This 59-year-old female with a history of diabetes was referred for a non-healing corneal ulcer. At symptom onset five weeks prior, she was seen in the emergency department for a small (1mm) central corneal ulcer and given tetracaine and bacitracin ointment. Two days later, she saw her local optometrist and was switched to Vigamox (Alcon) QID and Nevanac (Alcon) BID; also, a bandage contact lens (BCL) was applied. Two days later, the central ulcer was resolving. The Nevanac was discontinued but Vigamox was continued.
A week later, vision had improved to 20/60 and the epithelium was nearly resolved. The BCL was removed and Pred Forte (Allergan) added to control scarring. After another week, the nasal central corneal ulcer remained. Current meds were discontinued and she was started on fortified vancomycin, tobramycin and ofloxacin and referred for tertiary care.
The clinical image below shows a small, ~1.5mm x 0.5mm paracentral area of subepithelial haze with feathery edges and surrounding corneal haze without stromal thinning. Confocal microscopy demonstrated multiple areas suspicious for trophozoites near Bowman’s membrane and several areas of branching elements in the mid to deep stroma.
Concern is for an amoebic keratitis as well as possible branching fungal elements. Recommend treatment for Acanthamoeba
keratitis is PHMB and oral ketoconazole. The decision was made to hold off on treating for a superimposed fungal keratitis. A corneal biopsy was performed for further pathogenic characterization that will further guide treatment. Topical antimicrobials will continue until there is clinical improvement on anti-amoebic therapy.
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