Management of severe Acanthamoeba keratitis and complicated cataract following laser in situ keratomileusis

According to previous studies, the incidence of postoperative laser in situ keratomileusis (LASIK) infections are rare, as such 1 in 2919 cases have been reported with Mycobacteria and Staphylococci[123] being the most common organisms implicated. In the present study, we are reporting a challenging case of Acanthamoeba keratitis, a rare infection following LASIK, managed medically as well as surgically with flap amputation. On subsequent follow-up, the development of complicated cataract was observed which was well-managed, leading to good anatomical and functional outcome. A 24-year-old lady, who underwent microkeratome-assisted LASIK elsewhere, 3 months ago for myopia (-4DS), presented with a painful decrease of vision in the left eye. At presentation, the visual acuity was counting fingers close to face, while on examination, cornea [Fig. 1a] showed diffuse anterior to mid-stromal infiltrate with overlying necrotic flap. On microbiological examination, smears made from the stromal bed after lifting and later amputating the unsalvageable flap, revealed Acanthamoeba cysts [Figs. 2 and 3]. Postoperatively, [Fig. 1b] both topical 0.02% polyhexamethylene biguanide with 0.02% chlorhexidine were started hourly. After observing the signs of resolving infection with deep vessels [Fig. 1c], topical 1% prednisolone acetate was added every 3 hours along with gradual tapering of biguanides and steroids. Keratitis was completely resolved in 6 months leading to scar (CCT-392μ) and regression of vessels [Fig. 1d]. Complicated cataract observed during follow up was managed with intraocular lens implantation as calculated with SRK-T formula, resulting into visual acuity of 20/20 (p) with +2.0/[email protected]Figure 1: (a) At the presentation to our institute with diffuse stromal infiltration (8.2 mm vertically and 6.4 mm horizontally) (b) After the flap amputation (c) After 1 month of treatment, when steroids were added since deep vessels were noticed (d) Final follow-up after cataract surgeryFigure 2: Gram stain (a) of the corneal scraping showing hexagonal double-walled cyst of Acanthamoeba (100×) and 10% KOH + 1% CFW STAIN (b) of the corneal scraping showing multiple fluorescent Acanthamoeba cysts (40×)Figure 3: Excised LASIK flap shows double-walled cysts of Acanthamoeba (H and E stain (a), GMS (b); 40×)Discussion This case emphasizes the importance of precise microbiological diagnosis and need of long-term treatment (average 3–4 months) along with timely tapering of medications to avoid toxicity and judicious use of topical steroids in post-Lasik Acanthamoeba keratitis. Flap amputation may be considered therapeutic as reported in the literature.[4] Although visual acuity improved in our case study, use of ASCRS calculator[5] for IOL power, would have enhanced better uncorrected visual acuity. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.