and then after that we can go ahead with the with any sort of keratoplasty so thank you very much for patient listening and anything any suggestion any question if you thank you thank you rajesh for highlighting the you know again throughout
Transcribed from video
AIOC2022 IC538 Topic DR RAJESH SINHA Acanthamoeba Keratitis By AIOS Editor Proceedings 2