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CLINICAL MANAGEMENT GUIDELINES Atopic Keratoconjunctivitis (AKC) Aetiology Severe ocular surface disease affecting some atopic individuals Complex immunopathology Sometimes follows childhood Vernal Keratoconjunctivitis (VKC) (see Clinical Management Guideline on Vernal Keratoconjunctivitis) Predisposing factors Typically affects young adult atopic males There may be a history of asthma, hay fever, eczema and atopic dermatitis and VKC in childhood Specific allergens may exacerbate the condition There are associations with facial eczema and staphylococcal lid margin disease Symptoms Ocular itching, watering, usually bilateral Blurred vision, photophobia White stringy mucoid discharge Onset of ocular symptoms may occur several years after onset of atopy Symptoms usually year-round, with exacerbations Signs Eyelids may be thickened, crusted and fissured Associated chronic staphylococcal blepharitis Tarsal conjunctiva: giant papillary hypertrophy, subepithelial scarring and shrinkage Entire conjunctiva hyperaemic Limbal inflammation Corneal involvement is common and may be sight-threatening: beginning with punctate epitheliopathy that may progress to macro-erosion, plaque formation (usually upper half), progressive corneal subepithelial scarring, neovascularisation and thinning These patients are prone to develop herpes simplex keratitis, corneal ectasia such as keratoconus, atopic (anterior or posterior polar) cataracts, retinal detachment Differential diagnosis Vernal Keratoconjunctivitis Other allergic conjunctivitis, eg Giant Papillary Conjunctivitis (GPC) (often contact lens-related) Toxic Keratoconjunctivitis Management by Optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere Non pharmacological Lid hygiene and treatment of associated staphylococcal blepharitis (see Clinical Management Guideline on Blepharitis) Cool compresses Advise avoidance of specific allergens if known, e.g. elimination of pets and carpeting, where necessary; instillation of air filtering devices and alterations to bedding materials (GRADE*: Level of evidence=low, Strength of recommendation=strong) Pharmacological Systemic antihistamines e.g. cetirizine Topical mast cell stabilisers, e.g. gutt. sodium cromoglicate 2%, gutt. lodoxamide 0.1%, gutt. nedocromil sodium 2%, or dual acting agents e.g. olopatadine 0.1%, may also provide symptomatic relief (GRADE*: Level of evidence=moderate, Strength of recommendation=strong) Management Category Severe corneal complications are common and potentially sightthreatening. If corneal epithelial macro-erosion or plaque are present: A3: First aid measures followed by urgent referral (within one week) to an Ophthalmologist Milder cases (without active corneal involvement): Atopic Keratoconjunctivitis (AKC) Version 12, Page 1 of 2 Date of search 13.09.14; Date of revision 14.11.14; Date of publication 28.10.14; Date for review 12.09.16 © College of Optometrists CLINICAL MANAGEMENT GUIDELINES Atopic Keratoconjunctivitis (AKC) B1: Possible prescription of drugs; routine referral Possible management by Ophthalmologist Topical steroids with monitoring and management of complications, eg steroid glaucoma and cataract. Topical/systemic antibiotic for lids. Topical immunosuppression (e.g. ciclosporin) (see evidence base) Treatment of facial eczema and atopic blepharitis Surgery for atopic cataract Evidence base *GRADE: Grading of Recommendations Assessment, Development and Evaluation (see http://www.gradeworkinggroup.org/index.htm) Sources of evidence Power WJ, Tugal-Tutkun I, Foster CS. Long-term follow-up of patients with atopic keratoconjunctivitis. Ophthalmology 1998;105:637-42 Chen JJ, Applebaum DS, Sun GS, Pflugfelder SC. Atopic keratoconjunctivitis: a review. J Am Acad Dermatol. 2014;70(3):569-75 González-López JJ, López-Alcalde J, Morcillo Laiz R, Fernández Buenaga R, Rebolleda Fernández G. Topical cyclosporine for atopic keratoconjunctivitis. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD009078 LAY SUMMARY Atopic keratoconjunctivitis is a chronic (long-term) allergic condition of the eyelids and front surface of the eye. It is present in a high percentage of patients suffering from the skin condition, atopic dermatitis. Atopic keratoconjunctivitis requires long-term treatment to prevent sight-threatening complications such as scarring of the cornea (the clear window at the front of the eye). In the early stages of the disease, symptoms can be controlled by standard anti-allergy drugs. However, shortterm use of steroid eye drops is often required when symptoms are severe. There is some evidence that cases that do not respond to steroids, or those requiring steroids eye drops long term, may benefit from ciclosporin eye drops or ointment. Atopic Keratoconjunctivitis (AKC) Version 12, Page 2 of 2 Date of search 13.09.14; Date of revision 14.11.14; Date of publication 28.10.14; Date for review 12.09.16 © College of Optometrists