You are in: eMedicine Specialties > Ophthalmology > CORNEA Keratoconjunctivitis, AtopicArticle Last Updated: Sep 29, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Anne Chang-Godinich, MD, Assistant Clinical Professor, Department of Ophthalmology, Baylor College of Medicine Anne Chang-Godinich is a member of the following medical societies: American Academy of Ophthalmology Coauthor(s): Michael B Raizman, MD, Director of Cornea, External Disease, Anterior Segment Service, Associate Professor, Department of Ophthalmology, Tufts School of Medicine Editors: Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center; Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles; Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Hospital; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences Author and Editor Disclosure Synonyms and related keywords: atopic keratoconjunctivitis, AKC, bilateral conjunctivitis, atopic dermatitis, allergic conjunctivitis, giant papillary conjunctivitis, vernal keratoconjunctivitis, systemic allergy INTRODUCTIONSection 2 of 11
  BackgroundAtopic keratoconjunctivitis (AKC) is a relatively uncommon but potentially blinding ocular condition. In 1952, Hogan described AKC as a bilateral conjunctivitis occurring in 5 male patients with atopic dermatitis. Originally described to flare with worsening dermatitis, Foster et al noted that some patients' ocular involvement evolves independent of dermatitis. AKC is associated with a 95% prevalence of concomitant eczema and an 87% prevalence of asthma. Other than AKC, common ocular atopic phenomena include allergic conjunctivitis, giant papillary conjunctivitis, and vernal keratoconjunctivitis. PathophysiologyAtopy refers to hypersensitivity in patients with familial histories of allergic disease. Individuals with atopy often have environmental allergies, allergic asthma, rhinitis, and atopic dermatitis or eczema. Less commonly, they exhibit food allergies, urticaria, and nonhereditary angioedema. Immunoglobulin E (IgE) is the serum mediator of the exuberant responses. Hypersensitivity reactions associated with types I and IV contribute to the inflammatory changes of the conjunctiva and the cornea that are found in AKC. During exacerbations, patients have increased tear and serum IgE levels and increased numbers of circulating B cells; T-cell levels are depressed. FrequencyInternationalAtopy affects 5-20% of the general population. AKC occurs in 20-40% of individuals with atopic dermatitis. Mortality/MorbidityDecreased vision and blindness result from chronic superficial punctate keratitis, persistent epithelial defects, corneal scarring or thinning, keratoconus, cataracts, and symblepharon formation. The use of corticosteroids to medically treat AKC can further promote the development of cataracts, glaucoma, and secondary corneal infections. SexThis condition is more prevalent in men than in women. AgePeak age of incidence is in persons aged 30-50 years. The age range is from the late teenaged years to 50 years. CLINICALSection 3 of 11
HistoryLook for the following in past medical history:
Physical
CausesSee Pathophysiology. DIFFERENTIALSSection 4 of 11
Blepharitis, Adult Cicatricial Pemphigoid Conjunctivitis, Allergic Conjunctivitis, Giant Papillary Conjunctivitis, Viral Red Eye Evaluation Trachoma
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| Drug Name | Cromolyn sodium 4% (Opticrom, Crolom) |
|---|---|
| Description | Inhibits histamine and SRS-A (slow-releasing substance of anaphylaxis) release from mast cells but has no intrinsic anti-inflammatory, antihistamine, or vasoconstrictive effects. |
| Adult Dose | 1-2 gtt 4-6 times/d |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Not for use while wearing contact lenses; transient ocular stinging or burning upon instillation is most frequently reported adverse reaction; uncommon adverse reactions include conjunctival infections, watery eyes, itchy eyes, dryness around eyes, puffy eyes, eye irritation, and styes |
| Drug Name | Lodoxamide tromethamine 0.1% (Alomide) |
|---|---|
| Description | Stabilizes mast cells and inhibits increased vascular permeability, which is associated with IgE and antigen-mediated reactions. Alomide has been reported to prevent calcium influx into mast cells upon antigen stimulation without intrinsic anti-inflammatory, antihistamine, or vasoconstrictive effects. |
| Adult Dose | 1-2 gtt qid |
| Pediatric Dose | <2 years: Not established >2 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Not for injection; patients often experience transient burning or stinging from instillation; soft contact lens wearers should refrain from using them while under treatment |
| Drug Name | Nedocromil sodium 2% (Alocril) |
|---|---|
| Description | Interferes with mast cell degranulation, specifically with release of leukotrienes and platelet activating factor. |
| Adult Dose | 1-2 gtt bid |
| Pediatric Dose | <3 years: Not established >3 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Adverse events include ocular irritation/burning, headache, nasal congestion, and unpleasant taste in 10-40% of patients |
| Drug Name | Pemirolast potassium 0.1% (Alamast) |
|---|---|
| Description | Interferes with mast cell degranulation and mast cell stabilizer in both early and late phases. |
| Adult Dose | 1-2 gtt qid |
| Pediatric Dose | <3 years: Not established >3 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | For topical ophthalmic use only (not for injection or oral use); instruct patients who wear soft contact lenses and whose eyes are not red to wait >10 min after applying drops to insert contact lenses |
Act by competitive inhibition of histamine at the H1 receptor. For prophylaxis and symptomatic relief.
