British Journal of Ophthalmology 1996;80:849-853 849 Br J Ophthalmol: first published as 10.1136/bjo.80.9.849-a on 1 September 1996. Downloaded from LETTERS TO THE EDITOR

Acanthamoeba keratitis: first recorded Table 1 Drug sensitivity ofAcanthamoeba the clinical features in this case were not espe- case from a Palestinian patient with isolatefrom cornea cially reminiscent of those generally recorded trachoma for such an amoebal infection.9 Minimum amoebicidal Traumatic injury is likely to predispose the concentration (fuglml) Keratitis due to Acanthamoeba is a potentially then compromised cornea to Acanthamoeba infection. For the contact lens wearer, there is sight threatening condition if unrecognised, or Drug Trophozoites Cysts if inappropriate medical therapy is used.' The now irrefutable evidence to demonstrate that the protozoa are derived from contaminated infection is being recognised worldwide.'A It Chlorhexidine 1.6 1.6 is often associated in Europe and in the USA Polyhexamethylene tap water,'0 which is used as part of the clean- with contact lens wear; elsewhere, particularly biguanide 3.2 6.3 ing disinfection procedures for the lenses and in the tropics, it occurs most often in rural Alexidine 6.3 6.3 associated paraphernalia. communities and can be associated with Propamidine 6.3 25.0 The observations from this case indicate trauma and mud splashing.5 Pentamidine 12.5 50.0 that chronic trachomatous disease may also Hexamidine 6.3 25.0 compromise the corneal surface such as to We present here the first recorded isolation Neomycin 12.5 50.0 of Acanthamoeba in a Palestinian patient with facilitate invasion by Acanthamoeba, and that keratitis, not associated with either contact this should be considered where other predis- lens wear or the patient's recollection of not used initially because of local unavailabil- posing factors cannot be readily identified. trauma. The patient suffered from previous ity of the diamidine. Neomycin was likewise Further, the clinical appearance ofthe Acanth- trachoma (Fig 1). Herbert's pits were clearly unavailable as a single agent. The treatment amoeba infection, as in this case, may not be observable at the superior limbus, although brought about a rapid improvement in the typical. there was no evidence of trichiasis. appearance of the cornea. The patient was A PYOT discharged 4 days later, having been taught StJohn's Ophthalmic Hospital, CASE REPORT the procedure for self administration of the Jerusalem 97200, Israel A 65-year-old female UNRWA refugee pre- antiprotozoal chemotherapy. J HAY sented with a 2 day history of diminished The corneal samples were incubated in a D SEAL vision (counting fingers) in the right eye. The defined medium.8 After 1 week at 32°C there Tennent Institute of Ophthalmology, cornea was hazy and a small (2 mm) central was prolific growth ofAcanthamoeba. No bac- Western Infirmary, Glasgow GlI 6NT teria or were isolated. abscess was present. Fundal examination fungi Drug sensitivity Correspondence to: Dr J Hay. revealed an old central retinal vein occlusion. tests were performed6 (Table 1). Accepted for publication 6 May 1996 Initial treatment was topical cephalothin Two weeks later, the patient was readmitted with ocular There was marked corneal (10%) and topical gentamicin (1.5%) both 2 pain. 1 Kirkness CM, Hay J, Seal DV, Aitken D. hourly, and topical homatropine (2%). Local oedema secondary to rubeotic glaucoma, the Acanthamoeba keratitis. Ophthal Clin N Am microbiology laboratory investigations proved pressure being 55 mm Hg. Initially the 1994;7:605-16. pressure was reasonably well controlled with 2 Seal DV, Hay J, Kirkness CM. Acanthamoeba unhelpful. The condition improved and she keratitis and contact lens wear: the need for a was discharged after 4 days. oral acetazolamine (250 mg, four times daily) global strategy for prevention of corneal infec- On first review, 1 week later, there was a and topical Timolol (0.5%, twice daily). tion. Community Eye Health 1995;8:4-5. significant improvement. Treatment was There was considerable fluctuation over the 3 Mohamed Kamel AG, Norazah A. First case of following 5 weeks, however, and vision Acanthamoeba keratitis in Malaysia. Trans Roy changed to chloramphenicol (0.5%) ointment