Update on Acanthamoeba Keratitis: Diagnosis, Treatment, and Outcomes

Recent in vitro advances in the ocular antimicrobial agents against Acanthamoeba

This review examines the advancements in antimicrobial drug discovery with in vitro assays for Acanthamoeba, highlighting the efficacy of current topical antimicrobial agents. In recent decades, the treatment and diagnosis of Acanthamoeba keratitis (AK) have presented clinical challenges. Clinicians often rely on clinical judgment, risk factors, and patient travel history to guide initial treatment decisions. The clinical presentation of AK frequently coincides with bacterial and fungal keratitis, leading to delays in diagnostic confirmation. This review compiles a list of commonly used antimicrobial agents that may be useful in controlling and preventing Acanthamoeba and other microbial infections during the diagnostic waiting period. Due to their unique life cycle, consisting of both trophozoite and cyst stages, amoebae exhibit resistance to various clinical drugs. Current research efforts are focused on identifying alternative and effective treatment options. Despite the ongoing characterization of various cytocidal agents from natural and synthetic sources, chlorhexidine gluconate (CHG) and polyhexamethylene biguanide (PHMB) have emerged as the most effective therapies for AK. Drawing from previous studies, we catalog several commonly used antimicrobial agents that may enhance the efficacy of PHMB and CHG while also preventing other microbial infections. These alternative agents present promising options for treating AK cases. This review evaluates progress in anti-amoebic drug discovery, focusing on antibiotics and cataloging their activity at different stages of Acanthamoeba.

Enhancing Acanthamoeba diagnostics: rapid detection of viable Acanthamoeba trophozoites and cysts using viability PCR assay

Acanthamoeba keratitis (AK) is a sight-threatening corneal infection that is challenging to diagnose and treat due to the resistance of Acanthamoeba to standard antimicrobial agents. Current detection methods have limitations. This study aimed to develop and validate a sensitive viability PCR (v-PCR) assay using a photoreactive dye to distinguish viable from non-viable Acanthamoeba for rapid identification of viable Acanthamoeba trophozoites and cysts. Propidium monoazide (PMAxx) was used as a photoreactive dye. Mixtures containing decreasing percentages of viable Acanthamoeba, including reference strains Acanthamoeba polyphaga trophozoites and cysts, Acanthamoeba castellanii trophozoites, and Acanthamoeba castellanii trophozoites from a clinical sample, were prepared. Disinfectant efficacy against Acanthamoeba was also assessed. Samples were divided into PMAxx-treated and non-PMAxx-treated parts, and v-PCR assay was applied to both. The difference in viable Acanthamoeba was determined by subtracting the cycle threshold (Ct) value of the PMAxx-treated sample from the non-PMAxx-treated sample. Mixtures with decreasing concentrations of viable Acanthamoeba trophozoites and cysts showed increasingly lower delta Ct values as the percentage of viable Acanthamoeba decreased, as expected. This relationship was observed across all tested samples. Menicon Progent effectively eliminated A. polyphaga trophozoites and cysts, while propamidine, chlorhexidine, or their combination resulted in approximately 2-log reductions in A. polyphaga trophozoites and cysts. In the current study, a rapid v-PCR assay was developed that can distinguish between viable and non-viable Acanthamoeba, for both trophozoites and cysts, across multiple species. The presence of viable Acanthamoeba, as determined by v-PCR, allows monitoring of treatment response and efficacy in AK.IMPORTANCEThe development of a sensitive viability PCR (v-PCR) assay using propidium monoazide (PMAxx) as a photoreactive dye marks a significant advancement in the diagnosis and treatment of Acanthamoeba keratitis (AK), a severe corneal infection notorious for its resistance to conventional antimicrobials. This innovative assay offers a rapid and accurate method to distinguish viable from non-viable Acanthamoeba trophozoites and cysts, addressing a critical need in the field. By effectively distinguishing between viable and non-viable Acanthamoeba, this test enables monitoring of treatment response and efficacy, essential for guiding clinical interventions in AK cases. The successful validation of this v-PCR assay across various Acanthamoeba species and its ability to assess disinfectant efficacy further underline its potential as a valuable tool for improving diagnostic precision and therapeutic outcomes in the treatment of AK.

Effects of electroporation on Acanthamoeba Polyphaga

BACKGROUND

Species of the genus Acanthamoeba spp. are ubiquitous and can cause Acanthamoeba keratitis (AK), a serious corneal infection. Due to the toxicity and ineffectiveness of currently available prolonged therapies, we investigated electroceutical treatment aimed at facilitating the permeation of molecules through the membrane of cysts and trophozoites, which allows for faster elimination of the parasite.

METHODS

Cysts and trophozoites of Acanthamoeba polyphaga (ATCC® 30461TM) were exposed in vitro to an electric field with intensities of 2,000 volts and 2,500 volts. Viability after electroporation was assessed by the exclusion method with 0.4% trypan blue dye, while permeabilization was assessed by fluorescence microscopy using propidium iodide (PI), since both are impermeable to the membrane of viable and intact cells. The images were acquired on a Nikon Eclipse TI-U microscope and analyzed using ImageJ software.

RESULTS

With regard to viability, 40% of the trophozoites electroporated at 2,000 V and 42% of those electroporated at 2,500 V were lost, while for cysts the loss was 13% and 16% respectively. Considering permeabilization, 55% of trophozoites and cysts were permeabilized at 2,000 V (p ≤ 0.05); and 59% at 2,500 V for both (p ≤ 0.05). Values of p < 0.05 were considered statistically significant.

CONCLUSION

The voltages tested were effective for both cysts and trophozoites, since the percentages of permeabilization were close, with no statistical significance between them, only with the control groups. These results suggest the possibility that an electroceutical treatment could be applied as a complement to the standard treatment for AK.

Perspectives on the Incidence of Acanthamoeba Keratitis: A Systematic Review and Meta-Analysis

TOPIC

To provide an overview on the incidence of Acanthamoeba keratitis (AK).

CLINICAL RELEVANCE

Although being a sight-threatening cause of infectious keratitis, a comprehensive assessment of the incidence of AK is lacking.

METHODS

Incidence of AK was computed as the number of eyes with AK per health care center, per year (annualized center incidence [ACI]). Two meta-analytical ratios also were calculated: (1) the ratio of eyes with AK to the count of eyes with nonviral microbial keratitis (MK) and (2) the ratio of eyes with AK to the overall population (i.e., the total number of people in a nation or region, as indicated by the authors in each study). Center was defined as the health care facility where the study took place. Actual and projected estimates of the number of eyes with AK in years were calculated multiplying the ratio of eyes with AK to the total population and the corresponding population estimates, sourced from the United Nations Population Prospects.

RESULTS

Overall, 105 articles were included, published between 1987 and 2022. The total number of eyes identified was 91 951, with 5660 eyes affected by AK and 86 291 eyes affected by nonviral MK. The median ACI was 1.9 eyes with AK per health care center per year (95% confidence interval [CI], 1.5-2.6 eyes), with no statistically significant differences among continents. The ratio of eyes with AK to the total number of eyes with MK was 1.52% (95% CI, 1.03%-2.22%), whereas the ratio of eyes with AK in relationship to the entire population was estimated at 2.34 eyes per 1 000 000 people (95% CI, 0.98-5.55 per 1 000 000 people). The projected increase in the numbers of eyes with AK indicated an increase of 18.5% (n = 15 355 eyes with AK) in 2053 and 25.5% (n = 16 253 eyes with AK) in 2073, compared with the baseline of 2023 (n = 12 953 eyes with AK).

DISCUSSION

Acanthamoeba keratitis emerged as a relatively low-incident disorder, and no significant differences in terms of its incidence were found among different continents.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Acanthamoeba keratitis in the last decade. What have we learned?

INTRODUCTION

Acanthamoeba keratitis continues to be one of the most feared corneal infections due to its severity and capacity to generate irreversible visual sequelae. Despite diagnostic and therapeutic advances, this disease is increasing in our environment every year, related to a growing number of contact lens users. This last decade marked by the COVID-19 pandemic represents an unprecedented historical scenario whose impact must be analyzed from different health points of view. This study aims to describe the epidemiology, clinical presentation, treatment and evolution of Acanthamoeba keratitis in a tertiary hospital in the last 10 years.

RESULTS

The results have been obtained from a total of 13 eyes of 13 patients. This series of cases shows a diagnostic gap during the pandemic period, with a greater number of patients in the previous and post-pandemic stages. The different parameters of clinical presentation, microbiological diagnosis and clinical evolution are analyzed. All patients in our study wore contact lenses. Five of the cases were initially diagnosed in other centers as herpetic keratitis. Seven patients had a pseudo-dendrite as initial presentation, while six cases presented as an annular infiltrate. In all cases, 0.02% chlorhexidine eye drops were prescribed and this was associated with 0.1% propamidine in 11 cases. The results were variable, achieving an improvement in visual acuity in 10 of the cases.

