2017/2018
Daniela Filipa Silva Cerqueira
Clinical profile of patients with Acanthamoeba keratitis – what
are the por prognosis indicators?
Daniela Filipa Silva Cerqueira
Clinical profile of patients with Acanthamoeba keratitis – what
are the poor prognosis indicators?
Mestrado Integrado em Medicina
Área: Oftalmologia
Tipologia: Dissertação
Trabalho efetuado sob a Orientação de:
Doutor João Pinheiro-Costa
E sob a Coorientação de:
Dra. Carolina Madeira
Trabalho organizado de acordo com as normas da revista:
Cornea
março, 2018DEDICATÓRIA
Terminada a realização desta Tese de Mestrado, não faria sentido deixar de agradecer
ao meu Orientador, Doutor João Pinheiro-Costa, e à minha Co-orientadora, Doutora
Carolina Madeira, por toda a disponibilidade e atenção prestada no decorrer da sua
execução.
Um agradecimento especial à Joana Ferraz Brandão, que procedeu à revisão
linguística do texto.
Por último, mas não menos importante, um enorme agradecimento à minha família e
amigos, pelo apoio e pela paciência.
1
CLINICAL PROFILE OF PATIENTS WITH ACANTHAMOEBA KERATITIS - WHAT
2
ARE THE POOR PROGNOSIS INDICATORS?
3
4
Carolina Madeira, MD*
15
Daniela Cerqueira, 2
6
Luís Torrão, MD, 1
7
Raúl Moreira, MD, 1
8
Manuel Falcão, MD, PhD, 1,3
9
Fernando Falcão-Reis, MD, PhD, 1,3
10
João Pinheiro-Costa, MD, 1,4
11
12
*1Corresponding author: Department of Ophthalmology, Centro Hospitalar São João,
13
Porto, Portugal.
Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.
14
[email protected]; +351917860495.
15
1. Department of Ophthalmology, Centro Hospitalar São João, Porto, Portugal
16
2. Faculty of Medicine, University of Porto, Portugal
17
3. Department of Surgery and Physiology, Faculty of Medicine, University of Porto,
18
Portugal
19
4. Department of Biomedicine, Faculty of Medicine, University of Porto, Portugal
20
21
Conflict of interest: None declared.
22
Keywords: Acanthamoeba, keratitis, risk factors, prognosis factors, polymerase chain
23
reaction
24
25
Financial Disclosure: The authors declare that they received no funding to conduct
26
this work.
28
ABSTRACT
29
Purpose: To describe the risk factors, established treatment, visual outcome and to
30
establish poor prognosis predictors in patients with Acanthamoeba Keratitis (AK).
31
Methods: A retrospective analysis of 34 cases of AK diagnosed by polymerase chain
32
reaction (PCR) between march 2010 and august 2017 followed at Cornea Department
33
of Centro Hospitalar de São João. Clinical processes of these patients were reviewed,
34
and it has been collected data about demographics, visual acuity (VA), biomicroscopy,
35
therapeutics, visual outcome and complications of the disease.
36
Diagnosis was considered early if established before the first 15 days after the onset of
37
the symptoms and late if established afterwards. It was defined as poor visual outcome
38
a final best-corrected visual acuity (BCVA) ≥ 1 logarithm of minimal angle of resolution
39
(logMAR).
40
Results: A total of 34 eyes
from 29 patients, all contact lens (CL) wearers, were
41
diagnosed with AK. Concerning the BCVA
index, patients with poor visual outcome
42
were diagnosed later than those who had better results (28 [4-150] vs 14 [1-60] days;
43
p=0.01). The worst visual outcome was associated with an upper median age (37
[23-44
66] vs 33 [19-43] years; p=0.04), poorer initial VA (1,3 [0.3-2.0] vs 0.5 [0.1-2.0]
45
logMAR; p=0.02) and stromal infiltrate (41.2 vs 7.1%; p=0.03) in biomicroscopy. About
46
35% patients underwent debridement and 29% keratoplasty. Those who underwent
47
cirurgical debridment had a better visual outcome (p=0.002). Complications rate was
48
higher in patients with worse visual outcome (82.4% vs 50.0%; p=0.06).
49
Conclusion: Patients with worse final VA had a later diagnosis with worse initial VA
50
and more advanced corneal disease in biomicroscopy at admission.
51
Diagnosis and treatment of patients with AK is still a challenge, it requires a high level
52
of surmise from eye care' providers to establish an early diagnosis which is crucial for a
53
good visual outcome.
54
55
56
INTRODUCTION
57
Acanthamoeba Keratitis (AK) is recognized as an increasing cause of infectious
58
keratitis
1,2, whose etiology includes several species of Acanthamoeba genus
3,4.
These
59
free-living protozoa can be found in water, soil and water-air interface
2,5,6, with two
60
existing forms: trophozoites, the infectious form, and cysts, responsible for the disease
61
resistance.
262
With the use of contact lenses (CL) as the main risk factor
5, 7, 8, AK may also be
63
associated with corneal trauma.
5,764
The initial symptomatology is often non-specific, and may include ocular pain
65
associated with photophobia, foreign body sensation and tearing.
6,8In addition, more
66
characteristic signs, such as radial neuritis, aren’t always present.
