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Despite worldwide awareness of Acanthamoeba as a cause of corneal infection, Acanthamoeba keratitis continues to be misdiagnosed or inadequately treated. The clinical presentation can range from the non-specific (corneal epithelial irregularities and microerosions with some pain and irritation), to the classic (radial keratoneuritis and ring or double ring infiltrates).1 Early lesions presenting as coarse punctuate keratitis are often attributed to dryness or contact-lens-related corneal epitheliopathy that has been treated with artificial tears and some antibiotic drops. When the infection manifests as (pseudo)dentritiform epithelial lesions, it is often mistaken for herpes simplex keratitis and treated with antiviral medication. On several occasions, an associated anterior chamber reaction has directed the observer to a diagnosis of iritis with use of steroid drops as part of the treatment plan. Delay allows the organism, which may primarily be in the epithelium at the onset of disease, to make its way into the stroma feeding on keratocytes and along stromal nerves, entrenching itself and resulting in an indolent recalcitrant keratitis. The emphasis on “pain out of proportion to signs” is not always borne …
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