CONCLUSION

This is a study on an emerging disease and with increasingly advanced knowledge and use of diagnostic and therapeutic tools in the historical context of a pandemic. This text attempts to shed light on the different forms of presentation and management of cases of Acanthamoeba keratitis.

Acanthamoeba castellanii trophozoites need oxygen for normal functioning and lipids are their preferred substrate, offering new possibilities for treatment

Acanthamoebae, pathogenic free-living amoebae, can cause Granulomatous Amoebic Encephalitis (GAE) and keratitis, and for both types of infection, no adequate treatment options are available. As the metabolism of pathogens is an attractive treatment target, we set out to examine the energy metabolism of Acanthamoeba castellanii and studied the aerobic and anaerobic capacities of the trophozoites. Under anaerobic conditions, or in the presence of inhibitors of the electron-transport chain, A. castellanii trophozoites became rounded, moved sluggishly and stopped multiplying. This demonstrates that oxygen and the respiratory chain are essential for movement and replication. Furthermore, the simultaneous activities of both terminal oxidases, cytochrome c oxidase and the plant-like alternative oxidase, are essential for normal functioning and replication. The inhibition of normal function caused by the inactivity of the respiratory chain was reversible. Once respiration was made possible again, the rounded, rather inactive amoebae formed acanthopodia within 4 h and resumed moving, feeding and multiplying. Experiments with radiolabelled nutrients revealed a preference for lipids over glucose and amino acids as food. Subsequent experiments showed that adding lipids to a standard culture medium of trophozoites strongly increased the growth rate. Acanthamoeba castellanii trophozoites have a strictly aerobic energy metabolism and β-oxidation of fatty acids, the Krebs cycle, and an aerobic electron-transport chain coupled to the ATP synthase, producing most of the used ATP. The preference for lipids can be exploited, as we show that three known inhibitors of lipid oxidation strongly inhibited the growth of A. castellanii. In particular, thioridazine and perhexiline showed potent effects in low micromolar concentrations. Therefore, this study revealed a new drug target with possibly new options to treat Acanthamoeba infections.

Contact Lens-Related Corneal Infections

Our review provides an update on the current landscape of contact lens-associated microbial keratitis (MK). We discuss the prevalence and risk factors associated with MK, emphasizing the role of overnight wear, poor hygiene, and contact lens type. CL-related MK is commonly caused by bacteria, though can also be caused by fungi or protozoa. Clinical presentation involves ocular pain, redness, and vision loss, with more specific presenting symptoms based on the culprit organism. Treatment strategies encompass prevention through proper hygiene and broad-spectrum antibiotic, antifungal, or antiprotozoal therapy, with surgical management reserved for severe recalcitrant cases.

Concomitant Potentially Contagious Factors Detected in Poland and Regarding Acanthamoeba Strains, Etiological Agents of Keratitis in Humans

BACKGROUND

Diseases in humans caused by amphizoic amoebae that can result in visual impairment and even blindness, have recently been identified more frequently worldwide. Etiologically complex incidents of keratitis, including those connected with Acanthamoeba strains detected in Poland, were evaluated in this study.

METHODS

Corneal samples from cases resistant to antimicrobial therapy assessed for epidemiological, microbiological and parasitological aspects were investigated by phase-contrast microscope, slit lamp and by confocal microscopy. In vitro techniques were applied for detection of bacteria and fungi, and corneal isolates cultured under axenic condition using BSC medium-for detection of Acanthamoeba spp.; molecular techniques were applied for amoeba species identification.

RESULTS

Most etiologically complicated keratitis cases, detected in ~84% of incidents, was due to exposure of contact lenses to tap water or pool water; trophozoites and cysts of Acanthamoeba, concomitant bacteriae, e.g., Pseudomonas aeruginosa, fungi and microfilariae were identified in contact lens users.

CONCLUSIONS

In samples from contact lens wearers where microbial keratitis is identified along with some connection with the patient's exposure to contaminated water environments, a risk of Acanthamoeba spp. infections should be considered. Understanding the complicated relationship between Acanthamoeba spp., co-occurring pathogens including associated endosymbionts is needed. In vivo confocal microscopy and in vitro cultivation were necessary to identify potentially contagious concomitant factors affecting the complex course of the keratitis.

Increasing incidence of contact-lens-related Acanthamoeba keratitis in a tertiary ophthalmology department in an Italian population

PURPOSE

The purpose of this paper is to report the increasing incidence of contact-lens related Acanthamoeba keratitis (AK) in a tertiary ophthalmology department in Umbria, central Italy.

METHODS

Observational and retrospective case series were carried out. A total of nine eyes with a diagnosis of AK were examined. All patients underwent a full slit lamp examination, in vivo confocal microscopy (IVCM) and corneal scraping. The IVCM was repeated at one and two-week and at one, three and six-month intervals. Samples of domestic tap water were also examined for PCR analysis. Patients were treated with levofloxacin0,5%, Polyhexamethylene biguanide 0.02%, and Propamidine Isetionate0,1%.

RESULTS

All patients were contact lens wearers. The average patient age was 27.75 (range 18-45), with three men and five women. The main clinical features were ciliary congestion, diffuse epitheliopathy with punctuated keratitis, multiple, small sub-epithelial, greyish, corneal infiltrates with epithelial defect, pseudodendritic corneal lesions, perineural infiltrates, corneal stromal cellularity, and stromal infiltrates. IVCM was indicative of Acanthamoeba in seven out of the nine eyes. All the positive IVCM images were section images showing double walled, bright-spot cysts with a clear chain-like arrangement of five or more cysts identified in three of the patients. PCR analysis of the water was negative in all cases.

CONCLUSION

Although PCR is the most common method used, the increased incidence of AK could mainly be related to a proper IVCM interpretation. A broad-spectrum antibiotic, such as levofloxacin might play a role in the early treatment of AK reducing the virulence of the amoeba.

Clinical perspective and outcome of culture-negative microbial keratitis: A retrospective study

PURPOSE

To study the risk factors, clinical features, and treatment outcomes of patients with culture-negative keratitis (CNK).

METHODS

A retrospective data review of 933 patients with CNK was performed from January 2018 to December 2020. The variables such as the history of injury, visual acuity, slit-lamp findings with measurements of size and depth of ulcer, microbiological evaluation, duct patency, blood glucose levels, and treatment were considered, and clinical outcome was analyzed.

RESULTS

Of the 933 patients with CNK, 763 (81.8%) were medically managed, with a mean treatment duration of 2.08 ± 1.7 weeks. Among them, 622 (66.7%) were both smear and culture-negative, and 311 (33.3%) showed only smear positivity. Smear-positive patients showed a positive correlation with the history of injury. A higher incidence of fungal growth on repeat culture was observed. Surgical interventions were done only in 18.2% of the patients; the rest were treated with topical medications alone.

CONCLUSION

High clinical suspicion, differentiation of causative organisms based on clinical findings, and initiating empirical therapy with broad-spectrum antibiotics and antifungals improve the ultimate prognosis in patients with CNK, even though a standard protocol for empirical medical treatment may differ among institutions and surgeons based on their clinical experience and geographical variations.

Clinical Profile and Demographic Distribution of Acanthamoeba Keratitis: An Electronic Medical Record-Driven Data Analytics from an Eye Care Network in India

OBJECTIVE

To describe the clinical profile of patients presented with Acanthamoeba keratitis (AK) to a multi-tier ophthalmology hospital network in India.

METHODS

This cross-sectional hospital-based study included 1945339 new patients registering between September 2016 and May 2022. Patients with clinically confirmed diagnosis of AK in one or both eyes were included in the study. All the relevant data were documented using an electronic medical record (EMR) system.

RESULTS

A total of 245 (0.013%) patients were diagnosed with AK and majority were male (62.86%) with unilateral (99.59%) affliction. The most common age group was during the fourth decade of life, 65 (26.53%) patients and predominantly were adults (95.51%). The prevalence of the infection was higher in patients from a lower socioeconomic status (43.27%) from rural geography (52.24%) and in agriculture-related work (28.16%). The most common inciting factor was injury with vegetative matter (8.98%), dust (7.76%) and contact lens wear (4.49%). The majority of the eyes had blindness (20/400 to 20/1200) in 116 (47.15%) eyes with a presenting visual acuity (logMAR) of 2.14 ± 1.04. Among the surgical interventions, therapeutic keratoplasty was performed in 41 (16.67%) eyes, penetrating keratoplasty in 22 (8.94%) eyes, and evisceration in 2 (0.81%) eyes.

CONCLUSION

AK more commonly affects males presenting during the fourth decade of life from lower socio-economic status and is predominantly unilateral. A fourth of the affected eyes underwent keratoplasty and the majority had significant visual impairment at presentation.

