Total necrosis of cornea, iris and crystalline lens with exposure of vitreous hyaloid face in the context of recalcitrant acanthamoeba keratitis

To report a rare and complicated case of acanthamoeba keratitis (AK) presented with total necrosis and dislodgment of cornea, iris, and crystalline lens with exposure of vitreous hyaloids face. Case report of 28-year-old female referred to the Farabi Eye Hospital with a history of known left eye AK since 4 months earlier. She also had a history of soft contact lens wear for two years and topical steroid use before proper diagnosis. Slit-lamp examination of the left eye revealed ring infiltration and stromal edema with haziness. The patient was prescribed anti-acanthamoeba treatment. She returned after 2 weeks with increasing ring infiltration and slight vision loss. Slit-lamp examination showed spontaneous total necrosis of cornea, iris, and crystalline lens with vitreous exposure to the air. The patient underwent an urgent operation consisting of total debridement of necrotic tissues including a 1 mm rim of the sclera, anterior vitrectomy, tectonic penetrating keratoplasty, and amniotic membrane transplantation (AMT) with temporary lateral tarsorrhaphy. The graft was clear within the 4 years of follow-up. At the last examination, the left eye was pthysic due to ciliary shut down and visual acuity remained light perception. Early suspicion to AK, especially in contact lens wearers, and applying diagnostic modalities like confocal microscopy and early appropriate management with cysticide agents such as polyhexamethylene biguanide may prevent these untoward complications.