title: Corneal cross-linking for Acanthamoeba keratitis in an orthokeratology patient after swimming in contaminated water.
abstract: OBJECTIVE
  To report a case of Acanthamoeba keratitis diagnosed using confocal microscopy in a patient corrected by orthokeratology and treated with corneal crosslinking (CXL) after failure to respond to medical treatment.
  
  
  METHODS
  After diagnosis, the patient was treated with several medications until CXL was applied during one 30-min session using ultraviolet A radiation and application of riboflavin. The clinical signs of the disease observed using slit-lamp biomicroscopy and confocal microscopy were evaluated and the visual acuity was measured during the course of the infection and treatment over a period of 30 months including 12 months of medical treatment, 9 months after cross-linking and amniotic membrane transplant and 9 months after penetrating keratoplasty and cataract extraction.
  
  
  RESULTS
  In this case, confocal microscopy facilitated early diagnosis of an Acanthamoeba infection even if other signs and symptoms might be confounding. CXL was more effective than aggressive medication against the microorganism. After CXL, the symptoms and the corneal appearance improved significantly but the ulcer did not heal completely. After amniotic membrane transplantation, the patient underwent penetrating keratoplasty (PK) with no rejection, and the visual function substantially improved over 9 months of follow-up.
  
  
  CONCLUSIONS
  Swimming in contaminated water might represent a risk for orthokeratology patients. CXL was effective for treating Acanthamoeba keratitis in an orthokeratology patient to eliminate active and cystic forms of the microorganism. Confocal microscopy was useful to confirm the diagnosis in the presence of confounding clinical signs observed during a conventional slit-lamp examination. Both CXL and confocal microscopy are essential to the outcome of PK.
authors.affiliation: Clínica Oftalmológica Novovision, Paseo de la Castellana, Madrid, Spain.
authors.forename: Ángeles
authors.initials: Á
authors.lastname: Arance-Gil
authors.affiliation: Clínica Oftalmológica Novovision, Paseo de la Castellana, Madrid, Spain.
authors.forename: Ángel Ramón
authors.initials: ÁR
authors.lastname: Gutiérrez-Ortega
authors.affiliation: Universidad Europea de Madrid, Spain.
authors.forename: César
authors.initials: C
authors.lastname: Villa-Collar
authors.affiliation: Universidad Complutense de Madrid, Spain.
authors.forename: Amelia
authors.initials: A
authors.lastname: Nieto-Bona
authors.affiliation: Clinical & Experimental Optometry Research Lab (CEORLab), Center of Physics, University of Minho, Braga, Portugal.
authors.forename: Daniela
authors.initials: D
authors.lastname: Lopes-Ferreira
authors.affiliation: Clinical & Experimental Optometry Research Lab (CEORLab), Center of Physics, University of Minho, Braga, Portugal. Electronic address: jgmeijome@fisica.uminho.pt.
authors.forename: José Manuel
authors.initials: JM
authors.lastname: González-Méijome
mesh_terms: D015823:Acanthamoeba Keratitis / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy*; D000328:Adult; D003261:Contact Lenses / Q000469:parasitology*; D003432:Cross-Linking Reagents / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D054158:Orthokeratologic Procedures / Q000009:adverse effects* / Q000295:instrumentation; D012256:Riboflavin / Q000627:therapeutic use*; D013550:Swimming; D013551:Swimming Pools; D016896:Treatment Outcome
chemical_list: D003432:Cross-Linking Reagents; D012256:Riboflavin
keywords: Acanthamoeba keratitis; Amniotic membrane; CXL; Confocal microscopy; Orthokeratology; Penetrating keratoplasty