Approach Considerations
Prophylactic measures, prompt 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.
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.
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]
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, topical application of tacrolimus dermatologic ointment in children and adults has shown promise as an effective steroid-sparing alternative. [11, 12, 13]
More recently, the successful use of dupilumab by allergists to alleviate AKC has been reported [14, 15] despite previous reports by dermatologists that the use of dupilumab in treating dermatitis can cause/ worsen AKC. [16]
It is important to keep in mind that when medically treating with steroids, cyclosporine, or other immunomodulators, patients must be monitored regularly for drug-related adverse effects and complications.
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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Atopic keratoconjunctivitis. Limbal Trantas dots can be seen in this image.
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Atopic keratoconjunctivitis. A corneal shield ulcer is illustrated in this image.
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Atopic keratoconjunctivitis. This image depicts a symblepharon.