Development of ophthalmic nanoemulsions of β-caryophyllene for the treatment of Acanthamoeba keratitis

Although rare, amoebic keratitis (AK) is a disease caused by Acanthamoeba spp. that can lead to blindness. The drugs currently available for its treatment are very toxic, which has motivated the investigation for more effective and safe therapeutic options. In this study, the in vitro activity of ß-caryophyllene (BCP) was exploited taking into account its action against other protozoans as well as its well-known healing and anti-inflammatory properties (aspects relevant for the AK pathogenesis). On the other hand, high volatilization and oxidation phenomena are found for this compound, which led to its incorporation into nanoemulsions (NEs). Two emulsifying agents were tested, resulting in monodisperse systems with reduced droplet size (<265 nm) and high surface charge (positive and negative for NEs prepared with cetrimonium bromide -CTAB and Phosal® 50+, respectively). NEs prepared with CTAB were shown to be more stable after long-term storage at 4 and 25 °C than those prepared with Phosal®. Pure BCP, at the highest concentration (500 µM), resulted in a level of inhibition of Acanthamoeba trophozoites equivalent to that of reference drug (chlorhexidine). This activity was even greater after oil nanoencapsulation. The reduced droplet size could improve the interaction of the oil with the microorganism, justifying this finding. Changes in surface charge did not impact the activity. Positively charged NEs improved the interaction and retention of BCP in the cornea and thus should be prioritized for further studies.

The ecto-3'-nucleotidase activity of Acanthamoeba castellanii trophozoites increases their adhesion to host cells through the generation of extracellular adenosine

Acanthamoeba castellanii, a free-living amoeba, can be pathogenic to humans causing a corneal infection named Acanthamoeba keratitis (AK). The mannose-binding protein (MBP) is well established as the major factor related to Acanthamoeba pathogenesis. However, additional factors that participate in the adhesion process and protect trophozoites from cytolytic effects caused by host immune responses remain unknown. Ectonucleotidases, including 3'-nucleotidase/nuclease (3'-NT/NU), a bifunctional enzyme that was recently reported in A. castellanii, are frequently related to the establishment of parasitic infections. We verified that trophozoites can hydrolyze 3'-AMP, and this activity is similar to that observed in other protists. The addition of 3'-AMP increases the adhesion of trophozoites to LLC-MK2 epithelial cells, and this stimulation is completely reversed by DTT, an inhibitor of ecto-3'-nucleotidase activity. Lesions in corneal cells caused by AK infection may elevate the extracellular level of 3'-AMP. We believe that ecto-3'-nucleotidase activity can modulate the host immune response, thus facilitating the establishment of parasitic infection. This activity results from the generation of extracellular adenosine, which can bind to purinergic receptors present in host immune cells. Positive feedback may occur in this cascade of events once the ecto-3'-nucleotidase activity of trophozoites is increased by the adhesion of trophozoites to LLC-MK2 cells.

Understanding Acanthamoeba Keratitis: An In-Depth Review of a Sight-Threatening Eye Infection

Acanthamoeba keratitis (AK) is a rare but potentially sight-threatening corneal infection caused by the Acanthamoeba parasite. This microorganism is found ubiquitously in the environment, often in freshwater, soil, and other sources of moisture. Despite its low incidence, AK presents significant challenges due to delayed diagnosis and the complex nature of therapeutic management. Early recognition is crucial to prevent severe ocular complications, including corneal ulceration and vision loss. Diagnostic modalities and treatment strategies may vary greatly depending on the clinical manifestation and the available tools. With the growing reported cases of Acanthamoeba keratitis, it is essential for the ophthalmic community to thoroughly understand this condition for its effective management and improved outcomes. This review provides a comprehensive overview of AK, encompassing its epidemiology, risk factors, pathophysiology, clinical manifestations, diagnosis, and treatment.

Corneal acetylcholine regulates sensory nerve activity via nicotinic receptors

PURPOSE

Sensory nerve terminals are highly distributed in the cornea, and regulate ocular surface sensation and homeostasis in response to various endogenous and exogenous stimuli. However, little is known about mediators regulating the physiological and pathophysiological activities of corneal sensory nerves. The aim of this study was to investigate the presence of cholinergic regulation in sensory nerves in the cornea.

METHODS

Localization of choline acetyltransferase (ChAT) and vesicular acetylcholine transporter (vAChT) was evaluated using western blotting and immunohistochemical analysis. The synthesis and liberation of acetylcholine from the cornea were assessed using corneal segments pre-incubated with [3H]choline. The responsiveness of corneal neurons and nerves to cholinergic drugs was explored using calcium imaging with primary cultures of trigeminal ganglion neurons and extracellular recording from corneal preparations in guinea pigs.

RESULTS

ChAT, but not vAChT, was highly distributed in the corneal epithelium. In corneal segments, [3H] acetylcholine was synthesized from [3H]choline, and was also released in response to electrical stimuli. In cultured corneal neurons, the population sensitive to a transient receptor potential melastatin 8 (TRPM8) agonist exhibited high probability of responding to nicotine in a calcium imaging experiment. The firing frequency of cold-sensitive corneal nerves was increased by the application of nicotine, but diminished by an α4 nicotinic acetylcholine receptor antagonist.

CONCLUSIONS

The corneal epithelium can synthesize and release acetylcholine. Corneal acetylcholine can excite sensory nerves via nicotinic receptors containing the α4 subunit. Therefore, corneal acetylcholine may be one of the important regulators of corneal nerve activity arranging ocular surface condition and sensation.

Clinical outcomes and prognostic factors in Acanthamoeba keratitis

PURPOSE

To report clinical findings and prognostic factors for visual and morphological outcomes in patients with Acanthamoeba keratitis (AK).

METHODS

Single-center, retrospective, longitudinal study of 51 cases of AK diagnosed by real-time polymerase chain reaction (RT-PCR) between March 2010 and October 2022. The primary outcome was the final best corrected visual acuity (BCVA). Poor visual outcome was defined as a final BCVA ≥ 1 logMAR unit, while good visual outcome was defined as a final BCVA < 1 logMAR unit. Eyes from these two groups were compared, regarding demographic and initial clinical variables, anti-Acanthamoeba treatment used, and complications of the disease. Early diagnosis was defined as ≤ 14 days from symptom onset to diagnostic confirmation and initiation of Acanthamoeba medical treatment. Multivariable logistic regression was used to determine predictors of poor visual outcome.

RESULTS

A total of 51 eyes from 46 patients diagnosed with AK, all contact lens (CL) wearers, were included in this study. Average follow-up was 39.0 ± 30.2 [total range 14-120] months. Thirty-one eyes (60.8 %) presented good visual outcome, with a lower baseline age (30.5 ± 9.0 vs. 42.3 ± 15.8; p = 0.020), better initial BCVA (0.8 ± 0.7 logMAR units vs. 1.3 ± 0.9 logMAR units; p = 0.047), higher rate of early diagnosis (45.2 % vs. 5.6 %; p = 0.004), and higher rate of therapeutic epithelial debridement (64.5 % vs. 10 %; p < 0.001). 20 eyes (39.2 %) presented poor visual outcome, with 12 eyes undergoing evisceration/enucleation (23.5 %). These 20 eyes presented a higher rate of complications (90 % vs. 61.3 %; p = 0.031). In multivariable analysis, early diagnosis of AK (OR 19.78; 95 % CI 2.07-189.11; p = 0.010) and therapeutic epithelial debridement (OR 19.02; 95 % CI 3.27-110.57; p = 0.001) were associated with a good visual outcome.

CONCLUSIONS

In the present study, poor visual outcome was present in 39 % of affected eyes. Early AK diagnosis (≤14 days from symptom onset) and therapeutic epithelial debridement were associated with good final visual outcome.

Marine Natural Products Rescuing the Eye: A Narrative Review

Different degrees of visual impairment lead to a decrease in patient wellbeing, which has an adverse effect on many facets of social and professional life. Eye disorders can affect several parts of the eye, most notably the retina and the cornea, and the impacted areas might share a common form of cellular damage or dysfunction (such as inflammation, oxidative stress and neuronal degeneration). Considering that marine organisms inhabit a broad variety of marine habitats, they display a great degree of chemical diversity. As a result, molecules with a marine origin are receiving more and more attention in the hopes of developing novel therapeutic approaches. For instance, fucoxanthin has been demonstrated to be effective in protecting the retina against photo-induced damage, while largazole, astaxanthin and spirulina have all shown antioxidant, anti-inflammatory and antiapoptotic activities that can be useful for the management of several ocular diseases, such as age-related macular degeneration and ocular surface disorders. The aim of this review is to analyze the scientific literature relating to the therapeutic effects on the eye of the main natural marine products, focusing on their mechanism of action and potential clinical uses for the management of ocular diseases.

