Atopic Keratoconjunctivitis

Atopic keratoconjunctivitis (AKC) is a chronic bilateral allergic inflammation of the conjunctiva and eyelids in patients with atopic dermatitis.

• Typically affects adults aged 20 to 50 years, with peaks in the late teens to 30s; about 20 to 40 percent of patients with atopic dermatitis have ocular involvement.
• Perennial symptoms with flares; Th2-driven with a chronic cell mediated component.
• More destructive than vernal disease: scarring of conjunctiva and cornea, and association with keratoconus, cataract and herpes simplex keratitis.
• Staphylococcus aureus colonisation of lids is common.

• Itching, burning, mucoid discharge, photophobia, and bilateral red eyes.
• Eczematous eyelids with thickening, scaling, madarosis, Dennie-Morgan folds, and lower lid ectropion.
• Papillae on the lower tarsus (the lower predominates, unlike vernal), pale milky conjunctival oedema, subepithelial fibrosis, symblepharon and forniceal shortening.
• Corneal findings: punctate keratopathy, persistent epithelial defects, neovascularisation, scarring, keratoconus.
• Anterior or posterior subcapsular cataract (shield like anterior subcapsular plaque) from atopy and steroids.
• Other: recurrent herpetic keratitis, staphylococcal blepharitis.

• Clinical, from the atopic history and ocular findings.
• Conjunctival scraping for eosinophils (fewer than in vernal disease), raised tear and serum IgE, eosinophilia.
• Cultures for S. aureus and herpes simplex PCR in recurrent keratitis.
• Corneal topography for keratoconus; lens examination; intraocular pressure; dilated retinal examination for retinal detachment (higher risk).

• Dermatology collaboration for atopic dermatitis: emollients, lid hygiene, avoid eye rubbing.
• Dual action topical agents (olopatadine 0.1 percent twice daily, ketotifen 0.025 percent twice daily) for maintenance.
• Topical calcineurin inhibitors: cyclosporine 0.05 to 0.1 percent four times daily or tacrolimus 0.03 percent ointment applied to the lids twice daily or 0.1 percent drops, for steroid sparing control.
• Short courses of corticosteroid drops for flares (loteprednol 0.5 percent or fluorometholone 0.1 percent four times daily for 1 to 2 weeks), with monitoring of pressure and lens.
• Treat blepharitis: lid hygiene, azithromycin 1.5 percent drops twice daily for 3 days, doxycycline 100 mg daily for 4 to 8 weeks.
• Antiviral prophylaxis in recurrent herpetic keratitis: aciclovir 400 mg twice daily orally.
• Systemic therapy for severe cases: oral cyclosporine 2.5 to 5 mg/kg/day, azathioprine, or biologic agents such as dupilumab 600 mg then 300 mg every 2 weeks (note that dupilumab can cause conjunctivitis).
• Surgery: cataract extraction and treatment of keratoconus, amniotic membrane or lamellar keratoplasty for cornea, symblepharon release.
• Regular review every 3 months for pressure, lens, cornea.