Transcript Topical Netilmicine as a treatment for Acanthamoeba keratitis

N ETILMICINE AS A TREATMENT FOR
A CANTHAMOEBA KERATITIS : THREE
CASES
Oregon M. Eric Y, Vanzzini Z. Virginia, Sierra A. Antonio,
Zand H. Igal M, Moreno A. Gilberto, Naranjo T. Ramón
Cornea & Refractive Surgery department , Asociación para evitar la ceguera en México A.P.E.C.
Universidad Nacional Autónoma de México U.N.A.M.
The first author of this poster received travel expense reimbursement by SIFI laboratories México.
Off label use of topical netilmicine for Acanthamoeba keratitis.
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
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
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.
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.
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).
Final treatment: Topical Netilmicine every 2
hours, polimixin B/neomycin/gramicidin every
3 hours and oral itraconazole 200 mg b.i.d.
Case 1. Left image: notess the
perineural infiltrate in a radial
disposition that starts in the
center of the cornea.
Right image: the infiltrate on
detail, notess also the
conjunctival hyperemia.
Case 2:
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.
30 year old female comes with
ocular pain, low visual acuity and
photophobia. She wore her contact lenses
during the previous 72 hrs.
Case 2: Up in the left: look at the
ring infiltrate on the center of the
cornea.
Left: fluorescein diffuse staining
Up on the right.- notess the faint
ring at the end of follow up.
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.
Case 3: 54 year old femenine comes with
2 weeks later, less pain, less corneal peripheral 3 months later: No staining, diffuse corneal
edema, it only stains 30% on the center.
leucoma, visual acuity 20/80
Right image: Cysts on confocal
microscopy at the anterior stroma.
Left image: Trophozoites on the
culture
Cinetics of the effect of netromycin 100mg/ml- (netilmicine brand of systemic presentation in México & US) on
the growing of three Acanthamoeba colonies. Special thanks to Dr. Marco Rodríguez PhD
Y= Number of amoebas X= Hours. Notess the difference with the control (in black).
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.
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]