Life · 3 authors, 4 centres
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In-vivo confocal microscopy (IVCM) improved diagnosis and treatment in three complex corneal cases where standard methods were inconclusive. IVCM identified Acanthamoeba cysts, residual fungal infection, and corneal neuromas, guiding targeted therapy and avoiding unnecessary treatments. This non-invasive imaging technique enhances diagnostic precision and clinical decision-making in challenging corneal disorders.
**Background:** Complex corneal disorders, such as microbial keratitis and dry eye disease, are challenging to diagnose and manage. Standard diagnostic methods like microbial culture and PCR have limitations, including poor sensitivity, long processing times, and inconclusive results. In-vivo confocal microscopy (IVCM) provides high-resolution, real-time imaging of corneal structures at the cellular level, potentially improving diagnostic accuracy and treatment guidance. This study describes three cases where IVCM influenced clinical decision-making.
**Methods:** Three patients with complex corneal disorders were examined using the Heidelberg Retinal Tomograph with Rostock Corneal Module (HRT-RCM). All scans were performed by a single trained examiner after topical anesthesia. Images of 400 × 400 microns were acquired, and those with artifacts were discarded. The cases were reviewed retrospectively to assess how IVCM findings altered diagnosis and management.
**Key Results:** - **Case 1:** A 36-year-old contact lens wearer with suspected corneal ulcer. Initial PCR was inconclusive. IVCM revealed scattered round double wall cysts and oval-shaped hyper-reflective structures consistent with Acanthamoeba cysts, confirming Acanthamoeba keratitis. Treatment was adjusted accordingly, and IVCM monitored response, allowing cessation of therapy when vision fully recovered. - **Case 2:** A 66-year-old keratoconus patient with recurrent fungal infection after corneal graft, on immunosuppression for psoriasis. Corneal scrapes and excised tissue were negative for fungi. IVCM showed multiple round bodies highly suggestive of yeast/candida infection. This led to discontinuation of immunosuppression and focused antifungal treatment, resolving pain and infection without evisceration. - **Case 3:** A 64-year-old woman with primary Sjögren’s syndrome and severe dry eye disease, unresponsive to standard therapies. IVCM identified micro-neuromas at nerve endings, indicating neuropathic corneal pain. This finding supported the prescription of allogeneic serum eye drops, addressing the underlying neural pathology.
**Clinical Implications:** IVCM is a valuable non-invasive tool for diagnosing and managing complex corneal disorders when conventional methods are inconclusive. It provides immediate cellular-level information, enabling targeted treatment and avoiding unnecessary or harmful therapies. In Acanthamoeba keratitis, IVCM can confirm diagnosis and monitor treatment response. In fungal infections, it can detect residual organisms despite negative cultures. In dry eye disease, IVCM can identify neuropathic changes that guide advanced therapies like serum eye drops. Incorporating IVCM into clinical practice may improve outcomes and reduce reliance on empirical treatment. Future integration with artificial intelligence could further enhance its utility.