Soc Trop Med Hyg 1995;89:652. http://bjo.bmj.com/ and topical Liquifilm three times daily. The dropped to no perception of light. Ultimately, 4 Hay J, Seal DV. Acanthamoeba keratitis, contact patient re-presented 6 weeks later with a 3 day pressure reduction and comfort were achieved lenses, and the potential health implications of through use of cyclotherapy. By this time, global marketing. Trans Roy Soc Trop Med Hyg history of severe pain; vision had decreased to 1996;90:33 1. light perception. There was an elevated Brolene had been received from Glasgow. At 5 Thomas PA. Acanthamoeba keratitis. Ind J Med central lesion with surrounding ring abscess. this point there was no perceptable progres- Microbiol 1995;13:51-3. The intraocular pressure was 35 mm Hg. A sion of the ring abscess, but the rubeotic glau- 6 Hay J, Kirkness CM, Seal DV, Wright P. Drug coma remained problematic. resistance and Acanthamoeba keratitis; the stromal biopsy was performed the following quest for alternative antiprotozoal chemo- day and the tissues forwarded to the Tennent After discharge 4 weeks later, the patient therapy. Eye 1994;8:555-63. Institute in Glasgow, for microbiological attended clinic intermittently. She was not 7 Seal D, Hay J, Kirkness C, Morrell A, Booth A, on September 27, 2021 by guest. Protected copyright. altogether compliant with the fairly demand- Tullo A, et al. Successful medical therapy of analysis. Acanthamoeba keratitis with topical chlorhexi- Meanwhile, with a high index of clinical ing schedule required for self administration dine and propamidine. Eye (in press). suspicion of Acanthamoeba infection of the of the chlorhexidine-Brolene therapy. The 8 Byers TJ, Akins RA, Maynard BJ, Lefken RA, cornea, novel therapy with chlorhexidine corneal infection, however, appeared to be Martin SM. Rapid growth of Acanthamoeba in well controlled using this combination. Two defined medium: association of encystment by (0.02%, 2 hourly) was instituted, in combina- glucose-acetate starvation. J Protozool 1980;27: tion with topical dexamethasone (0.1%, four months later, the patient re-presented with an 216-9. times daily), atropine (1%, twice daily), and area of central corneal staining and hypopyon. 9 Bacon AS, Dart JKG, Ficker LA, Matheson MM, A deep corneal scrape was performed but rig- Wright P. Acanthamoeba keratitis the value of topical Polycidin (polymyxin B, neomycin, early diagnosis. Ophthalmology 1993;100:1238- gramidicin). The combination of chlorhexi- orous microbiological examination failed to 43. dine digluconate and propamidine isethionate reveal any organisms, including Acan- 10 Ledee DR, Hay J, Byers TJ, Seal DV, Kirkness thamoeba. The patient was, however, treated CM. Acanthamoeba griffini. Molecular charac- (as Brolene), known to be effective against terization of a new corneal pathogen. Invest Acanthamoeba both in vitro and in vivo,6 7 was with topical chlorhexidine (0.02%, 2 hourly), Brolene (2 hourly), dexamethasone (0.1%, Ophthalmol Vis Sci 1996;37:544-50 four times daily), and chloramphenicol oint- ment (twice daily). Within 4 days, there was resolution and the patient was once again dis- charged. There has been no subsequent recur- Cytomegalovirus retinitis associated rence of the ocular disease. with long term oral corticosteroid use COMMENT EDrroR,-We examined a patient with a small Antibiotic therapy alone was unsuccessful for area of peripheral retinitis in her left eye. She treatment of the keratitis in this case, resolu- had been using oral corticosteroids continu- tion being accomplished only when a combi- ously for 17 years for asthma. Despite nation of a cationic antiseptic (chlorhexidine) treatment with intravenous acyclovir and laser and an aromatic diamidine (propamidine photocoagulation the lesion recurred and isethionate) was used. It was considered resembled cytomegalovirus (CMV) retinitis. Figure 1 Appearance of cornea 1 week after fortunate that corneal scrapings were for- CMV DNA was detected in the aqueous biopsy, showing Herbert's pits and warded to a centre with expertise in cultiva- humour using the polymerase chain reaction. Acanthamoeba keratitis. tion and identification ofAcanthamoeba, since She was HIV negative with normal T cell 850 Letters