Comparison of therapeutic effects between big-bubble deep anterior lamellar keratoplasty and penetrating keratoplasty for medically unresponsive Acanthamoeba keratitis

PURPOSE

To compare the outcomes of big-bubble deep anterior lamellar keratoplasty (BB-DALK) and penetrating keratoplasty (PKP) in the management of medically unresponsive Acanthamoeba keratitis (AK).

METHODS

This retrospective study included 27 eyes of BB-DALK and 24 eyes of PKP from a tertiary ophthalmology care centre. Glucocorticoid eye drops were subsequently added to the treatment plan 2 months postoperatively based on the evaluation using confocal laser scanning microscopy. The clinical presentations, best-corrected visual acuity (BCVA), postoperative refractive outcomes, graft survival, and Acanthamoeba recurrence were analyzed.

RESULTS

The AK patients included in the study were in stage 2 or stage 3, and the percentage of patients in stage 3 was higher in the PKP group (P = 0.003). Clinical presentations were mainly corneal ulcers and ring infiltrates, and endothelial plaques, hypopyon, uveitis and glaucoma were more common in the PKP group (P = 0.007). The BCVA and the graft survival rate showed no statistically significant differences between the two groups at 1 year after surgery. However, 3 years postoperatively, the BCVA of 0.71 ± 0.64 logMAR, the graft survival rate of 89.5%, and the endothelial cell density of 1899 ± 125 cells per square millimeter in the BB-DALK group were significantly better than those of the PKP group (P = 0.010, 0.046, and 0.032, respectively). 3 eyes (11.1%) in the BB-DALK group and 2 eyes (8.3%) in the PKP group experienced Acanthamoeba recurrence, but the rates showed no statistically significant difference between the two groups (P = 1.000). In the PKP group, immune rejection and elevated intraocular pressure were observed in 5 and 6 eyes, respectively.

CONCLUSION

Corneal transplantation is recommended for AK patients unresponsive to antiamoebic agents. The visual acuity and graft survival can be maintained after BB-DALK surgery. Acanthamoeba recurrence is not related to the surgical approach performed, whereas complete dissection of the infected corneal stroma and delayed prescribing of glucocorticoid eye drops were important to prevent recurrence.

Self-assembled micelles loaded with itraconazole as anti-Acanthamoeba nano-formulation

Acanthamoeba castellanii are opportunistic pathogens known to cause infection of the central nervous system termed: granulomatous amoebic encephalitis, that mostly effects immunocompromised individuals, and a sight threatening keratitis, known as Acanthamoeba keratitis, which mostly affects contact lens wearers. The current treatment available is problematic, and is toxic. Herein, an amphiphilic star polymer with AB2 miktoarms [A = hydrophobic poly(ℇ-Caprolacton) and B = hydrophilic poly (ethylene glycol)] was synthesized by ring opening polymerization and CuI catalyzed azide-alkyne cycloaddition. Characterization by 1H and 13C NMR spectroscopy, size-exclusion chromatography and fluorescence spectroscopy was accomplished. The hydrophobic drug itraconazole (ITZ) was incorporated in self-assembled micellar structure of AB2 miktoarms through co-solvent evaporation. The properties of ITZ loaded (ITZ-PCL-PEG2) and blank micelles (PCL-PEG2) were investigated through zeta sizer, scanning electron microscopy and Fourier-transform infrared spectroscopy. Itraconazole alone (ITZ), polymer (DPB-PCL), empty polymeric micelles (PCL-PEG2) alone, and itraconazole loaded in polymeric micelles (ITZ-PCL-PEG2) were tested for anti-amoebic potential against Acanthamoeba, and the cytotoxicity on human cells were determined. The polymer was able to self-assemble in aqueous conditions and exhibited low value for critical micelle concentration (CMC) 0.05-0.06 µg/mL. The maximum entrapment efficiency of ITZ was 68%. Of note, ITZ, DPB, PCL-PEG2 and ITZ-PCL-PEG2 inhibited amoebae trophozoites by 37.34%, 36.30%, 35.77%, and 68.24%, respectively, as compared to controls. Moreover, ITZ-PCL-PEG2 revealed limited cytotoxicity against human keratinocyte cells. These results are indicative that ITZ-PCL-PEG2 micelle show significantly better anti-amoebic effects as compared to ITZ alone and thus should be investigated further in vivo to determine its clinical potential.

Influence of salt and temperature in the growth of pathogenic free-living amoebae

Introduction

Free-living amoebae are an extensive group of protistans that can be found in a wide variety of environments. Among them, the Acanthamoeba genus and Naegleria fowleri stand out as two of the most pathogenic amoebae and with a higher number of reported cases. N. fowleri is mainly found in warm freshwater water bodies whereas amoebae of the Acanthamoeba genus are broadly distributed through natural and anthropogenic environments. In this regard, the management and the control of the amoebic populations in swimming pools has become a major public health challenge for institutions.

Methods

The aim of this work was to evaluate the growth pattern of trophozoites of A. griffini and N. fowleri at different temperatures and salt concentrations.

Results and discussion

Our results showed that A. griffini resisted a higher concentration of salt than N. fowleri. Moreover, no trophozoites could withstand the salt levels of the sea in in vitro conditions. This work supports the contention that salinity could represent an important and useful tool for the control of the most pathogenic amoebic populations in recreational water bodies.

Novel Drug Screening Assay for Acanthamoeba castellanii and the Anti-Amoebic Effect of Carbonic Anhydrase Inhibitors

Acanthamoeba castellanii is an amoeba that inhabits soil and water in every part of the world. Acanthamoeba infection of the eye causes keratitis and can lead to a loss of vision. Current treatment options are only moderately effective, have multiple harmful side effects, and are tedious. In our study, we developed a novel drug screening method to define the inhibitory properties of potential new drugs against A. castellanii in vitro. We found that the clinically used carbonic anhydrase inhibitors, acetazolamide, ethoxzolamide, and dorzolamide, have promising antiamoebic properties.

Diagnosing and monitoring the characteristics of Acanthamoeba keratitis using slit scanning and laser scanning in vivo confocal microscopy

INTRODUCTION

Acanthamoeba keratitis (AK) is a serious and potentially blinding ocular infection caused by the free-living amoeba, Acanthamoeba. In vivo confocal microscopy (IVCM) is a non-invasive device which has been proven of great use to diagnose Acanthamoeba infections immediately. The aim of this review was to establish different patterns and signs of AK that appear on the IVCM both before and after treatment.

METHODS

A systematic review of the literature from 1974 until September 2021 was performed using Embase and PubMed, following The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty different signs of AK were observed using IVCM. The included studies used vastly different criteria to diagnose infections, ranging from just 1 to 13 of the signs, demonstrating the current lack of a standardised diagnosis of this infection using the IVCM. The appearance of double wall cysts, trophozoites, signet rings, target signs and clusters were shown to be pathognomonic to AK infections. Bright spots located in the corneal epithelium were demonstrated as non-reliable predictors of AK. The presence of cysts in clusters and single file can predict the need for corneal transplantation. The morphological changes in cysts using the IVCM following treatment were described as breaking down to hollow forms and occasionally surrounded by black cavities. Using this information, a visual guideline for identifying AK signs in diagnosis and follow-up using IVCM was created.

CONCLUSION

Increased awareness of the different signs and patterns of AK that appear on the IVCM is crucial in order to correctly identify an infection and increase the potential of this device. Our guidelines presented here can be used, but further studies are needed in order to determine the relationship and aetiology of these signs and cellular changes on the IVCM both before and after anti-amoeba treatment.

Induction of Programmed Cell Death in Acanthamoeba culbertsoni by the Repurposed Compound Nitroxoline

Acanthamoeba is a ubiquitous genus of amoebae that can act as opportunistic parasites in both humans and animals, causing a variety of ocular, nervous and dermal pathologies. Despite advances in Acanthamoeba therapy, the management of patients with Acanthamoeba infections remains a challenge for health services. Therefore, there is a need to search for new active substances against Acanthamoebae. In the present study, we evaluated the amoebicidal activity of nitroxoline against the trophozoite and cyst stages of six different strains of Acanthamoeba. The strain A. griffini showed the lowest IC50 value in the trophozoite stage (0.69 ± 0.01 µM), while the strain A. castellanii L-10 showed the lowest IC50 value in the cyst stage (0.11 ± 0.03 µM). In addition, nitroxoline induced in treated trophozoites of A. culbertsoni features compatibles with apoptosis and autophagy pathways, including chromatin condensation, mitochondrial malfunction, oxidative stress, changes in cell permeability and the formation of autophagic vacuoles. Furthermore, proteomic analysis of the effect of nitroxoline on trophozoites revealed that this antibiotic induced the overexpression and the downregulation of proteins involved in the apoptotic process and in metabolic and biosynthesis pathways.

