eMedicine Specialties > Ophthalmology > Cornea

Keratoconjunctivitis, Atopic: Treatment & Medication

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

Treatment

Medical Care

  • Prophylaxis2,1
    • Topical mast cell stabilizers reduce the incidence of exacerbations.
    • Topical and oral antihistamines in combination with efforts to reduce or eliminate allergen exposure are invaluable for long-term control.
  • Exacerbations
    • Intensive topical steroids are used for short-term flare-ups, tapering according to clinical response.2,1
    • In some situations, more aggressive or steroid-sparing treatment may be indicated. Topical 0.05% or 2% cyclosporine suspended in oil used 4-6 times per day is proven to be effective for exacerbations and may be considered as an adjunct or as possible alternate therapy in situations where steroid use needs to be minimized.3,4 Systemic cyclosporine (5 mg/kg/d) has been shown to be effective in inducing remission.  Low-dose maintenance therapy (5 mg/kg q5d) may be required in refractory cases.5  
    • More recently, systemic immunomodulators, such as tacrolimus, have been used in refractory cases with good response.6

Surgical Care

  • Cataract surgery with intraocular lens implantation is associated with favorable outcomes.7
  • Penetrating keratoplasty for corneal scarring is associated with a higher than average incidence of graft failure. Ocular surface inflammation should be well controlled prior to surgery.
  • Plasmapheresis has been suggested as a successful adjunct therapy for patients with high IgE levels.

Consultations

Comanagement with an allergist is indicated for optimal long-term control.

Activity

Reduction or elimination of inciting environmental allergens is necessary for optimal prophylaxis.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Mast cell stabilizers and antihistamines are mainstays of prophylactic therapy. Antihistamines, steroids, and other immunosuppressives are used for immediate control of symptoms.

For additional information, see PDR.net.

Topical mast cell stabilizers

Inhibit degranulation of sensitized mast cells upon exposure to specific antigens.


Cromolyn sodium 4% (Opticrom, Crolom)

Inhibits histamine and SRS-A (slow-releasing substance of anaphylaxis) release from mast cells but has no intrinsic anti-inflammatory, antihistamine, or vasoconstrictive effects.

Adult

1-2 gtt 4-6 times/d

Pediatric

Not established

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not for use while wearing contact lenses; transient ocular stinging or burning upon instillation is most frequently reported adverse reaction; uncommon adverse reactions include conjunctival infections, watery eyes, itchy eyes, dryness around eyes, puffy eyes, eye irritation, and styes


Lodoxamide tromethamine 0.1% (Alomide)

Stabilizes mast cells and inhibits increased vascular permeability, which is associated with IgE and antigen-mediated reactions. Alomide has been reported to prevent calcium influx into mast cells upon antigen stimulation without intrinsic anti-inflammatory, antihistamine, or vasoconstrictive effects.

Adult

1-2 gtt qid

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not for injection; patients often experience transient burning or stinging from instillation; soft contact lens wearers should refrain from using them while under treatment


Nedocromil sodium 2% (Alocril)

Interferes with mast cell degranulation, specifically with release of leukotrienes and platelet activating factor.

Adult

1-2 gtt bid

Pediatric

<3 years: Not established
>3 years: Administer as in adults

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse events include ocular irritation/burning, headache, nasal congestion, and unpleasant taste in 10-40% of patients

Topical antihistamines

Act by competitive inhibition of histamine at the H1 receptor. For prophylaxis and symptomatic relief.


Olopatadine hydrochloride 0.1% (Patanol)

Inhibits histamine release through both selective H1 histamine receptor antagonism and less specific mast cell stabilization.

Adult

1-2 gtt bid at 6-8 h intervals

Pediatric

<3 years: Not established
>3 years: Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use while wearing contact lenses; not for injection; adverse reactions include burning or stinging, dry eye, foreign body sensation, hyperemia, keratitis, lid edema, pruritus, headaches, asthenia, cold syndrome, pharyngitis, rhinitis, sinusitis, and taste perversion


Ketotifen fumarate 0.025% (Zaditor)

Selective H1 histamine receptor antagonist and mast cell stabilizer. Inhibits release of mediators from cells involved in hypersensitivity reactions.