1,7In the early
67
stages, is frequent the formation of a dendritic pattern, resulting from the organization
68
of linear intraepithelial infiltrates, which is easily confused by signs of Herpes simplex
69
virus
8, and in later stages, there are characteristic ring infiltrates, which are only
70
present in about 50% of patients.
6All these characteristics can make AK difficult to
71
diagnose, which leads to a delayed onset of the treatment and to a worse prognosis.
72
The diagnosis of AK implies the identification of the etiological agent in the corneal
73
scrapings and biopsy specimens
8, by cultural exam, that remains the gold-standard
74
diagnostic examination.
5More recently, new diagnostic tools have emerged, such as
75
confocal microscopy, that can be perfomed in vivo
5, however it is expensive and
76
requires an experienced operator.
3The polymerase chain reaction (PCR) testing is
77
also a good alternative diagnostic exam, since it has a high sensitivity and is faster
78
than the cultural exam to identify the agent’s DNA and it is operator independent.
979
The AK treatment is challenging. An incomplete understanding of the pathophysiology
80
of the disease
10and, mainly, the treatment resistance caused by cysts
6are recognized
81
as treatment obstacles. Moreover, the use of steroids seems to degrade the prognosis
82
of the disease.
6,7There is no specific treatment described for AK
6,11, however there
83
are some therapy regimens that can be used as the biguanides (they act at the
84
membrane and include polyhexamethylene biguanide and chlorhexidine) or the
85
diamines (inhibitors of DNA synthesis, include propamidine, hexamidine and
86
pentamidine).
2,11Although there
weren’t significant differences in the efficacy of both
87
drugs, biguanides had a higher effectiveness against cystic form using lower dosage,
88
so these are generally prefered. In more severe cases or when medical therapy is not
89
sufficient, debridement, penetrating keratoplasty or even amniotic membrane
90
transplantation may be used.
291
Treatment is time consuming and complicated and a close follow-up is required to
92
assess the appearance of complications, ranging from ulcers or even corneal
93
perforation to blindness and enucleation.
894
The present dissertation aims to describe the risk factors, established treatment, visual
95
outcome and to establish poor prognosis predictors in patients with positive PCR for
96
Acanthamoeba followed at the Cornea Department on Centro Hospitalar de São João.
97
98
METHODS
99
We performed a retrospective analysis of all suspected cases of AK that undergone
100
PCR screening for Acanthamoeba at Centro Hospitalar de São João, a tertiary
101
ophthalmologic centre in Porto, Portugal, between march 2010 and august 2017.
102
Of the 127 suspected cases analyzed, those that were positive and followed in our
103
Ophthalmology Cornea Department were described.
104
Clinical files of these patients were consulted and information about demographic data,
105
visual acuity (VA), clinical presentation symptoms, biomicroscopy findings,
106
therapeutics, visual outcome and complications of the disease were collected. VA was
107
recorded by the Snellen chart and converted logarithm of minimal angle of resolution
108
(logMAR) units for statistical analysis.
109
Diagnosis was considered early if established before the first 15 days after the onset of
110
the symptoms and late if established afterwards. It was defined as bad visual prognosis
111
a final best-corrected visual acuity (BCVA) ≥ 1 logMAR.
112
All patients described were followed and treated continuously by Corneal Specialists of
113
Hospital São João Cornea Department (LT, RM and JPC). All surgeries (epithelial
114
debridement, cataract surgery, glaucoma surgery and corneal transplant) were
115
performed in operating room, in an out-patient basis. Epithelial debridement (with 20%
116
ethanol-balanced salt solution applied on corneal surface for 30 seconds) was
117
performed as a therapeutic procedure in patients without advanced disease.
118
Chlorhexidine and propamidine eye drops were always delivered by the outpatient
119
pharmacy of the Hospital São João.
120
Statistical analysis was performed using the SPSS® statistical software (version 21.0
121
for Mac OS; SPSS Inc., Chicago, IL., USA). Parametric or non-parametric tests were
122
used for continuous variables comparison between groups, according to the normality
123
of data. Chi2 or Fisher´s exact tests were performed for categorical variables
124
comparison. Statistical significance for all the analyses was set at a P value less than
125
0.5.
126
The tenets of the Declaration of Helsinki were followed and local Ethics Committee
127
approval was obtained.
128
129
RESULTS
130
Among 127 cases with AK suspect, 54 cases (43%) were confirmed by positive PCR
131
for Acanthamoeba. From those, only 34 cases were followed in our Ophthalmology
132
Cornea Department. The other 20 positive cases were patients referred by other
133
centers only to perform the PCR analysis in suspected cases. Between 2015 and 2017,
134
number of AK cases has doubled per year (figure 1).
135
Table 1 presents demographic and clinical characteristics of the analyzed patients. A
136
total of 34 eyes from 29 patients were diagnosed with AK, from those 18 (67.6%) were
137
females. The average age was 35.5 ± 13.4 years. In 5 patients, both eyes were
138
affected (n=10, 29.4%). All patients were CL wearers that did not complied
with its
139
hygiene and safety measures, and in 2 cases there was stagnant water exposure. The
140
median time from symptoms onset to diagnosis was 22 days, ranging from 1 to 150
141
days. From the 32 cases with available information (2 missing data), 13 (40.6%) were
142
diagnosed early (until 15 days from symptoms onset) and 19 (59.4%) were late
143
diagnosis (more than 15 days from symptoms onset). An initial diagnosis was
144
described in 32 cases, from those only 2 cases (6.3%) were at first diagnosed with AK.
