eMedicine Specialties > Ophthalmology > Cornea

Keratoconjunctivitis, Atopic

Author: Anne Chang-Godinich, MD, Assistant Clinical Professor, Department of Ophthalmology, Baylor College of Medicine
Coauthor(s): Michael B Raizman, MD, Associate Professor, Department of Ophthalmology, Tufts School of Medicine; Consulting Staff, Ophthalmic Consultants of Boston, Inc
Contributor Information and Disclosures

Updated: Jan 16, 2009

Introduction

Background

Atopic keratoconjunctivitis (AKC) is a relatively uncommon but potentially blinding ocular condition. In 1952, Hogan described AKC as a bilateral conjunctivitis occurring in 5 male patients with atopic dermatitis. Originally described to flare with worsening dermatitis, Foster et al noted that some patients' ocular involvement evolves independent of dermatitis.1

AKC is associated with a 95% prevalence of concomitant eczema and an 87% prevalence of asthma. Other than AKC, common ocular atopic phenomena include allergic conjunctivitis, giant papillary conjunctivitis, and vernal keratoconjunctivitis.

Pathophysiology

Atopy refers to hypersensitivity in patients with familial histories of allergic disease. Individuals with atopy often have environmental allergies, allergic asthma, rhinitis, and atopic dermatitis or eczema. Less commonly, they exhibit food allergies, urticaria, and nonhereditary angioedema. Immunoglobulin E (IgE) is the serum mediator of the exuberant responses. Hypersensitivity reactions associated with types I and IV contribute to the inflammatory changes of the conjunctiva and the cornea that are found in AKC. During exacerbations, patients have increased tear and serum IgE levels and increased numbers of circulating B cells; T-cell levels are depressed.

Frequency

International

Atopy affects 5-20% of the general population. AKC occurs in 20-40% of individuals with atopic dermatitis.

Mortality/Morbidity

Decreased vision and blindness result from chronic superficial punctate keratitis, persistent epithelial defects, corneal scarring or thinning, keratoconus, cataracts, and symblepharon formation. The use of corticosteroids to medically treat AKC can further promote the development of cataracts, glaucoma, and secondary corneal infections.

Sex

This condition is more prevalent in men than in women.

Age

Peak age of incidence is in persons aged 30-50 years. The age range is from the late teenaged years to 50 years.

Clinical

History

Look for the following in past medical history:

  • Chronic or chronically relapsing atopic disease
    • Dermatitis
    • Asthma
    • Rhinitis
  • Ocular symptoms with little or no seasonal variation (as opposed to vernal conjunctivitis that is seen only in warm weather)
    • Itching
    • Tearing
    • Ropy discharge
    • Burning
    • Photophobia
    • Decreased vision

Physical

  • Periorbita - Dennie-Morgan folds (linear lid folds secondary to chronic eye rubbing) and Hertoghe sign (absence of lateral eyebrows)
  • Lids - Thickening and tylosis, crusting, edema, fissures, ptosis, and staphylococcal blepharitis
  • Conjunctiva
    • Small- or medium-sized papillae, hyperemia, edema, excessive mucin, and limbal Trantas dots (clusters of necrotic eosinophils, neutrophils, and epithelial cells)
    • Formation of keratinization, cicatrization, and symblepharon in advanced disease
  • Cornea
    • Punctate epitheliopathy and keratitis, persistent epithelial defects, shield-shaped ulcers, anterior stromal scarring, and micropannus
    • Extensive peripheral corneal vascularization in later stages
    • Higher incidence of keratoconus (16%) and recurrent herpes simplex keratitis associated with AKC
  • Lens - Posterior or anterior subcapsular shield-shaped cataracts
  • Fundus - Degenerative vitreous changes and retinal detachment

Causes

See Pathophysiology.

More on Keratoconjunctivitis, Atopic

Overview: Keratoconjunctivitis, Atopic
Differential Diagnoses & Workup: Keratoconjunctivitis, Atopic
Treatment & Medication: Keratoconjunctivitis, Atopic
Follow-up: Keratoconjunctivitis, Atopic
Multimedia: Keratoconjunctivitis, Atopic
References
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References

  1. Foster CS, Calonge M. Atopic keratoconjunctivitis. Ophthalmology. Aug 1990;97(8):992-1000. [Medline].

  2. Casey R, Abelson MB. Atopic keratoconjunctivitis. Int Ophthalmol Clin. Spring 1997;37(2):111-7. [Medline].

  3. Akpek EK, Dart JK, Watson S, et al. A randomized trial of topical cyclosporin 0.05% in topical steroid-resistant atopic keratoconjunctivitis. Ophthalmology. Mar 2004;111(3):476-82. [Medline].

  4. Hingorani M, Moodaley L, Calder VL, Buckley RJ, Lightman S. A randomized, placebo-controlled trial of topical cyclosporin A in steroid-dependent atopic keratoconjunctivitis. Ophthalmology. Sep 1998;105(9):1715-20. [Medline].

  5. Hoang-Xuan T, Prisant O, Hannouche D, Robin H. Systemic cyclosporine A in severe atopic keratoconjunctivitis. Ophthalmology. Aug 1997;104(8):1300-5. [Medline].

  6. Anzaar F, Gallagher MJ, Bhat P, Arif M, Farooqui S, Foster CS. Use of systemic T-lymphocyte signal transduction inhibitors in the treatment of atopic keratoconjunctivitis. Cornea. Sep 2008;27(8):884-8. [Medline].

  7. Power WJ, Tugal-Tutkun I, Foster CS. Long-term follow-up of patients with atopic keratoconjunctivitis. Ophthalmology. Apr 1998;105(4):637-42. [Medline].

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Further Reading

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Keywords

atopic keratoconjunctivitis, AKC, bilateral conjunctivitis, atopic dermatitis, allergic conjunctivitis, giant papillary conjunctivitis, vernal keratoconjunctivitis, systemic allergy

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Contributor Information and Disclosures

Author

Anne Chang-Godinich, MD, Assistant Clinical Professor, Department of Ophthalmology, Baylor College of Medicine
Anne Chang-Godinich, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Michael B Raizman, MD, Associate Professor, Department of Ophthalmology, Tufts School of Medicine; Consulting Staff, Ophthalmic Consultants of Boston, Inc
Michael B Raizman, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Pan-American Association of Ophthalmology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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