Br J Ophthalmol: first published as 10.1136/bjo.80.9.849-a on 1 September 1996. Downloaded from markers and no systemic immunodeficiency ment surgery. The corticosteroids were given disorder. She had reduced numbers of B cells following craniotomy for evacuation of a and tests of T cell function showed a global subacute right subdural haematoma. reduced response to stimulation by antigens. Ophthalmologists should now be aware of The CMV retinitis probably resulted from another potential complication of corticoster- long term oral corticosteroid use. oid usage. M K KULSHRESTHA CASE REPORT R R GOBLE A 39-year-old woman presented in November P I MURRAY Midland Eye Centre 1994 to the Accident and Emergency Depart- Birmingham and ment of the Birmingham and Midland Eye Correspondence to: Mr P I Murray, Academic Unit Hospital with a recent onset of a shadow and of Ophthalmology, Birmingham and Midland Eye floaters in the temporal field of her vision of Centre, City Hospital NHS Trust,Dudley Road, Bir- mingham B18 7QH. her left eye. She had previously attended in October Figure 2 A recurrence detected superior to Accepted for publication 24 May 1996 1993 with an unusual appearance of the tem- original lesion and laser photocoagulation scars. This lesion poral periphery of the right retina. 1 Winkler A, Finan MJ, Pressly T, Roberts R. was thought to be a retinoschisis and was Cytomegalovirus retinitis in rheumatic disease: adjacent to a region of chorioretinal atrophy. After an initial improvement a recurrence a case report. Arthritis Rheum 1987:30:106-8. There was no evidence of inflammation in the resembling CMV retinitis was detected supe- 2 Ong ELC. Viral infections in the immunocom- to lesion 2). An anterior promised host. Clin Virol 1995:18-23. vitreous or retina. The schisis was observed rior the original (Fig 3 Scott WJ, Giangiacomo J, Hodges KE. Acceler- but a retinal detachment subsequently oc- chamber tap was performed. Polymerase ated cytomegalovirus retinitis secondary to curred and she underwent a vitrectomy in chain reaction testing for herpesviral DNA immunosuppressive therapy. Arch Ophthalmol detected CMV DNA in the aqueous humour 1986;104:1 117-24. September 1994 following failure of conven- 4 England AC, Miller SA, Maki DG. Ocular find- tional detachment surgery. A devastating but was negative for varicella zoster and ings of acute cytomegalovirus infection in an Haemophilus influenzae endophthalmitis devel- herpes simplex type 1 and 2 viral DNA. immunologically competent adult. NEnglJMed oped 3 days after surgery. Despite treatment She was induced with intravenous ganciclo- 1982;8:94-5. for 2 5 Chawla HB, Ford MJ, Munro JF, Scorgie RE, with systemic and intravitreal antibiotics, and vir at a dose of 5 mg/kg, twice daily Watson AR. Ocular involvement in cytomegalo- prednisolone 60 mg per day the eye became weeks. Maintenance therapy was oral ganci- virus infection in a previous healthy adult. BMJ blind and phthisical. The corticosteroid dose clovir at a dose of 1 g three times per day, three 1976;2:281-2. to mg over the next times a week, resulting in resolution of the 6 Berger BB, Weingerg RS, Tessler HH, Wyhinny was gradually reduced 15 GJ, Vygantas CM. Bilateral cytomegalovirus 2 weeks. retinitis. Over the next 12 months the oral panuveitis after high dose corticosteroid She was a severe asthmatic who had ganciclovir was reduced to a once a week dos- therapy. Am 7Ophthalmol 1979;88:1020- suffered from recurrent bouts oflower respira- age with no recurrence of the retinitis. tory tract infection and had been on systemic Investigations showed a normal full blood prednisolone continuously for the last 17 count, serum biochemistry, and serum immu- years. She had undergone many acute admis- noglobulins. Anticardiolipin, antinuclear and with sions to hospital for her asthma, necessitating antinuclear cytoplasmic antibodies were all Unilateral choroidal melanoma short term increases in her corticosteroid negative. Her HIV antibody test was also bilateral retinal vasculitis therapy. This was gradually reduced to a negative. Peripheral blood B cell numbers maintenance dose of 5 mg per day. She were reduced to 0.02 x 109/1 (0.22 x 1094/ in a EDITOR,-The association of choroidal presented