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
Gonzlez-Lpez JJ, Lpez-Alcalde J, Morcillo Laiz R, Fernndez
Buenaga R, Rebolleda Fernndez 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)

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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