145
The other initial diagnosis included acute conjunctivitis (n=4, 12.5%), herpetic
146
keratitis/ulcer (n=14, 43.8%), bacterial keratitis/ulcer (n=9, 28.1%) and fungal
147
keratitis/ulcer (n=3, 9.4%). In 22 eyes (64.7%) it was been used a topic corticoid before
148
AK diagnosis.
149
Symptoms at admission included eye redness (100%), eye pain (68%), photophobia
150
(38%), blurred vision (15%), foreign body sensation (12%) and tearing (3%).
151
In biomicroscopy, the most common finding were punctate keratophaty (32%),
152
epithelial defect (29%), ring infiltrate (29%), pseudodendritic defect (24%), stromal
153
infiltrate (24%), ring ulcer (21%) and epithelial/subepithelial infiltrate (12%).
154
The final BCVA was ≥ 1 logMAR in 55% of the cases and smaller than 1 logMAR in
155
45%. Table 2 presents a comparison between cases with good visual outcome (BCVA
156
<1 logMAR) and cases with poor visual outcome (BCVA
≥ 1logMAR). Those whose
157
visual outcome was poorer had an upper median age (37 [23-66] vs 33 [19-43] years;
158
p=0.04)
. Furthermore, the cases with BCVA ≥ 1logMAR had a longer time from
159
symptoms onset to diagnosis than the cases with good visual outcome (28 [4-150] vs
160
14 [1-60] days; p=0.01). Early diagnosis was associated with a better outcome than a
161
late diagnosis (p=0,005) and
the worst visual outcome was associated with poorer
162
initial VA (1.3 [0.3-2.0] vs 0.5 [0.1-2.0] logMAR; p=0.02). There were no significant
163
differences in the gender and in the administration pre-diagnosis of corticoid therapy
164
between cases with final BCVA
≥ 1logMAR and those with final BCVA < 1 logMAR.
165
Concerning the biomicroscopy findings at admission, described on table 2, stromal
166
infiltrate was significantly more common in patients with a poorer visual outcome (41.2
167
vs 7.1%; p=0.03).
168
Treatment and outcomes
169
Among the patients with available information about AK treatment, 1 case (3.3%) was
170
prescribed with chlorhexidine, 6 cases (20%) were prescribed with propamidine and in
171
23 cases (76.7%) it was administered a combination of chlorhexidine and propamidine.
172
Concerning the different medical therapies, there were no significant differences in the
173
final BCVA of these patients.
174
About 35% patients (n=12) underwent epithelial debridement, this therapy was
175
associated with a better visual outcome (p=0.002). Keratoplasty was performed in 10
176
cases (29.4%), 7 of that (70%) for control of infection and 3 cases (30%) to resolve a
177
central corneal opacity involving the visual axis. Regarding the type of keratoplasty, 9
178
cases underwent penetrating keratoplasty and 1 case was submitted to deep anterior
179
lamelar keratoplasty (DALK). There were no significant differences in the final BCVA
180
between patients that had been submitted to keratoplasty and those that hadn’t been,
181
nor there was a significant difference in the visual outcome towards the type of
182
keratoplasty.
183
Figure 2 shows the main complications found, being the most frequent ocular
184
hypertension (42.4%) and cataract (42.4%). Complications rate was higher in patients
185
with worse visual outcome (82.4% vs 50.0%; p=0.06). At table 3, it’s shown that ocular
186
hypertension (21.4% vs 64.7%; p=0.016), leukoma (21.4% vs 64.7%; p=0.016), vitritis
187
(0% vs 23.5%; p=0.05), ocular perforation (0% vs 35.3%; p=0.01) and enucleation (0%
188
vs 47.1%; p=0.003) were complications significantly more frequent in patients with final
189
BCVA ≥ 1logMAR.
190
191
DISCUSSION
192
This study describes a series of 34 cases of AK diagnosed by a positive PCR for
193
Acanthamoeba between march 2010 and august 2017 followed at Cornea Department
194
of Centro Hospitalar de São João. All cases were CL wearers, eye pain was the more
195
frequent symptom and patients’ age was a bad prognosis predictor. Also we found an
196
increasing incidence of this pathology at this centre. Moreover, patients with worse final
197
VA had a later diagnosis with worse initial VA and more advanced corneal disease in
198
biomicroscopy at admission. In this group, the incidence of complications was higher.
199
AK is a rare sight-threatening pathology with a worldwide increasing frequency,
200
incidence rate ranging from 1 to 33 cases per million between CL wearers
12, mainly
201
due to a CL use augment
6,13Our study verifies the proposed increasing rate of this
202
disease, also described in case series from China, New Zealand and Singapore
1,14,15,
203
although a decreasing frequency in other centers was also registed.
3In developed
204
countries, CL is established as the main risk factor for AK
2,3,16, specially in users with
205
poor
lens’ hygiene measures
17, and it was present in all our patients. Ocular trauma
206
and exposure to contaminated water are also important risk factors for AK
2,17, however
207
only 2 cases reported an exposure to stagnant waters, without ocular trauma reported.
208
There is no targeted age for development of AK
1, although it is more frequent in young
209
or middle-aged patients.
