Atopic Keratoconjunctivitis

Question 1

Aetiology?

Answer 1

Severe and sight threatening allergic eye disease due to chronic inflammation.
Type 4 T-cell mediated hypersensitivity - complex immunopathology
Symptoms begin in late teens/early twenties and persist into 4th/5th decade of life - peaking between 30-50years of age.
history of VKC.

Question 2

Predisposing factors?

Answer 2

Strong link with staphylococcal eyelid disease / bleph
May have asthma, eczema (affecting eyelid and periorbital skin).
History of atopy.
Family history of atopic disease.
Allergies may exacerbate condition.

Question 3

Symptoms?

Answer 3

Itching, burning, photophobia, watering
Blurred vision
White stringy mucoid discharge
Bilateral, all year round, with seasonal exacerbations.

Question 4

Signs?

Answer 4

Eyelids are thickened, crusted and fissures. May show staphylococcal eye disease (bleph).

Skin around eyelids is more pigmented.
Tarsal conjunctiva - giant papillary hypertrophy, shrinkage and scarring, subepithelial fibrosis.

Limbal inflammation - Tantras dots.

Entire conjunctiva is hyperaemic

Corneal involvement common - begins as punctate epitheliopathy, progressing to macro-erosions, plaque formation, sub epithelial scarring, neovasc/pannus, thinning, perforation.

Patients are more likely to develop HSK, cataracts, RD, keratoconus, recurrent corneal erosions.

Question 5

Differential diagnosis?

Answer 5

VKC
Other causes of chronic conjunctivitis such as GPC

Question 6

Non-pharmacological management?

Answer 6

Lid hygiene routine for bleph
Elimination of known allergens such as pets, carpeting, changing to bedding, installing air filters
Cold compresses

Question 7

Pharmacological management?

Answer 7

Lubricants - drops during day, ointment before bed
Antihistamines
MCS e.g. sodium cromoglicate 2% qds, lodoxamide 0.1% qds
or dual acting MCS+AH such as olopatadine 0.1% bds max 4/12, ketotifen 0.025% bds

maintain low threshold for referral as sight threatening

Question 8

Management?

Answer 8

All patients should be referred:

if mild without corneal involvement - refer routinely
if corneal involvement present e.g. macro erosion or plaque, refer urgently.

Question 9

Management at hospital?

Answer 9

multidisciplinary approach - immunology, dermatology, ophthalmology
topical steroids, topical/systemic antibiotics for eyelid disease, topical immunomodulators such as ciclosporin/tacrolimus, treatment of facial eczema, surgery for cataract,

usually a combo of topical and systemic treatment.