UTD – Atopic keratoconjunctivitis

SUMMARY AND RECOMMENDATIONS

●Atopic keratoconjunctivitis (AKC) is a chronic and aggressive form of ocular allergy that occurs most often in adults with a history of atopic dermatitis (AD). If not treated properly, AKC can damage the ocular surface, leading to corneal scarring, keratoconus due to persistent eye rubbing, and vision loss. (See ‘Introduction’ above and ‘Epidemiology’ above.)

●AKC is characterized by intense ocular itching, which can occur perennially or only in certain seasons. Most patients rub their eyes incessantly. Tearing, clear mucus discharge, and redness are also almost always present. Other symptoms include blurry vision, burning, photophobia, and foreign body sensation. (See ‘Symptoms and signs’ above.)

●AKC involves the eyelid, conjunctiva, and cornea. The eyelids may thicken, swell intermittently, and acquire a scaly and indurated appearance, with flaking dermatitis and a reddened base (picture 1). Ocular findings include conjunctival chemosis and hyperemia. (See ‘Physical findings’ above.)

●AKC should be suspected in a patient with a history of AD who presents with ocular pruritus and eyelid dermatitis. Referral to an ophthalmologist should be pursued in all patients with suspected AKC, regardless of severity. The diagnosis is based upon typical epidemiology and clinical features. Routine laboratory tests are not helpful, and there are no established diagnostic criteria. (See ‘Evaluation and diagnosis’ above.)

●The approach to patients with AKC includes basic eye care, topical medications, and systemic medications if needed. We suggest a topical dual-acting antihistamine/mast cell stabilizer as first-line therapy (Grade 2C). Specific medications include olopatadine (Patanol, Pataday, Pazeo), alcaftadine (Lastacaft), bepotastine (Bepreve), azelastine HCl (Optivar), epinastine (Elestat), ketotifen fumarate (generic, Ketotifen), and emedastine (Emadine). Treatments beyond first-line therapies (eg, topical corticosteroids and calcineurin inhibitors and systemic immunosuppressive agents) should be initiated only in consultation with an ophthalmologist. (See ‘Treatment’ above.)

●For patients with AKC who fail to respond to two to three weeks of a mast cell stabilizer or dual-acting antihistamine/mast cell stabilizer, we suggest a brief course of topical corticosteroids (Grade 2C). This should only be administered under the guidance of an ophthalmologist. (See ‘Topical corticosteroids’ above.)

●We suggest using topical cyclosporine (2%, compounded) as a steroid-sparing agent in patients with resistant or moderate-to-severe disease who require frequent or prolonged courses of topical corticosteroids (Grade 2C). As with topical corticosteroids, cyclosporine should only be administered under the guidance of an ophthalmologist. (See ‘Topical calcineurin inhibitors’ above.)

●We suggest treating the eyelid dermatitis component of AKC with topical tacrolimus, rather than topical corticosteroids (Grade 2B). (See ‘Treatment of eyelid dermatitis’ above.)