1,2In our study, patients age ranged from 19 to 66 years old,
210
with a median age of 35.5 ± 13.4 years, similar to other smaller portuguese’ case
211
series.
2Nevertheless, we found a significant worst visual outcome in older patients,
212
with a median age of 37 years, when compared with younger cases, also related in
213
other studies.
7This correlation between an upper age and poorer prognosis could
214
result from a higher susceptibility to infection due to the presence of more
215
comorbidities
18and a different immune response
19or from a
CL’ use longer than the
216
recommended period.
7217
An initial diagnosis of AK only occurred in 6.3% of our sample (2 cases) and this low
218
percentage may be due to a low familiarity with AK among the health care providers
7or
219
even because the initial symptoms, including eye redness (100%), eye pain (68%) and
220
photophobia (38%) are not specific and could be confused with other etiology keratitis.
2221
We found that stromal infiltrate was significantly more common in patients with a poorer
222
visual outcome and, in these patients, there was a tendency to have ring infiltrates.
223
These signs are characteristic of an advanced stage of the disease
3, 8, and a
224
multivariate analysis had shown that deep stromal involvement or the presence of a
225
ring infiltrate at presentation was independently associated with worse visual
226
outcomes.
20227
In agreement with Chew et al
21, we found that a poorer initial VA was associated with a
228
worst visual outcome. These patients have a higher probability of a severe and
229
prolonged disease period.
22230
The median time from symptoms onset to diagnosis was 22 days, and 19 cases
231
(59.4%) had a late diagnosis. This fact could be due to a mixture of an unspecific
232
presentation
7that leads to a wrong initial diagnosis, the lack of awareness for disease
233
from eye care providers
7or even because CL wearers typically seek medical help late.
6234
Furthermore, we found that delayed diagnosis was associated with a poorer visual
235
prognosis, like described in previous studies.
7Also, in accordance with many studies
3,236
14, 17, 23, an early diagnosis was associated with a better outcome. An early diagnosis is
237
essential to an early and adequate treatment. Claerhout et al
23had shown that a delay
238
of less than 18 days from onset of symptoms and start of AK treatment results in a
239
better final BCVA. Patients with a worse prognosis had a higher incidence rate of
240
complications, like ocular hypertension, leukoma, vitritis, ocular perforation and
241
enucleation, perhaps given the prolonged disease.
242
Topical corticosteroids use in the AK remains controversial. Although some authors
243
advocate steroids can be used for management of the pain, discomfort or severe
244
inflammation
24, it seems to suppress immune response of the patient and to augment
245
Acanthamoeba resistance, beyond that some studies concluded that its use is
246
predictive of a poorer visual prognosis.
25In our sample, 22 eyes (64.7%) were
247
medicated with a topical corticoid before AK diagnosis and we
didn’t find significant
248
differences between god and bad visual outcomes.
249
An early-stage epithelial debridement may be a valuable therapeutic weapon
17, since
251
study, 12 eyes (35%) were submitted to this treatment and it was associated with a
252
better visual outcome.
253
During this study we found several limitations. Our sample was small and it can limit
254
strong conclusions of our study. Although we had detected cases from several centers,
255
we only analyzed patients followed in our Ophthalmology Cornea Department,
256
constricting the sample size, and possibly not reflecting the demographic and clinical
257
characteristics of other centers’ population, this may anticipate an inadequate external
258
validity. Moreover, given this is a retrospective study and it were only available the
259
clinical files, in some cases we had missing data.
260
In conclusion, the bad prognosis was associated with an upper median age,
a later
261
diagnosis, with worse initial VA and a more advanced corneal disease in biomicroscopy
262
at admission. Diagnosis and treatment of patients with AK is still a challenge, it requires
263
a high level of surmise from eye care' providers to establish an early diagnosis which is
264
crucial for a good visual outcome.
265
266
ABBREVIATIONS
267
AK: Acanthamoeba Keratitis
268
PCR: Polymerase Chain Reaction
269
VA: Visual Acuity
270
BCVA: Best-Corrected Visual Acuity
271
LogMAR: Logarithm of Minimal Angle of Resolution
272
CL: Contact Lens
273
LT: Luís Torrão
274
RM: Raúl Moreira
275
JPC: João Pinheiro-Costa
276
DALK: Deep Anterior Lamelar Keratoplasty
277
279
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280
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341
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343
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345
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347
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FIGURE LEGENDS
360
361
Figure 1: Number of Acanthamoeba Keratitis (AK) cases per year from 2010 to 2017.
362
Table 1:
Patients’ demographic and clinical characteristics (n=34).
363
Table 2: Comparison between cases with best-corrected visual acuity (BCVA) < 1
364
logarithm of minimal angle of resolution (logMAR) – good prognosis – and cases with
365
BCVA ≥ 1logMAR – poor visual outcome – in terms of demographic and clinical
366
characteristics; VA: Visual Acuity.
367
Table 3: Comparison between cases with BCVA < 1 logMAR
– good prognosis – and
368
cases with BCVA
≥ 1logMAR – poor visual outcome – in terms of treatment and
369
complications; DALK: Deep Anterior Lamelar Keratoplasty.
370
Figure 2: AK-related observed complications.