Host cell-type and pathogen-specific immunomodulatory functions of macrophage migration inhibitory factor (MIF) in infectious keratitis

Therapeutic management of inflammation in infectious keratitis (IK) requires new strategy and targets for selective immunomodulation. Targeting host cell-type specific inflammatory responses might be a viable strategy to curtail unnecessary inflammation and reduce tissue damage without affecting pathogen clearance. This study explores the possibility of pathogen and host cell-type dependent differences in the inflammatory pathways relevant in the pathogenesis of IK. Human corneal epithelial cell line (HCEC) and phorbol 12-myristate-13 acetate (PMA) differentiated THP-1 macrophage line were infected with either Aspergillus flavus conidia or Acanthamoeba castellanii trophozoites and the elicited inflammatory responses were studied in terms of gene expression and secretion of proinflammatory factors interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-α) and an upstream inflammatory regulator and mediator protein-the Macrophage Migration Inhibitory Factor (MIF). Given the pleotropic mode of MIF function in diverse cell types relevant in many human diseases, we tested if MIF driven responses to infection is different in HCECs and THP-1 macrophages by studying its expression, secretion and involvement in inflammation by siRNA mediated knockdown. We also examined IK patient tear samples for MIF levels. Infection with A. flavus or A. castellanii induced IL-8 and TNF-α responses in HCECs and THP-1 macrophages but to different levels. Our preliminary human data showed that the level of secreted MIF protein was elevated in IK patient tear, however, MIF secretion by the two cell types were strikingly different in-vitro, under both normal and infected conditions. We found that HCECs released MIF constitutively, which was significantly inhibited with infection, whereas THP-1 macrophages were stimulated to release MIF during infection. MIF gene expression remained largely unaffected by infection in both the cell lines. Although MIF in HCECs appeared to be intracellularly captured during infection, MIF knockdown in HCECs associated with a partial reduction of the IL-8 and TNF-α expression produced by either of the pathogens, suggesting a pro-inflammatory role for MIF in HCECs, independent of its canonical cytokine like function. In contrast, MIF knockdown in THP-1 macrophages accompanied a dramatic increase in IL-8 and TNF-α expression during A. castellanii infection, while the responses to A. flavus infection remained unchanged. These data imply a host cell-type and pathogen specific distinction in the MIF- related inflammatory signaling and MIF as a potential selective immunomodulatory target in infectious keratitis.

Ultrasensitive and rapid diagnostic tool for detection of Acanthamoeba castellanii

Acanthamoeba keratitis is a devastating infectious disease of the cornea caused by an opportunistic amoeba, Acanthamoeba castellanii. It is poorly recognized, and diagnostic delays can lead to irreversible damage to the vision. The gold standard for diagnosis has been a sample culture that lasts approximately 2 weeks. Nevertheless, the essence of time has led to the need for an accurate and fast technique to detect A. castellanii from a sample. We developed both traditional and quantitative real-time-PCR-based methods to detect A. castellanii in less than 3 hours and with the sensitivity of one amoeba. Diagnostic laboratories can select the best-suited method for their purposes from 2 comparable methods. The correct treatment can be initiated from the emergency room when the diagnosis has been made quickly within a few hours, hence saving the patient from long-term complications.

Identification and characterization of an ectophosphatase activity involved in Acanthamoeba castellanii adhesion to host cells

Acanthamoeba castellanii is a free-living amoeba and an opportunistic pathogen for humans that can cause encephalitis and, more commonly, Acanthamoeba keratitis. During its life cycle, A. castellanii may present as proliferative and infective trophozoites or resistant cysts. The adhesion of trophozoites to host cells is a key first step in the pathogenesis of infection. A major virulence protein of Acanthamoeba is a mannose-binding protein (MBP) that mediates the adhesion of amoebae to cell surfaces. Ectophosphatases are ecto-enzymes that can dephosphorylate extracellular substrates and have already been described in several microorganisms. Regarding their physiological roles, there is consistent evidence that ectophosphatase activities play an important role in parasite-host interactions. In the present work, we identified and biochemically characterized the ectophosphatase activity of A. castellanii. The ectophosphatase activity is acidic, stimulated by magnesium, cobalt and nickel, and presents the following apparent kinetic parameters: Km = 2.12 ± 0.54 mM p-NPP and Vmax = 26.12 ± 2.53 nmol p-NP × h-1 × 10-6 cells. We observed that sodium orthovanadate, ammonium molybdate, sodium fluoride, and inorganic phosphate are able to inhibit ectophosphatase activity. Comparing the two stages of the A. castellanii lifecycle, ectophosphatase activity is significantly higher in trophozoites than in cysts. The ectophosphatase activity is stimulated by mannose residues and is significantly increased when trophozoites interact with LLC-MK2 cells. The inhibition of ectophosphatase by pretreatment with sodium orthovanadate also inhibits the adhesion of trophozoites to epithelial cells. These results allow us to conclude that the ectophosphatase activity of A. castellanii is somehow important for the adhesion of trophozoites to their host cells. According to our data, we believe that the activation of MBP by mannose residues triggers the stimulation of ectophosphatase activity to facilitate the adhesion process.

Acanthamoeba castellanii trophozoites escape killing by neutrophil extracellular traps using their 3'-nucleotidase/nuclease activity

Acanthamoeba castellanii is a free-living amoeba that acts as an opportunistic pathogen for humans and is the pathogenic agent of Acanthamoeba keratitis (AK). A. castellanii may present as proliferative and infective trophozoites or as resistant cysts during their life cycle. The immune response against AK is still poorly explored; however, it is well established that macrophages and neutrophils play essential roles in controlling corneal infection during the disease outcome. The release of NETs is one of the innate immune strategies to prevent parasite infection, especially when neutrophils interact with microorganisms that are too large to be phagocytosed, which is the case for amoeba species. The present work demonstrated that A. castellanii trophozoites can trigger NET formation upon in vitro interaction with neutrophils. Using DNase as a control, we observed increased parasite survival after coinciding with neutrophils, which may be correlated with NET degradation. Indeed, A. castellanii trophozoites degrade the NET DNA scaffold. Molecular analysis confirmed the occurrence of a 3'-nucleotidase/nuclease (3'-NT/NU) in the A. castellanii genome. We also demonstrated that trophozoites exhibit significantly higher 3'-NT/NU activity than cysts, which cannot trigger NET release. Considering that previous studies indicated the pathological role of 3'-NT-/NU in parasite infection, we suggest that this enzyme may act as the mechanism of escape of A. castellanii trophozoites from NETs.

Epidemiology of free-living amoebae infections in Africa: a review

FLA-related conditions are a rare medical occurrence. Despite their rarity, they are considered a public health concern for two reasons: the absence of a regular treatment regimen in the case of central nervous system infections and the fast progression of the symptoms leading to fatal outcomes. A total of 358 articles were retrieved from different databases (91 from PubMed, 26 from NCBI, 138 from Academia, 102 from Science Direct, and one from IJMED). 7 (46.6%) clinical cases came from Egypt, 2 (13.3%) cases of FLA infection came from Nigeria, 3 (20%) cases came from the Gambia, and 1 (6.6%) case was reported from African countries like Algeria, Tunisia, South Africa, and Zambia. Medical conditions caused by free-living amoeba are considered significant public health concerns. These ubiquitous organisms can cause both fatal and debilitating health conditions. Immediate diagnosis of cases and proper hygienic practices are necessary to provide direct medical intervention. They may be the key to reducing the morbidity and mortality rates from FLA-acquired infections. Although several government-led initiatives have been implemented to mitigate a plethora of parasitic diseases, the case of FLA-related conditions in African countries has yet to be realized.

Successive Acanthamoeba Corneal Isolates Identified in Poland Monitored in Terms of In Vitro Dynamics

BACKGROUND

Amoebae of the genus Acanthamoeba cause a sight-threatening infection called Acanthamoeba keratitis. It is considered a rare disease in humans but poses an increasing threat to public health worldwide, including in Poland. We present successive isolates from serious keratitis preliminary examined in terms of the identification and monitoring of, among others, the in vitro dynamics of the detected strains.

METHODS

Clinical and combined laboratory methods were applied; causative agents of the keratitis were identified at the cellular and molecular levels; isolates were cultivated in an axenic liquid medium and regularly monitored.

RESULTS

In a phase-contrast microscope, Acanthamoeba sp. cysts and live trophozoites from corneal samples and in vitro cultures were assessed on the cellular level. Some isolates that were tested at the molecular level were found to correspond to A. mauritanensis, A. culbertsoni, A. castellanii, genotype T4. There was variability in the amoebic strain dynamics; high viability was expressed as trofozoites' long duration ability to intense multiply.

CONCLUSIONS

Some strains from keratitis under diagnosis verification and dynamics assessment showed enough adaptive capability to grow in an axenic medium, allowing them to exhibit significant thermal tolerance. In vitro monitoring that was suitable for verifying in vivo examinations, in particular, was useful to detect the strong viability and pathogenic potential of successive Acanthamoeba strains with a long duration of high dynamics.

