O regon M. Eric Y, Vanzzini Z. Virginia, Sierra A. Antonio, Zand
H. Igal M, Moreno A. Gilberto, Naranjo T. Ramn Cornea &
Refractive Surgery department, Asociacin para evitar la ceguera en
Mxico A.P.E.C. Universidad Nacional Autnoma de Mxico U.N.A.M. The
first author of this poster received travel expense reimbursement
by SIFI laboratories Mxico. Off label use of topical netilmicine
for Acanthamoeba keratitis. N ETILMICINE AS A TREATMENT FOR A
CANTHAMOEBA KERATITIS : THREE CASES Slide 2 I NTRODUCTION The
standard treatment for Acanthamoeba keratitis includes clorhexidine
and/or propamidine Isethionate and aminoglucosides such as
Neomicyn. Together with oral Itraconazole and topical antifungals.
However none of this treatments have proven total efficiency and
Acanthamoeba keratitis is still a serious corneal disease. John
Thomas, Lin J, Sahm DF. Ann Ophthalmol 1990; 22:20-23 Ishibashi Y,
Matsumoto J, Katata T et al. Am Jour Ophthalmol 1990; 109: (2)
121-126 Bang S, Edell E, Eghrari AO, Gottsch JD. Treatment with
voriconazole in 3 eyes with resistant Acanthamoeba keratitis. Am J
Ophthalmol. 2010 Jan;149(1):66-9. Epub 2009 Oct 28 Slide 3 P URPOSE
To report 3 cases of Acanthamoeba keratitis succesfully treated
with a combination of topical Netilmicine (Netira- SIFI Lab.
Sicilly Italy), Polimixin, Neomycin and Gramicidin ( Polixin- Grin
Mexico city) with oral Itraconazole (Isox -Senosiain Mexico). Pre-
treatment End of follow up Slide 4 M ATERIAL & M ETHODS Corneal
samples were taken and cultured in NN agar with a lived
Enterobacter cloacae layer. The cultures were positive for
Acanthamoeba castellani. Photographs were taken on their 1st visit
and 3 months final follow up. Susceptibility by dilution method to
Netilmicine (Netromycin) was done. Slide 5 Case 1: Case 1: 19 year
old female Bilateral ocular pain She wore her contact lenses during
the previous 24 hrs. Visual acuity OD 20/400, OS 20/800.
Conjunctival hyperemia, cornea on the right eye with diffuse
edema.Cornea on the left eye with a ring and perineural
infiltrates. Initial diagnosis: herpetic keratitis vs Acanthamoeba
keratitis. Initial treatment: Aciclovir 400 mg 5 times a day and
moxifloxacin t.i.d. with no improvement within 72 hrs. Topical
netilmicine q.i.d. is added. 1 week later visual acuity 20/200 both
eyes, less pain, less perineural infiltrate. Clinical diagnosis:
Acanthamoeba keratitis. Cultures: Acanthamoeba castellani on both
corneal samples. Final treatment: Topical Netilmicine every 2
hours, polimixin B/neomycin/gramicidin every 3 hours and oral
itraconazole 200 mg b.i.d. 6 weeks later: no pain, visual acuity
20/25 OD and 20/50 OS, perineural infiltrate on left eyes continues
but is dissapearing. 3 months later: best corrected visual acuity
20/20 on both eyes, faint haze (this are the images on 2nd slide).
Slide 6 Slide 7 Case 2: Case 2: 30 year old female comes with
ocular pain, low visual acuity and photophobia. She wore her
contact lenses during the previous 72 hrs. Visual acuity 20/100.
Palpebral edema, conjunctival hyperemia, ciliary reaction, cornea
with a ring like, white infiltrate and edema. Celullarity on
anterior chamber +++. Initial treatment: Topical tobramicyn b.i.d,
homatropine 3 times a day and Itraconazole 100 mg b.i.d. 1 week
later she comes with a visual acuity of hand movement. Clinical
diagnosis: Acanthamoeba keratitis. Final treatment: Topical
Netilmicine every 2 hours, topical fluconazole every 2 hours and
oral itraconazole 200 mg b.i.d. 2 weeks later: no pain, visual
acuity 20/50, the corneal ring infiltrate is dissapearing. 3 months
later: visual acuity 20/20, corneal ring infiltrate less than 50%,
happy patient. Slide 8 Slide 9 Case 3: Case 3: 54 year old femenine
comes with ocular pain on her right eye 2 weeks ago, she was
originally diagnosed as having corneal desepitelization by other
ophthalmologist. Visual acuity 20/400. Cornea: 90% opacification
with an ulcer that stained with fluorescein. Cultures (5 days
later): Acanthamoeba castellani on corneal sample and therapeutical
contact lens. Initial treatment: Therapeutical contact lens,
autologous serum q.i.d., netilmicine q.i.d. and sodium hyaluronate
every hour. Post cultures treatment: Itraconazole 200 mg b.i.d.
Topical polimixin B, gramicidin, neomycin q.i.d. / Netilmicine
every 2 hours. 2 weeks later, less pain, less corneal peripheral
edema, it only stains 30% on the center. 3 months later: No
staining, diffuse corneal leucoma, visual acuity 20/80 Slide 10
Slide 11 D ISCUSSION We believe that the early diagnosis of
Acanthamoeba keratitis is crucial for the prognosis of the disease
in our cases and other reported on the literature. Netilmicine was
amoebostatic for Acanthamoeba castellani as showed on the graphic;
we have no knowledge of any other report of this fact. No surgical
intervention was needed in any case, no side effects were found on
any patient. Slide 12 C ONCLUSIONS A combined treatment of
antifungal (oral itraconazole) and the aminoglucoside Netilmicine,
seems to be a great option for the quick and sustained improvement
of our patients. [email protected]