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
Number of cases 8 7 6 5 4 3 2 1 0 12 10 8 6 4 2 0Number of cases
Clinical features (n=14) (%) Female gender 18 (67,6) Age (years) 35,5 ± 13,4 Laterality - Right eye 34 (100) - Left eye 2 (6,0) - Bilateral 0 (0) Risk factors
- Contact lens wear 34 (100) - Exposure to stagnant water 2 (6,0) - History of corneal traumatism 0 (0)
Time from symptoms onset to diagnosis (days) 22 [1-150] Diagnosis - Early (≤15 days) - Late (>15 days) 13 (40,6) 19 (59,4) Initial diagnosis - Acute conjunctivitis 4 (12,5) - Herpetic keratitis/ulcer 14 (43,8) - Bacterial keratitis/ulcer 9 (28,1) - Fungal keratitis/ulcer 3 (9,4) - Acanthamoeba keratitis/ulcer 2 (6,3) Prediagnosis topic corticoid 22 (64,7)
407
408
409
410
BCVA <1 (n=14) (%) BCVA ≥1 (n=17) (%) p Male gender 3 (21,4) 6 (35,3) 0,39 Age (years) 33 [19-43] 37 [23-66] 0,04
Time from symptoms onset to diagnosis (days) 14 [1-60] 28 [4-150] 0,01 Diagnosis - Early - Late 10 (71,4) 4 (28,6) 3 (20) 12 (80) 0,005 Initial VA (logMAR) 0,5 [0,1-2,0] 1,3 [0,3-2,0] 0,02 Initial corticoid 10 (71,4) 10 (58,8%) 0,47 Biomicroscopy - Epithelial/subepithelial infiltrate 1 (7,1) 1 (5,9) 0,89 - Punctate keratopathy 6 (42,9) 4 (23,5) 0,25 - Perineuritis 1 (7,1) 0 (0) 0,26 - Epithelial defect 2 (14,3) 7 (41,2) 0,10 - Pseudodendritic defect 5 (35,7) 2 (11,8) 0,11 - Stromal infiltrate 1 (7,1) 7 (41,2) 0,03 - Ring infiltrate 1 (7,1) 6 (35,3) 0,06 - Ring ulcer 2 (14,3) 4 (23,5) 0,52 - Hypopyon 0 (0) 2 (11,8) 0,19 - Scleritis 0 (0) 1 (5,9) 0,36
412
413
414
415
416
417
BCVA <1 (n=14) (%) BCVA≥1 (n=17) (%) p Treatment - Chlorhexidine 1 (8,3) 0 (0) - Propamidine 1 (8,3) 5 (29,4) 0,22 - Chlorhexidine+Propamidine 10 (83,3) 12 (70,6) Epithelial debridement 9 (64,3) 2 (11,8) 0,002 Keratoplasty - Yes 3 (21,4) 7 (41,2) 0,24 - No 11 (78,6) 10 (58,8) Motive of keratoplasty - Terapeutic 2 (66,7) 5 (71,4) 0,88 - Optic 1 (33,3) 2 (28,2) Type of keratoplasty - Penetrating 3 (100) 6 (85,7) 0,49 - DALK 0 (0) 11 (14,3) Complications 7 (50) 14 (82,4) 0,06 - Cataract 3 (21,4) 11 (64,7) 0,016 - Ocular hypertension 3 (21,4) 11 (64,7) 0,016 - Leukoma 4 (28,6) 1 (5,9) 0,09 - Vitritis 0 (0) 4 (23,5) 0,05 - Phtisis 0 (0) 2 (11,8) 0,19 - Ocular perfuration 0 (0) 6 (35,3) 0,01 - Enucleation 0 (0) 8 (47,1) 0,003
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419
420
421
422
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424
425
426
427
428
429
430
431
432
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434
435
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438
Cataract Vitritis Phtisis Ocular hypertension Central/Paracentral leukoma Perfuration Enucleation 6,1% 12,1% 15,3% 18,2% 24,2% 42,4% 42,4%Cornea
Online Submission and Review System SCOPE
Cornea is a peer reviewed, scientific journal for the submission of original manuscripts describing clinical observations, clinical trials, basic investigation with clinical applicability, and unique and important case reports related to diseases of and medical and surgical treatment of the cornea and external eye.
Ethical/Legal Considerations
Originality and validity of manuscript
A submitted manuscript must be an original contribution not previously published (except as an abstract or preliminary report), must not be under consideration for publication elsewhere, and, if accepted, must not be published elsewhere in similar form, in any language, without the consent of Lippincott Williams & Wilkins. Although the editors and reviewers make every effort to ensure the validity of published manuscripts, the final responsibility rests with the authors, not with the Journal, its editors, or the publisher.
Author’s Role
Each person listed as an author is expected to have participated in the study to a significant extent. Cornea abides by the Authorship Criteria as set by the International Committee of Medical Journal Editors. Please visit http://www.icmje.org/index.html to review the criteria and to determine whether contributors should be listed as authors or be listed in the acknowledgments. Patient anonymity and informed consent
It is the author's responsibility to ensure that a patient's anonymity is carefully protected. For photographs or videos, the author must obtain written and signed permission from the patient if the patient could be recognizable.
