Oral Miltefosine as Salvage Therapy for Refractory Acanthamoeba Keratitis.

Abstract Purpose To report a case series of patients with treatment-resistant Acanthamoeba keratitis (AK) using oral miltefosine, often as salvage therapy. Design Descriptive retrospective multi-center case series. Methods We reviewed 15 patients with AK unresponsive to therapy that were subsequently given adjuvant systemic miltefosine between 2011 to 2017. The main outcome measures were resolution of infection, final visual acuity, tolerance of miltefosine, and clinical course of disease. Results All patients were treated with biguanides and/or diamidines or azoles without resolution of disease prior to starting miltefosine. 11 of 15 patients retained count fingers or better vision, and all were considered disease-free at last follow up. 11 of 15 patients had worsening inflammation with miltefosine, with 10 of them improving with steroids. Six patients received multiple courses of miltefosine. Most tolerated oral miltefosine well, with mild gastrointestinal symptoms as the most common systemic side effect. Conclusion Oral miltefosine is a generally well-tolerated treatment adjuvant in patients with refractory acanthamoeba keratitis. The clinician should be prepared for a steroid-responsive inflammatory response frequently encountered during the treatment course.