Good Hope, Heartlands, and Solihull Eye Clinics

Atopic keratoconjunctivitis (AKC)

David Kinshuck


 

Atopic keratoconjunctivitis

Moorfields  In this condition the surface of the eye becomes red and sore and inflamed. This is a type of allergic eye disease, and is similar to vernal conjunctivitis and giant papillary conjunctivitis. The immune system becomes overactive; a type 2 hypersensitivity reaction. The cause is not known, but it is partly genetic. There are environmental factors we partly understand, and these are discussed below.

The condition affects the conjunctiva, the cornea, and the conjunctiva under the eyelids. 

labels for atopic keratoconjunctivitis

enlarge     the anatomy

Atopic keratoconjunctivitis diagram

enlarge      the problems

The condition causes inflammation of the surface of the eye. The conjunctiva (the skin covering the eye) can develop tiny lumps, limbitis. In addition, the under surface of the upper lid also becomes inflamed. The eye is very red and itchy to start with. When the condition is very active, it is very hard to open the eyes.

If the condition is not treated, the eye becomes very dry, and corneal scarring can reduce the sight. Corneal ulcers can develop, and later also scars. Later and the cornea and the undersurface of the upper lid can become scarred. Lids become thickened, lashes are lost. There may be an ectropion with epiphora (watering).

It tends to affect the upper lid with giant papillae, but these disappear if chronic, and the conjunctiva becomes scarred. The lower corneal surface may be damaged because of the lid problems. There may be relentless corneal vascularisation. As with VKC, herpes simplex infection may occur, and also keratoconus.

The condition tends to begin as an adult, and can continue for many years.

Wide range of allergens trigger the inflammation, but often staph aureus. Patients may develop secondary bacterial  or viral infections (geographic hsv ulcers in absence even of steroids), or rearely squamous cell conjunctiva. There is loss of lashes. There may be large corneal plaques. 

Symptoms

 

 

Medical treatment

This page outlines different treatments. If the condition is severe, advice from an ophthalmologist is essential. Anyone with sore eyes should ideally not use more than 4 eye drops a day containing preservative; if more drops are needed, they should be preservative free.

 

Extremely mild 

Eye drops containing antihistamines, such as antazoline (with xylometazoline hydrochloride as Otrivine-Antistin ®), azelastine hydrochloride, epinastine hydrochloride, ketotifen, and olopatadine, can be used for allergic conjunctivitis.BNF 20

Treat lids

Bactroban for lids

 

Preservative free lubricants

These are make the surface of the eye smooth. For mild disease Viscotears or Xailin gel 4 times a day may help. Xailin night may help at night.

Most patients attending hospital will need more intensive lubricant drops

dry eye with lubricants

enlarge

 

Moderate disease

Opatanol, Olopatadine bd (twice/day) US name is Patanol It is a mast cell stabiliser/antihistamine, and can help see   see.

 

Antihistamine tablets

Antihistamine tablets such as Cetirizine , Levocetirizine (5mg >6y age), Loratidine Others. They may make you too tired but are generally safe.
There are many types of antihistamine tablets and some make more people tired than others. Ask your doctor and pharmacist for advice. If you have many episodes of AKC and find this helps, start these as soon as the eyes get sore.

 

Steroid drops for more severe problems

Mild disease may respond to FML 3 times a day, reducing the dose over a few weeks. FML is a weak steroid, but is not ideal for continued use (see paragraph below).

Most hospital patients will need steroid eye drops, and these should be preservative free, such as dexamethasone preservative free e.g. Dropadex. They should not be used without an ophthalmologist's advice, unless your GP is experienced in their use and you only use them for short periods.

They have side effects, such as increasing the eye pressure, (causing glaucoma) and cataracts (which may need surgery later). Even short term use of steroid drops can activate herpes simplex keratitis.

If the eyes are red and sore and itchy, start 4 times a day. As soon as the redness fades, usually about 4 days, start to reduce the dose of the steroid to 3 and then twice a day. Once the redness has faded, continue for a few more days and then try to stop them.

If the redness and itch returns every time you stop, and as advised by your ophthalmologist, you may need to use a low dose regularly, such as once a day, and later alternate day use, or every third day etc, and then stopping.

Steroid drops have many side effects if used in the wrong manner. You need to be certain that you do have 'allergic conjunctivitis' and not another condition, and most people can recognise when their eyes are red and itchy the condition has returned.

If you have a scratchy and painful eye, you may have an ulcer and the drops should be stopped and you should get expert advice.

Protopic (tacrolimus)   as below should be added if continued steroid drops are needed.

 

Protopic/Tacrolimus ointment (and Cyclosporine)

Tacrolimus ointment 0.03 % twice day (Protopic) to skin around eye cream twice takes a few weeks to work, so it should be started whilst the patient is using the steroid drops, with a maximum effect at 6 months, although there should be a definite improvement after 4 weeks. Some of the Protopic ointment should be allowed to enter the eye (otherwise there will be no effect on the conjunctiva).

Once the Protopic is working, the dose of the steroid drops can be reduced and may be stopped or continued at a low dose (reducing from 4 times a day to once a day or less often perhaps). When the Protopic is started it stings for a few days, but the stinging effect wears off. see see  tacrolimus

Plaque

...excise

Extremely severe

Pulsed methylprednisolone and long term immunosuppression and newer treatments.

Differential diagnosis

This includes

 

General measures

NICE guidelines

 

Dust allergy : precautions

People with allergic eye disease may be sensitive to dust, and the measures below may help. (This includes a few patients with AKC, but the advice just here is mainly for patients with mild allergic conjunctivitis.)

If you have a dust allergy there is plenty you can do. Visit the websites below for more details. This page has many details....although written for asthma patients, advice may be helpful.

Lifestyle issues and Mediterranean diet

Lifestyle issues are critically important for patients with AKC

Summarising: stepwise treatment of allergic conjunctivitis, including children

Stepwise treatment of allergic conjunctivitis
  • Look again at prevention, especially if you are allergic to dust.
  • Anti-dust measures such as freezing bedding/pillows/pillow cases for a few hours or buying a new pillow or special covers can help.
  • Healthy diet, vegetables, fish, exercise, no smoking, vitamin D, avoiding obesity
  • vitamin D supplements
  • Eye drops containing antihistamines, such as antazoline (with xylometazoline hydrochloride as Otrivine-Antistin ®), azelastine hydrochloride, epinastine hydrochloride, ketotifen, and olopatadine, can be used for allergic conjunctivitis.BNF 20
  • Lubricants such as Vismed, Hyloforte, Hyabak, Clinitas (sodium hyaluronate 0.4% preservative-free) Visuxl, Thealoz do, every 1/2 -2 hourly
  • Night time lubricant: best VitApos at night, Xailin night second best.   
  • certainly seek your GPs help. 
  • Olopatadine (Opatanol) bd (twice/day) helps many people. (or Ketotifen)
  • At this stage it is best to seek specialist help if you are still having severe problems,
  • Antihistamine tablets may help. You may need a slightly higher than recommended dose if your hey fever is very troublesome. Cetirizine but there are many others. Levocetirizine (5mg >6y age), Loratidine Others.
  • FML drops for milder cases.
  • dexamethasone drops preservative free, and this should not be used without an ophthalmologist's advice, unless your GP is experienced in its use and you only use it for short periods, start 4 times a day for a week and reduce.
  • Severe cases, guided by an ophthalmologist. Protopic: Occ tacrolimus  0.03 % bd to skin around eye, allowing a little to enter the eye.
  • more severe patients may need immunosupression and other new treatment.

 

VKC or AKC?

 

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