Compliance with NIH and Other Research Funding Agency Accessibility Requirements A number of research funding agencies require or request authors to submit the post-print (the article after peer review and acceptance but not the final published article) to a repository that is accessible online by all without charge. As a service to our authors, LWW will identify to the National Library of Medicine (NLM) articles that require deposit and will transmit the post-print of an article based on research funded in whole or in part by the National Institutes of Health, Wellcome Trust, Howard Hughes Medical Institute, or other funding agencies to PubMed Central. The revised Copyright Transfer Agreement provides the appropriate mechanism. Permissions
Authors must submit written permission from the copyright owner (usually the publisher) to use direct quotations, tables, or illustrations that have appeared in copyrighted form elsewhere, along with complete details about the source. Any permission fees that might be required by the copyright owner are the responsibility of the authors requesting use of the borrowed material, not the responsibility of Lippincott Williams & Wilkins.
Copyright
on the disclosure of potential conflicts of interest based on the recommendations of the International Committee of Medical Journal Editors, "Uniform Requirements for Manuscripts Submitted to Biomedical Journals" (www.icmje.org/update.html).
Copyright forms are collected electronically. The Additional Information submission step will lead you through the process.
A copy of the form is made available to the submitting author within the Editorial Manager submission process. Co-authors will automatically receive an Email with instructions on completing the form upon submission of the manuscript.
You may edit a co-author's E-mail address if you receive an undeliverable E-mail, view their Form responses, or Resend the verification form to your co-authors via the 'Author Status' action item in your 'Submissions Being Processed' or 'Revisions Being Processed' folders. Conflicts of Interest
Authors must state all possible conflicts of interest in the manuscript, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest. If there is no conflict of interest, this should also be explicitly stated as none declared. All sources of funding should be acknowledged in the manuscript. All relevant conflicts of interest and sources of funding should be included on the title page of the manuscript with the heading “Conflicts of Interest and Source of Funding:” For example:
Conflicts of Interest and Source of Funding: A has received honoraria from Company Z. B is currently receiving a grant (#12345) from Organization Y, and is on the speaker’s bureau for Organization X – the CME organizers for Company A. For the remaining authors none were declared.
TYPES OF SUBMISSIONS
(Note: All Submissions Should be Succinct)
Basic Investigation: Laboratory studies related to the Cornea and having direct or indirect clinical importance.
Book Review: Limited to subject matter of the journal and are published on-line only. Books for review should be sent to Mark Mannis, MD, at: 4860 Y St, #2400, Sacramento, CA 95817-2307 Case Report: Should report new and important findings and should be limited to no more than 3 or 4 typescript pages, be limited to 10 references, and use only one or two high quality photographs. These are not strict rules, but suggestions.
Clinical Science: Should report well done clinical studies. Studies should be approved by an appropriate ethical committee/Institutional Review Board and adhere to the principles of the Declaration of Helsinki. Where appropriate, clinical trials should be registered with clinicaltrials.gov and the registration number included in the manuscript.
Editorial: The journal does not accept unsolicited editorials. If you are contemplating writing an editorial, please check with the Editor.
Letter to Editor: Readers’ comments on previously published articles in the Journal. Letters to the Editor should be limited in length and references.
Review: Should be on topics important to the field. Please check with the Editor to discuss potential topics.
Technique: Should succinctly describe new methods and include appropriate illustrations. Preparation and Submission of the Manuscript
The journal requires ALL manuscripts and illustrations to be submitted via our online submission site at http://www.editorialmanager.com/cornea/. We will NOT accept hard copy manuscript submission or submissions received by email or CD. Manuscripts that do not adhere to the following instructions will be returned to the corresponding author for technical revision before undergoing peer review.
General Format
All manuscripts must be submitted in English and double-spaced for all copy, including legends, footnotes, tables, and references. Use the automatic page
numbering and continuous line numbering functions. Please clearly label every file name to
correspond with content (e.g. Main Manuscript, Figure 1, Table 1, etc). Title page
Include:
Complete manuscript title Full author names
Academic degrees (e.g. PhD, MD)
Affiliations of all authors including city and country
Postal address, email address, and telephone number of the corresponding author
Conflict of interest statement (if there is no Conflict to disclose, please state so on the title page) 3-5 keywords
Disclosure of any funding received for this work – Please clearly identify if your research was funded from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); and other(s)
Please specify if the corresponding author is different from the author who is to receive reprints. Abstract
A structured abstract is required in 2 places: at the beginning of the submission process, where requested; and in the manuscript, following the title page.
It should include sections for purpose, methods, results and conclusion and is limited to 250- word count.
Text
Organize the manuscript into four main headings: Introduction, Materials and Methods, Results, and Discussion. A conclusion section should not be included. Define abbreviations at first mention in text and in each table and figure. If a brand name is cited, supply the manufacturer's name and address (city and state/country). Acknowledge all forms of support, including pharmaceutical and industry support, in an Acknowledgments paragraph.
Abbreviations
Write out the full term for each abbreviation at its first use unless it is a standard unit of measure.
References
The authors are responsible for the accuracy of the references. Key the references (double- spaced) at the end of the manuscript. Cite the references in the text in the order of appearance using superscripts. Cite unpublished data, such as papers submitted but not yet accepted for publication or personal communications, in parentheses in the text. If there are more than three authors, name only the first three authors and then use et al. Refer to the List of Journals Indexed in Index Medicus for abbreviations of journal names, or access the list at http://www.nlm.nih.gov/tsd/serials/lji.html.
