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Journal Français d'Ophtalmologie
Volume 40, n° 4
pages 341-342 (avril 2017)
Doi : 10.1016/j.jfo.2016.12.015
Pseudodendritic ulcer
Ulcère pseudodendritique
 

J. Ferreira Mendes , T. Monteiro
 Department of ophthalmology, hospital of Braga, Sete Fontes–São Victor, 4710-243 Braga, Portugal 

Corresponding author.

A 16-year-old male was referred to our ophthalmology department for photophobia, itching and red eye for one week. He has a previous history of bilateral myopia since the age of 7 and was currently using disposable soft contact lenses for the last 4 years; otherwise, presented no other remarkable medical or surgical events. He denied eye trauma or contact with relatives with similar symptoms in previous weeks. His best-corrected visual was 20/25 in right eye and 20/20 in left eye. Right eye slip-lamp examination revealed diffuse conjunctiva hyperaemia and watery secretions; fluorescein cornea staining displayed central corneal vesicles resembling a dendritic pattern. Patient was clinically diagnosed of herpes simplex keratitis and topical ganciclovir 0.15% was prescribed 5 times a day. One week later, no improvement was noticed; the central cornea presented a stromal ring shaped infiltrate associated with “perineuritis” of the mid-stromal corneal nerve branches (Figure 1); fluorescein dye exhibited a pseudo-dendritically ulcer pattern (Figure 2). Acanthamoeba keratitis is a rare, vision threatening, painful, parasitic infection; contact lens use is a recognized major risk factor.



Figure 1


Figure 1. 

Early presentation of Acanthamoeba keratitis: “Perineuritis” of the mid-stromal corneal nerve branches, two weeks after initial symptoms.

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Figure 2


Figure 2. 

Cobalt blue filter exhibiting a pseudo-dendritically ulcer pattern, after fluorescein dye.

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Early institution of topical therapy has more probability of success, but the disease has a chronic course and a high rate of indication for penetrating keratoplasty. Acanthamoeba cysts are known to be very resistant, with a waxing and waning course and frequently unreliable prognosis in late time diagnosis.

In this case, the diagnosis was confirmed by identification of amebic DNA by polymerase chain reaction (PCR) and patient was promptly treated with propamidine isethionate 0.1% (Brolene®) and chlorhexidine 0.02%. Pain and red eye reduced progressively and, after 3 months of treatment, there was no sign of corneal active infection, remaining a stable central scar (Figure 3). Anterior OCT revealed no attainment of Descemet layer by the scar, so patient is now schedule for DALK transplantation.



Figure 3


Figure 3. 

Presentation after 3 months from the diagnosis: There is a chronic and stable central scar, with no peripheral corneal edema, anterior chamber reaction or other signs of active infection.

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Disclosure of interest

The authors declare that they have no competing interest.



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