Atopic Keratoconjunctivitis (AKC)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Atopic Keratoconjunctivitis

 

 

 

 

 

 

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Aetiology 

Severe ocular surface disease affecting some atopic individuals

Complex immunopathology

Sometimes follows childhood Vernal Keratoconjunctivitis (VKC) (see Clinical Management Guideline on Vernal Keratoconjunctivitis)

Predisposing factors 

Typically affects young adult atopic males

There may be a history of asthma, hay fever, eczema and atopic dermatitis and VKC in childhood

Most patients have atopic dermatitis affecting the eyelids and periorbital skin

There is a strong association with staphylococcal lid margin disease

Specific allergens may exacerbate the condition

Symptoms

Ocular itching, watering, usually bilateral

Blurred vision, photophobia

White stringy mucoid discharge

Onset of ocular symptoms may occur several years after onset of atopy

Symptoms usually year-round, with exacerbations

Signs 

Eyelids may be thickened, crusted and fissured

Associated chronic staphylococcal blepharitis

Tarsal conjunctiva: giant papillary hypertrophy, subepithelial scarring and shrinkage

Entire conjunctiva hyperaemic

Limbal inflammation

Corneal involvement is common and may be sight-threatening: beginning with punctate epitheliopathy that may progress to macro-erosion, plaque formation (usually upper half), progressive corneal subepithelial scarring, neovascularisation, thinning, and rarely spontaneous performation 

These patients are prone to develop herpes simplex keratitis, corneal ectasia such as keratoconus, atopic (anterior or posterior polar) cataracts, retinal detachment 

Differential diagnosis

Vernal Keratoconjunctivitis

Other allergic conjunctivitis, eg Giant Papillary Conjunctivitis (GPC) (often contact lens-related)

Toxic Keratoconjunctivitis

Management by optometrist 

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere 

GRADE* Level of evidence and strength of recommendation always relates to the statement(s) immediately above

Non pharmacological 

Lid hygiene and treatment of associated staphylococcal blepharitis (see Clinical Management Guideline on Blepharitis)

Cool compresses

Advise avoidance of specific allergens if known, e.g. elimination of pets and carpeting, where necessary; instillation of air filtering devices and alterations to bedding materials

(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Pharmacological 

Systemic antihistamines e.g. cetirizine

Topical mast cell stabilisers, e.g. gutt. sodium cromoglicate 2%, gutt. lodoxamide 0.1%, gutt. nedocromil sodium 2%, or dual acting agents e.g. olopatadine 0.1%, may also provide symptomatic relief

(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Management category

Severe corneal complications are common and potentially sightthreatening.
If corneal epithelial macro-erosion or plaque are present:

A3: First aid measures followed by urgent referral (within one week) to an ophthalmologist

Milder cases (without active corneal involvement):

B1: Possible prescription of drugs; routine referral

Possible management by ophthalmologist

Topical steroids with monitoring and management of complications, eg steroid glaucoma and cataract

Topical/systemic antibiotic for lids

Topical immunosuppression (e.g. ciclosporin) (see evidence base)

Treatment of facial eczema and atopic blepharitis

Surgery for atopic cataract 

Evidence base 

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)

Sources of evidence

Brémond-Gignac D, Nischal KK, Mortemousque B, Gajdosova E, Granet DB, Chiambaretta F. Atopic Keratoconjunctivitis in Children: Clinical Features and Diagnosis. Ophthalmology. 2016;123(2):435-7


Chen JJ, Applebaum DS, Sun GS, Pflugfelder SC. Atopic keratoconjunctivitis: a review. J Am Acad Dermatol. 2014;70(3):569-75


González-López JJ, López-Alcalde J, Morcillo Laiz R, Fernández Buenaga R, Rebolleda Fernández G. Topical cyclosporine for atopic keratoconjunctivitis. Cochrane Database of Systematic Reviews 2012;9:CD009078


Nivenius E, Montan P. Spontaneous corneal perforation associated with atopic keratoconjunctivitis: a case series and literature review. Acta Ophthalmol. 2015;93(4):383-7


Power WJ, Tugal-Tutkun I, Foster CS. Long-term follow-up of patients with atopic keratoconjunctivitis. Ophthalmology. 1998;105:637-42

Lay summary

Atopic keratoconjunctivitis is a chronic (long-term) allergic condition of the eyelids and front surface of the eye. It is present in a high percentage of patients who have the skin condition, atopic dermatitis. Atopic keratoconjunctivitis requires long-term treatment to prevent sight-threatening complications such as scarring of the cornea (the clear window at the front of the eye). In the early stages of the disease, symptoms can be controlled by standard anti-allergy drugs. However, short- term use of steroid eye drops is often required when symptoms are severe. There is some evidence that cases that do not respond to steroids, or those requiring steroids eye drops long term, may benefit from ciclosporin eye drops or ointment.

Atopic Keratoconjunctivitis (AKC)
Version 13
Date of search 20.07.16 
Date of revision 22.12.16
Date of publication 01.06.17
Date for review 19.07.18
© College of Optometrists 

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