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Atopic Keratoconjunctivitis Treatment & Management

  • Author: Anne Chang-Godinich, MD, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Mar 17, 2015
 

Approach Considerations

Proper prophylactic measures, prompt effective treatment of exacerbations, and well-timed elective surgical intervention can reduce the incidence of poor vision and blindness.

Mast cell stabilizers and antihistamines are the mainstays of prophylactic therapy. Antihistamines, steroids, and other immunosuppressives are used for immediate control of symptoms. Comanagement with an allergist is indicated for optimal long-term control.

Plasmapheresis has been suggested as a successful adjunct therapy for patients with high immunoglobulin E (IgE) levels.

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Prophylaxis and Management of Exacerbations

Efforts to reduce or eliminate environmental allergen exposure must be addressed for optimal long-term control of atopic keratoconjunctivitis (AKC). These efforts in combination with topical and oral antihistamines are invaluable in controlling this condition.[1, 4]

Topical mast cell stabilizers reduce the incidence of exacerbations. Intensive topical steroids are used for short-term flare-ups, tapering according to clinical response.[1, 4]

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 in which steroid use needs to be minimized.[5, 6, 7]

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.[8]

It is important to keep in mind that when medically treating patients with steroids or cyclosporine, patients must be monitored regularly for drug-related adverse effects and complications.

T-lymphocyte immunomodulators, such as tacrolimus, have been used in refractory cases with good response. These agents are administered systemically[9] or topically in ointment form.[10] Internationally, application of tacrolimus dermatologic ointment in children and adults has shown promise as an effective steroid-sparing alternative.[11, 12]

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Elective Surgical Intervention

Atopic keratoconjunctivitis (AKC) is primarily managed medically. However, in some cases in which inflammation is well controlled, elective surgery may be of benefit. Cataract surgery with intraocular lens implantation has been associated with favorable outcomes.[2] However, penetrating keratoplasty for corneal scarring is associated with a higher than average incidence of graft failure. Ocular surface inflammation should be well controlled before surgery.

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Contributor Information and Disclosures
Author

Anne Chang-Godinich, MD, FACS Clinical Associate Professor, Department of Ophthalmology, Baylor College of Medicine; Physician, 1960 Eye Surgeons, PA; Attending Surgeon, Veterans Affairs Medical Center of Houston

Anne Chang-Godinich, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Cataract and Refractive Surgery, Texas Medical Association

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, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Phi Beta Kappa, Pan-American Association of Ophthalmology, American Uveitis Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, International Society of Refractive Surgery, Cornea Society, Eye Bank Association of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Andrew W Lawton, MD Neuro-Ophthalmology, Ochsner Health Services

Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, Southern Medical Association

Disclosure: Nothing to disclose.

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

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

  3. Hu Y, Matsumoto Y, Adan ES, Dogru M, Fukagawa K, Tsubota K, et al. Corneal in vivo confocal scanning laser microscopy in patients with atopic keratoconjunctivitis. Ophthalmology. 2008 Nov. 115(11):2004-12. [Medline].

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

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

  6. 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. 1998 Sep. 105(9):1715-20. [Medline].

  7. Donnenfeld E, Pflugfelder SC. Topical ophthalmic cyclosporine: pharmacology and clinical uses. Surv Ophthalmol. 2009 May-Jun. 54(3):321-38. [Medline].

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

  9. 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. 2008 Sep. 27(8):884-8. [Medline].

  10. Miyazaki D, Tominaga T, Kakimaru-Hasegawa A, Nagata Y, Hasegawa J, Inoue Y. Therapeutic effects of tacrolimus ointment for refractory ocular surface inflammatory diseases. Ophthalmology. 2008 Jun. 115(6):988-992.e5. [Medline].

  11. Labcharoenwongs P, Jirapongsananuruk O, Visitsunthorn N, Kosrirukvongs P, Saengin P, Vichyanond P. A double-masked comparison of 0.1% tacrolimus ointment and 2% cyclosporine eye drops in the treatment of vernal keratoconjunctivitis in children. Asian Pac J Allergy Immunol. 2012 Sep. 30(3):177-84. [Medline].

  12. Al-Amri AM. Long-term follow-up of tacrolimus ointment for treatment of atopic keratoconjunctivitis. Am J Ophthalmol. 2014 Feb. 157(2):280-6. [Medline].

 
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Atopic keratoconjunctivitis. Limbal Trantas dots can be seen in this image.
Atopic keratoconjunctivitis. A corneal shield ulcer is illustrated in this image.
Atopic keratoconjunctivitis. This image depicts a symblepharon.
 
 
 
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