Epidemiological profile of microbial keratitis in Alexandria-Egypt a 5 years retrospective study

OBJECTIVE

To evaluate the epidemiologic profile of microbial keratitis in Alexandria- Egypt, with special emphasis on risk factors, visual outcome and microbiological results.

METHODS

This retrospective study reviewed files of patients treated for microbial keratitis during a period of 5 years at Alexandria Ophthalmology Hospital Cornea Clinic, Alexandria- Egypt, between February 2017 and June 2022. The patients were evaluated for the risk factors e.g., trauma, eyelid disorders, co-morbidities, and contact lens use. They were also evaluated for their clinical picture, the identified microorganisms, visual outcomes, and complications. Non-microbial keratitis and incomplete files were excluded from the study.

RESULTS

A total of 284 patients were diagnosed as microbial keratitis in our study. Viral keratitis was the most common cause of microbial keratitis (n = 118 (41.55%)), followed by bacterial keratitis (n = 77 (27.11%)), mixed keratitis (n = 51 (17.96%)), acanthamoeba keratitis (n = 22 (7.75%)) and the least cause was fungal keratitis (n = 16 (5.63%)). Trauma was the most common risk factor for microbial keratitis (29.2%). Fungal keratitis had a statistically significant association with trauma (p < 0.001), while the use of contact lenses had a statistically significant association with Acanthamoeba keratitis (p < 0.001). The percentage of culture-positive results in our study was 76.8%. Gram-positive bacteria were the most frequently isolated bacterial isolate (n = 25 (36.2%)), while filamentous fungi were the most frequently isolated fungi (n = 13(18.8%)). After treatment, there was a significant increase in the mean visual acuity among all groups; it was significantly higher in Acanthamoeba keratitis group with a mean difference of 0.262 ± 0.161 (p = 0.003).

CONCLUSION

Viral keratitis followed by bacterial keratitis were the most frequent etiologic agents causing microbial keratitis found in our study. Although trauma was the most frequent risk factor for microbial keratitis, contact lens wear was found an important preventable risk factor for microbial keratitis in young patients. Performing culture properly whenever indicated before starting antimicrobial treatment increased the cultures' positive results.

The global epidemiology and clinical diagnosis of Acanthamoeba keratitis

Acanthamoeba keratitis is a rare parasitic infection of the cornea that can lead to permanent blindness if not diagnosed and treated promptly. We collected data on the incidences of Acanthamoeba keratitis from 20 countries and calculated an annual incidence of 23,561 cases, with the lowest rates in Tunisia and Belgium, and the highest in India. We analyzed 3755 Acanthamoeba sequences from the GenBank database across Asia, Europe, North America, South America, and Oceania and genotyped them into T1, T2, T3, T4, T5, T10, T11, T12, and T15. Many genotypes possess different characteristics, yet T4 is the most prevalent genotype. As efficient treatment against Acanthamoeba remains lacking, prevention from early diagnosis via staining, PCR, or in vivo confocal microscopy (IVCM) becomes significant for the condition's prognosis. IVCM is the most recommended approach for the early detection of Acanthamoeba. If IVCM is unavailable, PCR should be used as an alternative.

Novel Map Biopsy Technique to Define the Extent of Infection Before Penetrating Keratoplasty for Acanthamoeba Keratitis

PURPOSE

The purpose of this study was to report a novel approach of prepenetrating keratoplasty (PKP) corneal map biopsies to define the extent of Acanthamoeba cyst infiltration in recalcitrant Acanthamoeba keratitis.

METHODS

Corneal map biopsies were performed 1 week before PKP. Four biopsies, 1 from each peripheral corneal quadrant, were obtained to delineate the extent of microscopic infection. Histological results of these map biopsies were used to determine the size and location of the subsequent PKP.

RESULTS

In our first case, map biopsies revealed Acanthamoeba cysts in 2 of the 4 biopsies. This led to an inferotemporally eccentric 8.5-mm PKP. The final histology report indicated that the closest resection margin was 0.08 mm. In our second case, the peripheral map biopsies were clear and an inferiorly eccentric 8.25-mm PKP was performed. The final histology report indicated that the closest resection margin was 2.3 mm. Both grafts have remained clear at 6 months postoperatively.

CONCLUSIONS

Map biopsies of the cornea can achieve total removal of the corneal tissues infested with Acanthamoeba cysts and prevent reinfection of the donor graft.

Impact of implementation of polymerase chain reaction on diagnosis, treatment, and clinical course of Acanthamoeba keratitis

PURPOSE

Acanthamoeba keratitis (AK) is a painful and possibly sight-threatening ocular infection. While the correct diagnosis and specific treatment in the early stages significantly improve the prognosis, the disease is often misdiagnosed and in clinical examination confused with other forms of keratitis. Polymerase chain reaction (PCR) for the detection of AK was first introduced in our institution in December 2013 to improve the timely diagnosis of AK. The aim of this study was to assess the impact of implementation of Acanthamoeba PCR on the diagnosis and treatment of the disease in a German tertiary referral center.

PATIENTS AND METHODS

Patients treated for Acanthamoeba keratitis between 1st of January 1993 and 31st of December 2021 in the Department of Ophthalmology of the University Hospital Duesseldorf were identified retrospectively via in-house registries. Evaluated parameters include age, sex, initial diagnosis, method of correct diagnosis, duration of symptoms until correct diagnosis, contact lens use, visual acuity, and clinical findings as well as medical and surgical therapy by keratoplasty (pKP). In order to assess the impact of implementation of Acanthamoeba PCR, the cases were divided into two groups (before (pre-PCR group) and after PCR implementation (PCR group).

RESULTS

Seventy-five patients with Acanthamoeba keratitis were included (69.3% female, median age 37 years). Eighty-four percent (63/75) of all patients were contact lens wearers. Until PCR was available, 58 patients with Acanthamoeba keratitis were diagnosed either clinically (n = 28), by histology (n = 21), culture (n = 6), or confocal microscopy (n = 2) with a median duration until diagnosis of 68 (18; 109) days. After PCR implementation, in 17 patients, the diagnosis was established with PCR in 94% (n = 16) and median duration until diagnosis was significantly shorter with 15 (10; 30.5) days. A longer duration until correct diagnosis correlated with a worse initial visual acuity (p = 0.0019, r = 0.363). The number of pKP performed was significantly lower in the PCR group (5/17; 29.4%) than in the pre-PCR group (35/58; 60.3%) (p = 0.025).

CONCLUSIONS

The choice of diagnostic method and especially the application of PCR have a significant impact on the time to diagnosis and on the clinical findings at the time of confirmation of diagnosis and the need for penetrating keratoplasty. In contact lens-associated keratitis, the first crucial step is to take AK into consideration and perform a PCR test as timely confirmation of diagnosis of AK is imperative to prevent long-term ocular morbidity.

Akanthamöbenkeratitiden in Jugendlichen mit Orthokeratologielinsen

Hintergrund

Durch die rasant steigende Prävalenz der Myopie kommen zunehmend progressionshemmende Verfahren zum Einsatz. Auch die Orthokeratologie, basierend auf dem Ansatz des peripheren Defokus, erlebt eine Renaissance. Die gefährlichste Nebenwirkung der Orthokeratologie ist die mikrobielle Keratitis, unter ihnen eine Infektion mit Akanthamöben, welche oft spät diagnostiziert wird und potenziell visusbedrohende Verläufe nehmen kann.

Material und Methode

Diese Fallserie beschreibt die Diagnosefindung und den Behandlungsverlauf der Akanthamöbenkeratitis bei jugendlichen Patient*innen mit Orthokeratologielinsen, welche an der Spezialambulanz für Hornhauterkrankungen der Universitätsklinik für Augenheilkunde und Optometrie an der Medizinischen Universität Wien im Zeitraum eines Jahres betreut wurden.

Resultate

Vier Fälle von orthokeratologieassoziierten Akanthamöbenkeratitiden wurden mittels kornealer Konfokalmikroskopie und mikrobiologischer Verfahren zwischen August 2021 und August 2022 diagnostiziert. Die intensive Stufentherapie umfasste ein hochdosiertes, topisches Biguanid in Kombination mit einem Diamidinderivat, welches in der ersten Therapiephase mit antibakteriellen und antifungalen Augentropfen kombiniert wurde. Der Therapieverlauf und -erfolg wurde mittels der kornealen Konfokalmikroskopie beurteilt, und entsprechend angepasst.

Schlussfolgerung

Die Akanthamöbenkeratitis ist ein ernst zu nehmendes Erkrankungsbild im Zusammenhang mit Orthokeratologielinsen. Im Hinblick auf das Alter der Zielgruppe dieser myopieprogressionshemmenden Therapie sollte, neben sorgfältiger Patientenselektion, auf eine detaillierte Schulung der Kontaktlinsenträger in der Handhabung der Linsen sowie auf ein erhöhtes Bewusstsein für Zeichen einer frühen Infektion besonderes Augenmerk gelegt werden. Da alternative Möglichkeiten zur Myopieprophylaxe bestehen, müssen PatentInnen auf das Risiko der jeweiligen Methode hingewiesen werden.