Sample references are given below:
Journal article
1. Terry MA. The evolution of lamellar grafting techniques over twenty-five years. Cornea 2000;19:611-616.
Book chapter
2. Pels E, Beekhuis WH, Volker-Dieben HJ. Long-term tissue storage for keratoplasty. In: Brightbill FS, ed. Corneal surgery. Theory, technique, and tissue. St. Louis: Mosby, 1999:897.906.
Entire book
3. Brightbill FS, ed. Corneal surgery. Theory, technique, and tissue. St. Louis: Mostby, 1999.
Software
4. Epi Info [computer program]. Version 6. Atlanta: Centers for Disease Control and Prevention; 1994.
Online journals
5. Friedman SA. Preeclampsia: a review of the role of prostaglandins. Obstet Gynecol [serial online]. January 1988; 71:22.37. Available from: BRS Information Technologies, McLean, VA. Accessed December 15, 1990.
Database
6. CANCERNET-PDQ [database online]. Bethesda, MD: National Cancer Institute; 1996. Updated March 29, 1996.
Internet
7. Gostin LO. Drug use and HIV/AIDS [JAMA HIV/AIDS web site]. June 1, 1996. Available at: http://www.ama-assn.org/special/hiv/ethics. Accessed June 26, 1997.
Figures
A) Creating Digital Artwork
1. Learn about the publication requirements for Digital Artwork: http://links.lww.com/ES/A42
2. Create, Scan, and Save your artwork and compare your final figure to the Digital Artwork Guideline Checklist (below).
3. Upload each figure to Editorial Manager in conjunction with your manuscript text and tables. B) Digital Artwork Guideline Checklist
Here are the basics to have in place before submitting your digital artwork:
Artwork should be saved as TIFF, EPS, or MS Office (DOC, PPT, XLS) files. High resolution PDF files are also acceptable.
Crop out any white or black space surrounding the image.
Diagrams, drawings, graphs, and other line art must be vector or saved at a resolution of at least 1200 dpi. If created in an MS Office program, send the native (DOC, PPT, XLS) file. Photographs, radiographs and other halftone images must be saved at a resolution of at least
300 dpi.
Photographs and radiographs with text must be saved as postscript or at a resolution of at least 600 dpi.
Each figure must be saved and submitted as a separate file. Figures should not be embedded in the manuscript text file.
Remember
Cite figures consecutively in your manuscript using superscripts.
Number figures in the figure legend in the order in which they are discussed.
Upload figures consecutively to the Editorial Manager web site and enter figure numbers consecutively in the Description field when uploading the files.
Figure Legends
Legends must be submitted for all figures. They should be brief and specific, and they should appear on a separate manuscript page after the references. Use scale markers in the image for electron micrographs, and indicate the type of stain used.
Color Figures
Authors may choose to pay to publish color figures in the print issue of the journal. There is a per figure color charge. At the proof stage, authors will be given the option to choose to pay for color in print. If an author does not want to pay for color, the publisher will convert the images for print to black and white for free. All color figures will appear in the online version of the article at no cost to the author.
Tables
Each table must be saved and submitted as a separate word doc file. Tables should not be embedded in the manuscript text file. Please do not upload images of tables. All tabular matter must be editable. An image of a table, such as a scan, is not acceptable for publication. Cite tables consecutively in the text and number them in that order. They should be self-explanatory and should supplement, rather than duplicate, the material in the text
Supplemental Digital Content (SDC)
Authors are encouraged to submit supplemental digital content to enhance their article's text and to be considered for online posting only. Supplemental digital content may include as the following types of content: text documents, graphs, tables, figures, graphics, illustrations, audio, and video. Cite all supplemental digital content consecutively in the text. Citations should include the type of material submitted, should be clearly labeled as "Supplemental Digital Content," should include a sequential number, and should provide a brief description of the
supplemental content. Provide a legend of supplemental digital content at the end of the text. List each legend in the order in which the material is cited in the text. The legends must be numbered to match the citations from the text. Include a title and a brief summary of the content. Authors must get written and signed permission from patients if the patient would be recognizable. Copyright and Permission forms for article content including supplemental digital content must be completed at the time of submission. If an article with SDC is accepted, our production staff will create a URL with the SDC file. The URL will be placed in the call-out within the article. SDC files are not copyedited by LWW staff, they will be presented digitally as submitted.
Supplemental Digital Content Size & File Type Requirements
To ensure a quality experience for those viewing supplemental digital content, it is suggested that authors submit supplemental digital files no larger than 10 MB each. Documents, graphs, and tables may be presented in any format. Figures, graphics, and illustrations should be submitted with the following extensions: .tif, .eps, .ppt, .jpg, .gif.
Supplemental Video and Audio Guidelines MP4 Video Format
This document provides general guidelines for encoding videos to MP4. All video destined for the journals platform MUST be encoded in MP4 Video (.mp4) format. This format allows for embedded, streaming playback through the journal website and also works on iOS and Android mobile devices.
H.264 Video Codec
Video should be encoded using the H.264/Advanced Video (AVC) codec with the extension as (.mp4). H.264 is an excellent codec for desktop video and can be played in wide variety of mobile browsers including the iPhone/iPod/iPad and Android. Its compression quality is better than any other widely available codec on the market, meaning that at the same bitrate, a H.264 video will generally look better than a video in another codec (and conversely, at the same visual quality, a H.264 file will generally be smaller).
