Prognostic factors affecting visual outcome in Acanthamoeba keratitis

Abstract

Objective: To identify clinical and demographic factors associated with a worse visual outcome in Acanthamoeba keratitis (AK).

Design: Retrospective, case control study.

Participants: A total of 72 eyes of 65 patients with AK who were diagnosed at the University of Illinois Eye and Ear Infirmary between May of 2003 and May of 2007 with treatment complete by October of 2007. The first affected eye was analyzed in bilateral disease.

Methods: Patient demographic, clinical characteristics, treatment methods, and final visual outcome data were collected through medical record reviews for all patients diagnosed with AK. Cases were defined as patients with AK with a visual outcome worse than 20/25 or those requiring penetrating keratoplasty (PKP). Controls were defined as patients with AK with a visual outcome of 20/25 or better. Logistic regression was used to estimate the odds ratio (OR) identifying prognostic factors associated with a worse visual outcome.

Main outcome measures: Final visual outcome worse than 20/25.

Results: AK was confirmed through microbiologic evidence in 48 of 65 eyes (73.8%) or with confocal microscopy in 62 of 65 eyes (95.4%). Final visual acuity data were available in 61 of 65 eyes (93.8%); of these 61 eyes, 40 (65.6%) achieved a final visual acuity of 20/25 or better. In multivariable analysis, deep stromal involvement or the presence of a ring infiltrate at presentation was independently associated with worse visual outcomes (OR, 10.27; 95% confidence interval [CI], 2.91-36.17). Symptom duration before diagnosis was statistically predictive of disease stage at presentation (OR, 4.43; 95% CI, 0.99-19.83; multivariable analysis) but not final visual outcome (OR, 2.55; 95% CI, 0.83-7.88; univariate analysis). PKP was performed in 11 of 12 eyes with active disease.

Conclusions: Corneal disease staging at presentation with slit-lamp examination was highly predictive of worse outcomes, allowing the identification of patients who might benefit from more aggressive medical or surgical intervention. Unlike in previous reports, patient-reported duration of symptoms before treatment was not reliable in predicting the final visual result in our series.

Figure 1

Slit-lamp photographs of AK. A and B, Isolated epitheliitis. Two patients with an isolated epithelial presentation of AK. Note the granular, cystic-appearing epithelium with little or no stromal inflammation. C, Epitheliitis with radial neuritis. A patient with irregular-appearing epithelium and an inflamed, nodular corneal nerve superiorly. D, Anterior stromal disease. A patient with anterior stromal involvement with clear surrounding cornea and without associated deep inflammation. E, Deep stromal keratitis. Note the diffuse central infiltrate with generalized central haze without a clear lateral or deep border. F, Ring infiltrate. An early ring infiltrate demonstrating an area of central corneal haze with a relative paracentral demarcation ring characteristic of an immune Acanthamoeba ring.