Antiamoebic Susceptibility in Acanthamoeba Keratitis: Comparison of Isolates From South India and Northern California

PURPOSE

Outcomes of Acanthamoeba keratitis are often worse in India than in the United States. The goal of this study was to determine whether antiamoebic susceptibility patterns were different when comparing Acanthamoeba isolates from India with those of the United States.

METHODS

Acanthamoeba isolates were obtained from corneal scrapings of 43 patients with infectious keratitis seen at the Francis I. Proctor Foundation (N = 23) and Aravind Eye Hospital (N = 20) from 2008 through 2012 and plated on growth media. A previously described minimum cysticidal concentration (MCC) assay was performed by a single laboratory technician to assess susceptibility to 5 antiamoebic agents for all isolates. Testing was conducted in triplicate, with the median MCC chosen for analyses.

RESULTS

The MCC (μg/mL) of polyhexamethylene biguanide was 6.25 [IQR 5.47-12.5] for Aravind isolates and 6.25 [IQR 6.25-9.375] for Proctor isolates ( P = 0.75), corresponding values were 6.25 [IQR 3.125-6.25] and 3.125 [IQR 3.125-9.375] for chlorhexidine ( P = 0.81), 2500 [IQR 2500-5000] and 5000 [IQR 1250-20,000] for voriconazole ( P = 0.25), 15.6 [IQR 15.6-39.0625] and 15.6 [IQR 15.6-31.25] for hexamidine ( P = 0.92), and 15.6 [IQR 7.81-15.6] and 15.6 [IQR 7.81-31.25] for propamidine ( P = 0.42).

CONCLUSIONS

This study found no statistically significant differences in antiamoebic susceptibility of Indian versus US samples from Acanthamoeba keratitis clinical isolates. These findings suggest that differences in antiamoebic susceptibility are likely not responsible for differential outcomes in Acanthamoeba keratitis between the 2 locations.

Use of Amniotic Membrane Transplant and Deep Anterior Keratoplasty in a Patient with Bilateral Acanthamoeba Infectious Keratitis: A Case Report

The aim of this study was to report a case with the use of amniotic membrane transplant and deep anterior keratoplasty in a patient with bilateral Acanthamoeba infectious keratitis as a treatment. A 20-year-old male presented with bilateral Acanthamoeba keratitis (AK) who was initially diagnosed with herpetic keratitis receiving full antiviral and corticosteroid topical treatment without any improvement. Corneal biopsy was performed to confirm the suspected diagnosis, and Acanthamoeba stromal cysts were identified in the sample. Treatment was initiated with 0.02% chlorhexidine, 0.1% propamidine isethionate, neomycin, and tropicamide/phenylephrine. Symptoms and clinical improvement were achieved between the 8th and 10th weeks, so corticosteroids were initiated. Treatment was continued until we observed a poor response in the left eye; therefore, an epithelial scraping and amniotic membrane placement were performed. Lately, the right eye underwent a deep anterior lamellar keratoplasty. A challenging case of bilateral AK managed with topical medications, amniotic membrane, and corneal keratoplasty. The earlier the disease is diagnosed, the better the outcome. If the diagnosis is delayed, the amoebas have penetrated deep into the corneal stroma, and successful therapy becomes difficult. A surgical option can be an early solution with a good prognosis for these cases.

Effectiveness of Polyclonal Antibody Immunoconjugate Treatment with Propamidine Isethionate for Amoebic Keratitis in Golden Hamsters

Acanthamoeba griffini is known to cause amoebic keratitis (AK); its main causes are inadequate hygiene when contact lenses are handled and/or its prolonged use at night, as well as the use of contact lenses during underwater activities. The most used treatment for AK is the combination of propamidine isethionate combined with polyhexamethylene biguanide, which disrupts the cytoplasmic membrane, and damages cellular components and respiratory enzymes. We proposed an immunoconjugate treatment obtained from Acanthamoeba immunized rabbit serum combined with propamidine isethionate; the corneas of hamsters inoculated with A. griffini (MYP2004) were treated with the combined, at 1, 2, and 3 weeks. Propamidine isethionate is frequently used for AK treatment, in vivo study we are found IL-1β and IL-10 expression and caspase 3 activity is significantly increased with respect to the group that was inoculated with the amoeba without receiving any treatment, suggesting that it may be an effect of the toxicity of this drug on the corneal tissue. Application of the immunoconjugate showed enhanced amoebicidal and anti-inflammatory activities, with comparison to propamidine isethionate only. The aim of this study is to evaluate the effect of the immunoconjugate of propamidine isethionate and polyclonal antibodies as a treatment of AK in golden hamsters (Mesocricetus auratus).

Biological characteristics and pathogenicity of Acanthamoeba

Acanthamoeba is an opportunistic protozoa, which exists widely in nature and is mainly distributed in soil and water. Acanthamoeba usually exists in two forms, trophozoites and cysts. The trophozoite stage is one of growth and reproduction while the cyst stage is characterized by cellular quiescence, commonly resulting in human infection, and the lack of effective monotherapy after initial infection leads to chronic disease. Acanthamoeba can infect several human body tissues such as the skin, cornea, conjunctiva, respiratory tract, and reproductive tract, especially when the tissue barriers are damaged. Furthermore, serious infections can cause Acanthamoeba keratitis, granulomatous amoebic encephalitis, skin, and lung infections. With an increasing number of Acanthamoeba infections in recent years, the pathogenicity of Acanthamoeba is becoming more relevant to mainstream clinical care. This review article will describe the etiological characteristics of Acanthamoeba infection in detail from the aspects of biological characteristic, classification, disease, and pathogenic mechanism in order to provide scientific basis for the diagnosis, treatment, and prevention of Acanthamoeba infection.

Update on Corneal Confocal Microscopy Imaging

In vivo corneal confocal microscopy (IVCM) is a non-invasive ophthalmic imaging technique that provides images of the cornea at the cellular level. Despite the uses in ocular surface pathologies, in the last decades IVCM has been used to provide more knowledge in refractive surgery wound healing, in neuropathies diagnosis, etc. The observation of the corneal cells, both normal and inflammatory, and the possibility of quantification of the corneal nerve density with manual or automated tools, makes IVCM have a significant potential to improve the diagnosis and prognosis in several systemic and corneal conditions.

Anti-Acanthamoeba activity of a semi-synthetic mangostin derivative and its ability in removal of Acanthamoeba triangularis WU19001 on contact lens

Garcinia mangostana L., also known as the mangosteen tree, is a native medicinal plant in Southeast Asia having a wide variety of pharmacologically active compounds, including xanthonoid mangostin. In this study, we examined the pharmacological activities of the selected semi-synthetic mangostin derivative, namely, amoebicidal activity, encystation inhibition, excystation activity, and removal capacity of adhesive Acanthamoeba from the surface of contact lens (CL). Among the three derivatives, C1 exhibited promising anti-Acanthamoeba activity against Acanthamoeba triangularis WU19001 trophozoites and cysts. SEM images displayed morphological changes in Acanthamoeba trophozoites, including the loss of acanthopodia, pore formation in the cell membrane, and membrane damage. In addition, the treated cyst was shrunken and adopted an irregular flat cyst shape. Under a fluorescence microscope, acridine orange and propidium iodide (AO/PI) staining revealed C1 induced condensation of cytoplasm and chromatin with the loss of cell volume in the treated trophozoites, while calcofluor white staining demonstrated the leakage of cell wall in treated cysts, leading to cell death. Interestingly, at the concentration ranges in which C1 showed the anti-Acanthamoeba effects (IC₅₀ values ranging from 0.035-0.056 mg/mL), they were not toxic to Vero cells. C1 displayed the highest inhibitory effect on A. triangularis encystation at 1/16×MIC value (0.004 mg/mL). While C1 demonstrated the excystation activity at 1/128×MIC value with a high rate of 89.47%. Furthermore, C1 exhibited the removal capacity of adhesive Acanthamoeba from the surface of CL comparable with commercial multipurpose solutions (MPSs). Based on the results obtained, C1 may be a promising lead agent to develop a therapeutic for the treatment of Acanthamoeba infections and disinfectant solutions for CL.

