Advances in Therapy

, Volume 36, Issue 9, pp 2528–2540 | Cite as

Early Penetrating Keratoplasty À Chaud May Improve Outcome in Therapy-Resistant Acanthamoeba Keratitis

  • Kornélia L. LaurikEmail author
  • Nóra Szentmáry
  • Loay Daas
  • Achim Langenbucher
  • Berthold Seitz
Case Series



Long-standing acanthamoeba keratitis (AK) may result in corneal neovascularization, extension of the infiltrate to the limbus or sclera, broad peripheral synechiae, mature cataract or ischemic posterior segment inflammation. We investigated the impact of early emergency penetrating keratoplasty (PKP) in therapy-resistant cases among the patients of a highly specialized tertiary care center.


In this retrospective, observational cohort within a single institution, we collected data on best-corrected visual acuity (BCVA), epithelial wound healing, graft survival and secondary complications of AK patients who underwent PKP. A total of 23 eyes of 23 patients diagnosed with acute, therapy-resistant AK between 2006 and 2015 were enrolled. Postoperative combined topical treatment was tapered for 6–9 months.


Eyes were grouped based on preoperative disease duration as shorter (group 1) or longer (group 2) than the median. The median was 5.3 (0.66–36) months. The BCVA in group 1 (20/44 ± 20/18; 0.32 ± 0.18 logMAR) was significantly better than in group 2 (20/1200 ± 20/1133; 1.28 ± 0.89; logMAR); p = 0.015. Persisting epithelial defects occurred in 5 patients (50%) of group 1 and in 10 patients (77%) of group 2. In 5 eyes (group 2), no epithelial healing could be achieved. After 36 months, graft survival (Kaplan–Meier) was 78% (18 grafts) for all patients (90% in group 1 and 44% in group 2).


PKP à chaud within 5.3 months after first symptoms of therapy-resistant AK seems to result in better final BCVA than delayed graft surgery if the disease is resistant to a classical topical triple therapy. In addition, early PKP may have a favorable impact on epithelial healing and graft survival.


We thank the Alexander von Humboldt Foundation for supporting the work of Prof. N. Szentmáry at the Department of Ophthalmology of Saarland University Medical Center in Homburg/Saar, Germany. We thank the University of Saarland for funding the medical writing assistance and the Rapid Service Fees. The funding organisation had no role in the design or conduct of this research.


Acanthamoeba keratitis Epithelial healing Graft survival Penetrating keratoplasty à chaud 




We thank the Alexander von Humboldt Foundation for supporting the work of Prof. N. Szentmáry at the Department of Ophthalmology of Saarland University Medical Center in Homburg/Saar, Germany. We thank the University of Saarland for funding the medical writing assistance and the Rapid Service Fees. The funding organisation had no role in the design or conduct of this research.

Medical Writing Assistance

Language editing and assistance for this article was provided by Chrisitna Turner of the ACT-Fachübersetzunge and was funded by the University of Saarland.


All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.


Kornélia L. Laurik, Nóra Szentmáry, Loay Daas, Achim Langenbucher and Berthold Seitz have nothing to disclose.

Compliance with Ethics Guidelines

All procedures performed in our study involving human participants were in accordance with the ethical standards of the Ethical Committee of the Medical Association of Saarland and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent for participation and publication of patient data was obtained from all individual participants included in the study.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

We hereby thank all the participants of the study.