to us 2 months after the episode of healthy control). She had normal T cell num- melanoma with ipsilateral ocular inflamma- serum count and has most endophthalmitis affecting her right eye and bers and subtypes with her CD4 tion is recognised frequently http://bjo.bmj.com/ was still on oral prednisolone 15 mg per day. being 1.18 x 109i/ (0.48 x 109/1 in a healthy been noted in those with tumour necrosis and She had active cold sores on her lips and in her control). Her T cells responded normally to mixed or epithelioid cell types.' Sympathetic left nostril. She did not appear malnourished. concanavalin A, phytohaemagglutinin, and ophthalmitis has also been observed with Visual acuity was 6/9 in the left eye. There pokeweed mitogen stimulation, but poorly to necrotic choroidal melanomas, often with was a mild anterior uveitis, with a 1 + cells in purified protein derivative, Candida albicans extrascleral extension.2 Distant carcinoma the anterior chamber and fine keratic precipi- and herpes simplex viral antigens. The global associated retinopathy and more recently tates on the inferior cornea. There was 1+ of nature of the antigen response defect sug- cutaneous melanoma associated retinopathy was to the corticoster- have both been reported with an accompany- cells in the vitreous. Ophthalmoscopic gested that it secondary on September 27, 2021 by guest. Protected copyright. examination showed a small, circumferential oid therapy. These results implied that the ing bilateral retinal vasculitis.34 We report a white area in the inferonasal periphery of the CMV retinitis resulted from long term oral case of a 22-year-old man with a left anterior retina associated with sheathing of retinal corticosteroid use. choroidal melanoma in association with a arterioles and scattered haemorrhages (Fig 1). bilateral retinal vasculitis. The lesion in the nasal periphery of her left COMMENT retina slowly progressed and a provisional Although the commonest intraocular infec- CASE REPORT diagnosis of acute retinal necrosis was made. tion seen in AIDS patients, CMV retinitis is A 22-year-old man was referred with a 6 week Treatment with intravenous acyclovir, 10 also a recognised complication of immuno- history of a gradually enlarging left nasal field mg/kg three times a day, was given and suppressive therapy,' particularly after organ defect in association with bilateral visual float- indirect laser photocoagulation applied transplantation. Cyclosporin, azathioprine, ers and occasional photopsia. He was other- around the lesion. and cyclophosphamide have an intermediate wise fit and well. effect and corticosteroids a minimal effect in Examination revealed 6/6 vision bilaterally. inducing CMV disease.2 Patients with rheu- There was a left nasal field defect. The right matological disorders on long term immuno- field was full. Bilateral medium sized keratic suppression may develop a rapidly progressive precipitates were present with a plus/minus of CMV retinitis.' anterior chamber cells. There have been two reports in the There were 1+ of vitreous cells bilaterally. literature of CMV retinitis in 'immunocompe- On the left he had a large solid anterior tent' patients.45 It was found to be reversible choroidal mass in the temporal periphery with without treatment in one case,4 and in the a base and depth of approximately 13 mm. other it was attributed to exposure to chroni- There was some subretinal fluid inferiorly. cally sick children.' No test results of immune Bilateral focal retinal venous sheathing was function were given and the diagnosis was evident with some associated retinal new ves- made on serological investigations alone. sels inferiorly in the right fundus. General A case of culture proved cytomegalovirus medical examination was unremarkable. panuveitis involving both eyes of a previously A fluorescein angiogram demonstrated healthy young woman receiving immunosup- mottled hyperfluorescence over the mass. pressive doses of corticosteroids has been There were focal areas of perivenous leakage Figure 1 Necrotising retinitis in nasal periphery reported.6 The virus was isolated from sub- in peripheral retinal venules but no capillary ofleft eye. retinal fluid obtained during retinal detach- closure.