Topical Sustained Delivery of Miltefosine Via Drug-Eluting Contact Lenses to Treat Acanthamoeba Keratitis

This study aimed to develop a miltefosine-eluting contact lens (MLF-CL) device that would allow sustained and localized miltefosine release for the treatment of Acanthamoeba keratitis. MLF-CLs were produced in three different miltefosine doses by solvent-casting a thin miltefosine-polymer film around the periphery of a methafilcon hydrogel, which was then lathed into a contact lens. During seven days of in vitro testing, all three formulations demonstrated sustained release from the lens at theoretically therapeutic levels. Based on the physicochemical characterization of MLF-CLs, MLF-CL's physical properties are not significantly different from commercial contact lenses in terms of light transmittance, water content and wettability. MLF-CLs possessed a slight reduction in compression modulus that was attributed to the inclusion of polymer-drug films but still remain within the optimal range of soft contact lenses. In cytotoxicity studies, MLF-CL indicated up to 91% viability, which decreased proportionally as miltefosine loading increased. A three-day biocompatibility test on New Zealand White rabbits revealed no impact of MLF-CLs on the corneal tissue. The MLF-CLs provided sustained in vitro release of miltefosine for a week while maintaining comparable physical features to a commercial contact lens. MLF-CL has a promising potential to be used as a successful treatment method for Acanthamoeba keratitis.

Clinical Observation of Corneal Endothelial Plaques With Fungal and Bacterial Keratitis by Anterior Segment Optical Coherence Tomography and In Vivo Confocal Microscopy

PURPOSE

Endothelial plaque is an important sign of fungal keratitis and is related to diagnosis, surgical indications, and prognosis. However, bacterial keratitis sometimes involves fibrin formation on the back corneal surface, similar to endothelial plaques. Because corneal infiltration interferes with precise observation of the posterior corneal plaque, distinguishing pathogens with a slitlamp is difficult. We hope to assist clinicians in early diagnosis and timely treatment by observing the connection state of endothelial plaques and the corneal endothelium through anterior segment optical coherence tomography (AS-OCT) and the different forms of endothelial plaques in infectious keratopathy through in vivo confocal microscopy (IVCM).

METHODS

We analyzed 52 patients in the Eye Hospital of the First Affiliated Hospital of Harbin Medical University who were clearly diagnosed with fungal or bacterial keratitis with endothelial plaques. All patients underwent AS-OCT and IVCM on admission.

RESULTS

According to the smear, IVCM, or fungal and bacterial culture results, the patients were diagnosed with fungal (28 patients) or bacterial keratitis (24 patients). AS-OCT in 25 patients diagnosed with fungal keratitis revealed that the corneal endothelium-endothelial plaque boundary was unclear and wavy, and 24 patients had unclear cell boundaries and a large number of compactly distributed inflammatory cells in the endothelial layer according to IVCM. AS-OCT in 23 patients diagnosed with bacterial keratitis revealed clear corneal endothelium-endothelial plaque boundaries, and insufficient endothelial cell boundaries with a large number of visible and scattered inflammatory cell structures were observed through IVCM in 22 patients.

CONCLUSIONS

Corneal endothelial plaque detection by AS-OCT and IVCM can be used for early diagnosis of infectious keratitis.

Polyhexamethylene biguanide hydrochloride (PHMB)-properties and application of an antiseptic agent. A narrative review

The prevention and management of ocular surface infections is still one of the great challenges for ophthalmologists. The spread of antimicrobial resistance makes it necessary to use antiseptic substances with a broad antimicrobial spectrum. Polyhexamethylene biguanide hydrochloride (Polyhexanide, PHMB) is a broad-spectrum antiseptic with excellent tolerance and a low-risk profile. Its physicochemical action on the phospholipid membrane and DNA replication or repair mechanism, prevents or impedes the development of resistant bacterial strains. PHMB revealed its effective against numerous organisms like viruses, Gram-negative and Gram-positive bacteria, and fungi. Polyhexanide is commonly used as preservative in commercially available disinfecting solutions for contact lens care and in ophthalmic formulations at different concentrations ranging from 1 µg/ml to 50 µg/ml. The administration of 0.02% (200 µg/ml) PHMB is often the first-line therapy of Acanthamoeba keratitis. However, to date, only one close-out randomized controlled study tested the efficacy of 0.02% PHMB in Acanthamoeba keratitis and a phase III study is still ongoing. This paper reviews the antiseptic agent PHMB, focusing on biochemical mechanisms, safety profile and applications in ophthalmology.

Efficacy of Off-Label Anti-Amoebic Agents to Suppress Trophozoite Formation of Acanthamoeba spp. on Non-Nutrient Agar Escherichia Coli Plates

Acanthamoeba keratitis (AK) is a dangerous infectious disease, which is associated with a high risk of blindness for the infected patient, and for which no standard therapy exists thus far. Patients suffering from AK are thus treated, out of necessity, with an off-label therapy, using drugs designed and indicated for other diseases/purposes. Here, we tested the capability of the off-label anti-amoebic drugs chlorhexidine (CH; 0.1%), dibromopropamidine diisethionate (DD; 0.1%), hexamidine diisethionate (HD; 0.1%), miltefosine (MF; 0.0065%), natamycin (NM; 5%), polyhexamethylene biguanide (PHMB; 0.02%), povidone iodine (PVPI; 1%), and propamidine isethionate (PD; 0.1%) to suppress trophozoite formation of Acantamoeba castellanii and Acanthamoeba hatchetti cysts on non-nutrient agar Escherichia coli plates. Of the eight off-label anti-amoebic drugs tested, only PVPI allowed for a complete suppression of trophozoite formation by drug-challenged cysts for all four Acanthamoeba isolates in all five biological replicates. Drugs such as NM, PD, and PHMB repeatedly suppressed trophozoite formation with some, but not all, tested Acanthamoeba isolates, while other drugs such as CH, DD, and MF failed to exert a relevant effect on the excystation capacities of the tested Acanthamoeba isolates in most, if not all, of our repetitions. Our findings suggest that pre-testing of the AK isolate with the non-nutrient agar E. coli plate assay against the anti-amoebic drug intended for treatment should be performed to confirm that the selected drug is cysticidal for the Acanthamoeba isolate.

Tannic Acid-Modified Silver Nanoparticles in Conjunction with Contact Lens Solutions Are Useful for Progress against the Adhesion of Acanthamoeba spp. to Contact Lenses

Acanthamoeba spp. are amphizoic amoebae that are widely distributed in the environment and capable of entering the human body. They can cause pathogenic effects in different tissues and organs, including Acanthamoeba keratitis (AK), which may result in a loss of visual acuity and blindness. The diagnostics, treatment, and prevention of AK are still challenging. More than 90% of AK cases are related to the irresponsible wearing of contact lenses. However, even proper lens care does not sufficiently protect against this eye disease, as amoebae have been also found in contact lens solutions and contact lens storage containers. The adhesion of the amoebae to the contact lens surface is the first step in developing this eye infection. To limit the incidence of AK, it is important to enhance the anti-adhesive activity of the most popular contact lens solutions. Currently, silver nanoparticles (AgNPs) are used as modern antimicrobial agents. Their effectiveness against Acanthamoeba spp., especially with the addition of plant metabolites, such as tannic acid, has been confirmed. Here, we present the results of our further studies on the anti-adhesion potential of tannic acid-modified silver nanoparticles (AgTANPs) in combination with selected contact lens solutions against Acanthamoeba spp. on four groups of contact lenses. The obtained results showed an increased anti-adhesion activity of contact lens solutions in conjunction with AgTANPs with a limited cytotoxicity effect compared to contact lens solutions acting alone. This may provide a benefit in improving the prevention of amoebae eye infections. However, there is still a need for further studies on different pathogenic strains of Acanthamoeba in order to assess the adhesion of the cysts to the contact lens surface and to reveal a more comprehensive picture of the activity of AgTANPs and contact lens solutions.

Specific Detection of Acanthamoeba species using Polyclonal Peptide Antibody Targeting the Periplasmic Binding Protein of A. castellanii

Acanthamoeba keratitis (AK) is a rare ocular disease, but it is a painful and sight-threatening infectious disease. Early diagnosis and adequate treatment are necessary to prevent serious complications. While AK is frequently diagnosis via several PCR assays or Acanthamoeba-specific antibodies, a more specific and effective diagnostic method is required. This study described the production of a polyclonal peptide antibody against the periplasmic binding protein (PBP) of A. castellanii and investigated its diagnostic potential. Western blot analysis showed that the PBP antibody specifically reacted with the cell lysates of A. castellanii. However, the PBP antibody did not interact with human corneal epithelial (HCE) cells and the other 3 major causative agents of keratitis. Immunocytochemistry (ICC) results revealed the specific detection of A. castellanii trophozoites and cysts by PBP antibodies when A. castellanii were co-cultured with HCE cells. PBP antibody specificity was further confirmed by co-culture of A. castellanii trophozoites with F. solani, S. aureus, and P. aeruginosa via ICC. The PBP antibody specifically reacted with the trophozoites and cysts of A. polyphaga, A. hatchetti, A. culbertsoni, A. royreba, and A. healyi, thus demonstrated its genus-specific nature. These results showed that the PBP polyclonal peptide antibody of A. castellanii could specifically detect several species of Acanthamoeba, contributing to the development of an effective antibody-based AK diagnostics.