Adult

1-2 gtt in affected eye(s) bid

Pediatric

<3 years: Not established
>3 years: Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

For topical ophthalmic use only; not for treatment of contact lens–related inflammation; wait 10 min before inserting lenses after ketotifen use; do not contaminate dropper tip or solution when placing drops in eyes; in controlled clinical studies, minor conjunctival injection, headaches, and rhinitis were reported at an incidence of 10-25%


Azelastine hydrochloride 0.05% (Optivar)

Antihistamine and mast cell stabilizer.

Adult

1 gtt in affected eye(s) bid

Pediatric

<3 years: Not established
>3 years: Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Instruct patients who wear soft contact lenses and whose eyes are not red to wait >10 min after applying drops to insert contact lenses; transient eye burning and stinging, headaches, and bitter taste were reported in 10-30% of patients


Epinastine hydrochloride 0.05% (Elestat)

H1 antihistamine and mast cell stabilizer.

Adult

1 gtt in affected eye(s) bid

Pediatric

<3 years: Not established
>3 years: Administer as in adults

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Ocular reactions of burning sensation, folliculosis, hyperemia, and pruritus reported in 1-10% of patients; nonocular reactions of cold symptoms and upper respiratory infections seen in 10% of patients

Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Prednisolone acetate 1%, 0.12% (Pred Forte, Pred Mild)

On the basis of weight, has 3-5 times the anti-inflammatory potency of hydrocortisone. Glucocorticoids inhibit edema, fibrin deposition, capillary dilation and proliferation, phagocytic migration of acute inflammatory response, deposition of collagen, and scar formation.

Adult

1-2 gtt bid/qid; may increase prn based on clinical response

Pediatric

Documented hypersensitivity; viral, fungal, or tubercular infections

Documented hypersensitivity; viral, fungal, or tubercular infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)


Fluorometholone 0.1%, 0.25% (FML, FML Forte)

Inhibits edema, fibrin deposition, capillary dilation and phagocytic migration of acute inflammatory response and capillary proliferation, collagen deposition, and scar formation. Used topically, it can elevate IOP and cause steroid-response glaucoma. In clinical studies of documented steroid responders, fluorometholone demonstrated a significantly longer average time to produce a rise in IOP than dexamethasone phosphate. In a small percentage of individuals, a significant rise in IOP occurred within 1 wk. The ultimate magnitude of the rise was equivalent.

Adult

1 gtt bid/qid; may increase prn depending on clinical response

Pediatric

<2 years: Not established
>2 years: Administer as in adults

Documented hypersensitivity; viral, fungal, or tubercular infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)


Loteprednol etabonate 0.5%, 0.2% (Lotemax, Alrex)

Structurally similar to other corticosteroids, but the number 20 position ketone group is absent. Highly lipid soluble, which enhances cell penetration. Undergoes a predictable transformation to an inactive carboxylic acid metabolite. Shown to be less effective than prednisolone acetate 1% in two 28-d controlled clinical studies in acute anterior uveitis; 72% of patients treated with Lotemax experienced resolution of anterior chamber cells compared to 87% of patients treated with prednisolone acetate 1%. Incidence of patients with clinically significant increases in IOP (>10 mm Hg) was 1% with Lotemax and 6% with prednisolone acetate 1%.

Adult

1 gtt qid; may increase to q1h during first wk prn for clinical response

Pediatric

Not established

Documented hypersensitivity; viral, fungal, or tubercular infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)

Immunosuppressants

Used as adjunctive or alternative treatment in situations where steroid use is ineffective or requires minimization.


Cyclosporine (Sandimmune)

Exact mechanism of immunosuppressive activity is unknown. Preferential and reversible inhibition of T lymphocytes in the G0 or G1 phase of the cell cycle suggested.

Adult

Cyclosporine 0.05% or 2% suspended in oil: Apply 0.05% 6 times daily for 2 wk then qid. Apply 2% qid; effective for flares and may consider as adjunct or possible alternate therapy when steroid use needs to be minimized
Aggressive treatment: 5 mg/kg/d PO may induce remission; may require low-dose maintenance therapy of 5 mg/kg q5d

Pediatric

Not established; children as young as 6 mo have received the drug with no adverse effects

If oral product use, monitor for drug interactions; carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease cyclosporine concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase cyclosporine toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Frequently evaluate renal and liver functions by measuring BUN, serum creatinine, serum bilirubin, and liver enzymes; may increase risk of infection and lymphoma; reserve IV use only for those who cannot take PO

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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