MP3 Audio Codec
Audio should be encoded using the MPEG Layer III (MP3) codec. Videos with people talking and no music can be encoded in mono. Videos using music should be encoded in stereo. File Size
Stand Alone
For standalone video that will be posted in the video gallery video size should be limited to (1) GB in size. Given the encoding recommendation for 1280x720, this would allow for around 45 minutes of video. It is advised to break videos more than 45 minutes into multiple parts for the best user experience.
SDC
For Supplemental Digital Content (SDC) video size should be limited to (100) MB in size. For more information, please review LWW's requirements for submitting supplemental digital content: http://links.lww.com/A142.
Style
Pattern manuscript style after the American Medical Association Manual of Style (10th edition). Refer to drugs and therapeutic agents by their accepted generic or chemical names, and do not abbreviate them. Use code numbers only when a generic name is not yet available. In that case, supply the chemical name and, if appropriate, a figure giving the chemical structure of the drug. Capitalize the trade names of drugs and place them in parentheses after the generic names. To comply with trademark law, include the name and location (city and state in USA; city and country outside USA) of the manufacturer of any drug, supply, or equipment mentioned in the manuscript. Use the metric system to express units of measure and degrees Celsius to express temperatures, and use SI units rather than conventional units.
For enquiries regarding submission of your manuscript
Please contact the Production Coordinator, Leslie Burke at: [email protected] or (703) 591-2220.
Open Access
LWW’s hybrid open access option is offered to authors whose articles have been accepted for publication. With this choice, articles are made freely available online immediately upon publication. Authors may take advantage of the open access option at the point of acceptance to ensure that this choice has no influence on the peer review and acceptance process. These articles are subject to the journal’s standard peer-review process and will be accepted or rejected based on their own merit.
Authors retain copyright
Authors retain their copyright for all articles they opt to publish open access. Authors grant LWW a license to publish the article and identify itself as the original publisher.
Creative Commons license
Articles opting for open access will be freely available to read, download and share from the time of publication. Articles are published under the terms of the Creative Commons License Attribution-NonCommerical No Derivative 3.0 which allows readers to disseminate and reuse the article, as well as share and reuse of the scientific material. It does not permit commercial exploitation or the creation of derivative works without specific permission. To view a copy of this license visit: http://creativecommons.org/licenses/by-nc-nd/3.0.
Compliance with NIH and Other research funding agency accessibility requirements A number of research funding agencies now require or request authors to submit the post-print (the article after peer review and acceptance but not the final published article) to a repository that is accessible online by all without charge. As a service to our authors, LWW identifies to the National Library of Medicine (NLM) articles that require deposit and transmits the post-print of an article based on research funded in whole or in part by the National Institutes of Health, Wellcome Trust, Howard Hughes Medical Institute, or other funding agencies to PubMed Central. The revised Copyright Transfer Agreement provides the mechanism. LWW ensures that authors can fully comply with the public access requirements of major funding bodies
worldwide. Additionally, all authors who choose the open access option will have their final published article deposited into PubMed Central.
FAQ for open access
http://links.lww.com/LWW-ES/A48
After Acceptance
Electronic Page Proofs and Corrections
Corresponding authors will receive electronic page proofs to check the copyedited and typeset article before publication. Portable document format (PDF) files of the typeset pages and support documents (such as the reprint order form) will be sent to the corresponding author by e-mail.
Complete instructions will be provided with the e-mail for downloading and printing the files and for faxing or e-mailing the corrected page proofs to the publisher.
It is the author's responsibility to ensure that there are no errors in the proofs. Changes that have been made to conform to journal style will stand if they do not alter the authors' meaning. Only the most critical changes to the accuracy of the content will be made. Changes that are stylistic or are a reworking of previously accepted material will be disallowed. The publisher reserves the right to deny any changes that do not affect the accuracy of the content. Authors may be charged for alterations to the proofs beyond those required to correct errors or to answer queries. Proofs must be checked carefully and corrections faxed within 24 to 48 hours of receipt, as requested in the cover letter accompanying the page proofs.
Reprints
Authors will receive a reprint order form with the electronic page proofs that includes reprint costs. Reprint requests should be faxed with the corrected proofs, if possible. Reprints are normally shipped 6 to 8 weeks after publication of the issue in which the item appears. Contact the Reprint Department, Lippincott Williams & Wilkins, 351 W. Camden Street, Baltimore, MD 21201; Fax: (410) 528-4434; E-mail: [email protected] with any questions.
Publisher's contact
E-mail corrected page proofs, reprint order form, and any other related materials to Aidan Derrico, E-mail: [email protected]
Eye pain Photophobia
Foreign body sensation Eye redness Blurred vision Tearing 12% 3% 15% 38% 68% 100%
APPENDIX
Figure 3: Initial symptoms of patients
Figure 4: Initial signs in biomicroscopy
Epithelial/subepithelial infiltrate Punctate keratopathy
Perineuritis Epithelial defect
Pseudodendritic defect Stromal infiltrate
Ring infiltrate Ring ulcer
Hypopyon Scleritis 3% 6% 3% 12% 21% 24% 24% 29% 29% 32%