  1. 1.
    Naginton J, Watson PG, Playfair TJ, McGill J, Jones BR, Steele AD. Amoebic infection of the eye. Lancet. 1974;2:1537–40.CrossRefGoogle Scholar
  2. 2.
    Meltendorf C, Duncker G. Akanthamöben-Keratitis. Klin Monbl Augenheilkd. 2011;228:R29–43.CrossRefGoogle Scholar
  3. 3.
    Szentmary N, Daas L, Matoula P, Goebels S, Seitz B. Akanthamöbenkeratitis. Ophthalmologe. 2013;110:1203–10.CrossRefGoogle Scholar
  4. 4.
    Claerhout I, Goegebuer A, Van Den Broecke C, Kestelyn P. Delay in diagnosis and outcome of Acanthamoeba keratitis. Graef Arch Clin Exp Ophthalmol. 2004;242:648–53.CrossRefGoogle Scholar
  5. 5.
    Daas L, Szentmary N, Eppig T, et al. Das Deutsche Akanthamöbenkeratitis-Register: Erste Ergebnisse einer multizentrischen Erhebung. Ophthalmologe. 2015;112:752–63.CrossRefGoogle Scholar
  6. 6.
    Lorenzo-Morales J, Khan NA, Walochnik J. An update on Acanthamoeba keratitis: diagnosis, pathogenesis and treatment. Parasite. 2015;22:10.CrossRefGoogle Scholar
  7. 7.
    Awwad ST, Heilman M, Hogan RN, et al. Severe reactive ischemic posterior segment inflammation in acanthamoeba keratitis: a new potentially blindign syndrome. Ophthalmology. 2007;114:313–20.CrossRefGoogle Scholar
  8. 8.
    Blackman HJ, Rao NA, Lemp MA, Visvesvara GS. Acanthamoeba keratitis successfully treated with penetrating keratoplasty: suggested immunogenic mechanisms of action. Cornea. 1984;3:125–30.CrossRefGoogle Scholar
  9. 9.
    Dart JK, Saw VP, Kilvington S. Acanthamoeba keratitis: diagnosis and treatment update 2009. Am J Ophthalmol. 2009;148:487–99.CrossRefGoogle Scholar
  10. 10.
    Robaei D, Carnt N, Minassian DC, Dart JK. Therapeutic and optical keratoplasty in the management of Acanthamoeba keratitis: risk factors, outcomes, and summary of the literature. Ophthalmology. 2015;122:17–24.CrossRefGoogle Scholar
  11. 11.
    Illingworth CD, Cook SD. Acanthamoeba keratitis. Surv Ophthalmol. 1998;42:493–508.CrossRefGoogle Scholar
  12. 12.
    Awwad ST, Parmar DN, Heilman M, Bowman RW, McCulley JP, Cavanagh HD. Results of penetrating keratoplasty for visual rehabilitation after Acanthamoeba keratitis. Am J Ophthalmol. 2005;140:1080–4.CrossRefGoogle Scholar
  13. 13.
    Hager T, Hasenfus A, Stachon T, Seitz B, Szentmary N. Crosslinking and corneal cryotherapy in acanthamoeba keratitis—a histological study. Graefes Arch Clin Exp Ophthalmol. 2015;254:149–53.CrossRefGoogle Scholar
  14. 14.
    Küchle M, Seitz B, Langenbucher A, Naumann GO. Nonmechanical excimer laser penetrating keratoplasty for perforated or predescemetal corneal ulcers. Ophthalmology. 1999;106:2203–9.CrossRefGoogle Scholar
  15. 15.
    Seitz B, Resch M, Schlötzer-Schrehardt U, Hofmann-Rummelt C, Sauer R, Kruse FE. Histopathology and ultrastructure of human corneas after amniotic membrane transplantation. Arch Ophthalmol. 2006;124:1487–90.CrossRefGoogle Scholar
  16. 16.
    Robaei D, Carnt N, Minassian DC, Dart JK. The impact of topical corticosteroid use before diagnosis on the outcome of Acanthamoeba keratitis. Ophthalmology. 2014;121:1383–8.CrossRefGoogle Scholar
  17. 17.
    Kashiwabuchi RT, de Freitas D, Alvarenga LS, et al. Corneal graft survival after therapeutic keratoplasty for Acanthamoeba keratitis. Acta Ophthalmol. 2008;86:666–9.CrossRefGoogle Scholar
  18. 18.
    Ficker LA, Kirkness C, Wright P. Prognosis for keratoplasty in Acanthamoeba keratitis. Ophthalmology. 1993;100:105–10.CrossRefGoogle Scholar
  19. 19.
    Illingworth CD, Cook SD, Karabatsas CH, Easty DL. Acanthamoeba keratitis: risk factors and outcome. Br J Ophthalmol. 1995;79:1078–82.CrossRefGoogle Scholar
  20. 20.
    Chen WL, Wu CY, Hu FR, Wang IJ. Therapeutic penetrating keratoplasty for microbial keratitis in Taiwan from 1987 to 2001. Am J Ophthalmol. 2004;137:736–43.Google Scholar
  21. 21.
    Sarnicola E, Sarnicola C, Sabatino F, Tosi GM, Perri P, Sarnicola V. Early Deep Anterior Lamellar Keratoplasty (DALK) for Acanthamoeba keratitis poorly responsive to medical treatment. Cornea. 2016;35:1–5.CrossRefGoogle Scholar
  22. 22.
    Ehlers N, Hjortdal J. Are cataract and iris atrophy toxic complications of medical treatment of acanthamoeba keratitis? Acta Ophthalmol Scand. 2004;82:228–31.CrossRefGoogle Scholar
  23. 23.
    Herz NL, Matoba AY, Wilhelmus KR. Rapidly progressive cataract and iris atrophy during treatment of Acanthamoeba keratitis. Ophthalmology. 2008;115:866–9.CrossRefGoogle Scholar
  24. 24.
    Daas L, Viestenz A, Schnabel PA, et al. Confocal microscopy as an early relapse marker for Acanthamoeba keratitis. Clin Anat. 2018;31:60–3.CrossRefGoogle Scholar
  25. 25.
    Dohlman CH, Terada H. Keratoprosthesis in pemphigoid and Stevens-Johnson syndrome. Adv Exp Med Biol. 1998;438:1021–5.CrossRefGoogle Scholar
  26. 26.
    Bach M, Kommerell G. Sehschärfebestimmung nach Europäischer Norm: wissenschaftliche Grundlagen und Möglichkeiten der automatischen Messung. Klin Monbl Augenheilkund. 1998;212(4):190–5.CrossRefGoogle Scholar

Copyright information

© Springer Healthcare Ltd., part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of OphthalmologySaarland University Medical Center, UKSHomburg/SaarGermany
  2. 2.Department of OphthalmologySemmelweis UniversityBudapestHungary
  3. 3.Institute of Experimental OphthalmologySaarland UniversityHomburg/SaarGermany

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