**3. Pre-surgical evaluation**

When the decision has been taken to perform a therapeutic Keratoplasty, a good examination is necessary to value the following points.

To evaluate the size, depth and place of the infiltrate or corneal ulcer, if the limbos is compromised, or if there is imminent or actual perforation.

To evaluate the posterior pole under dilation, if it is possible, specially the vitreo retinal area, and when it is not possible we must realize a B Scan ultrasound and if the integrity of the ocular globe is affected by an imminent perforation it is necessary to make a Trans palpebral ecography to evaluate a probable endophtalmitis. Increased risk for endophthalmitis at the time of therapeutic keratoplasty includes the presence of fungal disease, corneal perforation and patients who have undergone previous cataract extraction.

To evaluate the presence of cataract and to carefully decide the extraction of the crystalline since this is a barrier to avoid the extension of the infectious process toward the posterior pole. It is recommended to try to keep the posterior capsule to diminish the risk of Endophthalmitis. SpeakerMG et al 1991.

Fig. 13. *Acanthamoeba* cyst Giemsa stein, in light microscope view (20 X magnification)

biguanide 0.3% in aqueous solution (Brolene ®UK) we used in our

surgical treatment in Keratitis by *Acanthamoeba* is controversial.

examination is necessary to value the following points.

compromised, or if there is imminent or actual perforation.

**3. Pre-surgical evaluation** 

Endophthalmitis. SpeakerMG et al 1991.

Before carrying out therapeutic keratoplasty it is important to give a medical therapy and many drugs have been tested for *Acanthamoeba* infections as mentioned in the , the most used are Chlorexidine 0.01% in aqueous solution not commercially available, Polimethylene

Oral Itraconazole 100 mgs/ 12 hours combined with topical Netilmycin 0.3% (Netira® SCIFI laboratories Italy) are actually used in our acanthamoebic keratitis patient. Medical and

In some cases with early diagnosis these cases have been successfully treated with medical treatment without being necessary to undergo a surgical procedure of therapeutic keratoplasty. Ficker et al 1993, mention that the over life of the graft by Keratitis by *Acanthamoeba* is of poor outcome, reporting more than 50% recurrence incidence of the graft. However, in our personal opinion, the Keratoplasty continues to have a central role in the management of patients who progress or do not respond to medical treatment. The acute management of these active cases is to sterilize the infection as rapidly as posible and to

When the decision has been taken to perform a therapeutic Keratoplasty, a good

To evaluate the size, depth and place of the infiltrate or corneal ulcer, if the limbos is

To evaluate the posterior pole under dilation, if it is possible, specially the vitreo retinal area, and when it is not possible we must realize a B Scan ultrasound and if the integrity of the ocular globe is affected by an imminent perforation it is necessary to make a Trans palpebral ecography to evaluate a probable endophtalmitis. Increased risk for endophthalmitis at the time of therapeutic keratoplasty includes the presence of fungal disease, corneal perforation and patients who have undergone previous cataract extraction. To evaluate the presence of cataract and to carefully decide the extraction of the crystalline since this is a barrier to avoid the extension of the infectious process toward the posterior pole. It is recommended to try to keep the posterior capsule to diminish the risk of

dalay surgical management until the patient receives adequate antiamebic therapy.

Before surgery, intraocular pressure should be evaluated in eyes without a perforation.

Adequate pressure control remains essential. In patients with markedly elevated intraocular pressure or in patients with a corneal perforation in which the lens-iris-diaphragm has moved forward, we give intravenous manitol to control intraocular pressure and to reduce the vitreous volume.

In eyes with a crystalline lens or posterior chamber intraocular lens, and patients with iris incarcerated in a wound, we give Pilocarpina 2% 1 hour prior to surgery, to protect the lens, and maintain a posterior lens-iris diaphragm.

We do not recommend carrying out the surgery with local anesthesia, it is much better to perform it under general anesthesia and in all cases we must maintain the arterial pressure under control to reduce the risk of expulsive choroidal hemorrhage, especially in those patients with perforation.