| Drug Name | Olopatadine hydrochloride 0.1% (Patanol) |
|---|---|
| Description | Inhibits histamine release through both selective H1 histamine receptor antagonism and less specific mast cell stabilization. |
| Adult Dose | 1-2 gtt bid at 6-8 h intervals |
| Pediatric Dose | <3 years: Not established >3 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Do not use while wearing contact lenses; not for injection; adverse reactions include burning or stinging, dry eye, foreign body sensation, hyperemia, keratitis, lid edema, pruritus, headaches, asthenia, cold syndrome, pharyngitis, rhinitis, sinusitis, and taste perversion |
| Drug Name | Ketotifen fumarate 0.025% (Zaditor) |
|---|---|
| Description | Selective H1 histamine receptor antagonist and mast cell stabilizer. Inhibits release of mediators from cells involved in hypersensitivity reactions. |
| Adult Dose | 1-2 gtt in affected eye(s) bid |
| Pediatric Dose | <3 years: Not established >3 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | For topical ophthalmic use only; not for treatment of contact lens–related inflammation; wait 10 min before inserting lenses after ketotifen use; do not contaminate dropper tip or solution when placing drops in eyes; in controlled clinical studies, minor conjunctival injection, headaches, and rhinitis were reported at an incidence of 10-25% |
| Drug Name | Azelastine hydrochloride 0.05% (Optivar) |
|---|---|
| Description | Antihistamine and mast cell stabilizer. |
| Adult Dose | 1 gtt in affected eye(s) bid |
| Pediatric Dose | <3 years: Not established >3 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Instruct patients who wear soft contact lenses and whose eyes are not red to wait >10 min after applying drops to insert contact lenses; transient eye burning and stinging, headaches, and bitter taste were reported in 10-30% of patients |
| Drug Name | Epinastine hydrochloride 0.05% (Elestat) |
|---|---|
| Description | H1 antihistamine and mast cell stabilizer. |
| Adult Dose | 1 gtt in affected eye(s) bid |
| Pediatric Dose | <3 years: Not established >3 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Ocular reactions of burning sensation, folliculosis, hyperemia, and pruritus reported in 1-10% of patients; nonocular reactions of cold symptoms and upper respiratory infections seen in 10% of patients |
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
| Drug Name | Prednisolone acetate 1%, 0.12% (Pred Forte, Pred Mild) |
|---|---|
| Description | On the basis of weight, has 3-5 times the anti-inflammatory potency of hydrocortisone. Glucocorticoids inhibit edema, fibrin deposition, capillary dilation and proliferation, phagocytic migration of acute inflammatory response, deposition of collagen, and scar formation. |
| Adult Dose | 1-2 gtt bid/qid; may increase prn based on clinical response |
| Pediatric Dose | Documented hypersensitivity; viral, fungal, or tubercular infections |
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular infections |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate) |
| Drug Name | Fluorometholone 0.1%, 0.25% (FML, FML Forte) |
|---|---|
| Description | Inhibits edema, fibrin deposition, capillary dilation and phagocytic migration of acute inflammatory response and capillary proliferation, collagen deposition, and scar formation. Used topically, it can elevate IOP and cause steroid-response glaucoma. In clinical studies of documented steroid responders, fluorometholone demonstrated a significantly longer average time to produce a rise in IOP than dexamethasone phosphate. In a small percentage of individuals, a significant rise in IOP occurred within 1 wk. The ultimate magnitude of the rise was equivalent. |
| Adult Dose | 1 gtt bid/qid; may increase prn depending on clinical response |
| Pediatric Dose | <2 years: Not established >2 years: Administer as in adults |
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular infections |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate) |
| Drug Name | Loteprednol etabonate 0.5%, 0.2% (Lotemax, Alrex) |
|---|---|
| Description | Structurally similar to other corticosteroids, but the number 20 position ketone group is absent. Highly lipid soluble, which enhances cell penetration. Undergoes a predictable transformation to an inactive carboxylic acid metabolite. Shown to be less effective than prednisolone acetate 1% in two 28-d controlled clinical studies in acute anterior uveitis; 72% of patients treated with Lotemax experienced resolution of anterior chamber cells compared to 87% of patients treated with prednisolone acetate 1%. Incidence of patients with clinically significant increases in IOP (>10 mm Hg) was 1% with Lotemax and 6% with prednisolone acetate 1%. |
| Adult Dose | 1 gtt qid; may increase to q1h during first wk prn for clinical response |
| Pediatric Dose | Not established |
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular infections |
| Interactions | None reported |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate) |
Used as adjunctive or alternative treatment in situations where steroid use is ineffective or requires minimization.
| Drug Name | Cyclosporine (Sandimmune) |
|---|---|
| Description | Exact mechanism of immunosuppressive activity is unknown. Preferential and reversible inhibition of T lymphocytes in the G0 or G1 phase of the cell cycle suggested. |
| Adult Dose | Cyclosporine 0.05% or 2% suspended in oil: Apply 0.05% 6 times daily for 2 wk then qid. Apply 2% qid; effective for flares and may consider as adjunct or possible alternate therapy when steroid use needs to be minimized Aggressive treatment: 5 mg/kg/d PO may induce remission; may require low-dose maintenance therapy of 5 mg/kg q5d |
| Pediatric Dose | Not established; children as young as 6 mo have received the drug with no adverse effects |
| Contraindications | Documented hypersensitivity |
| Interactions | If oral product use, monitor for drug interactions; carbamazepine, phenytoin, isoniazid, rifampin, and phenobarbital may decrease cyclosporine concentrations; azithromycin, itraconazole, nicardipine, ketoconazole, fluconazole, erythromycin, verapamil, grapefruit juice, diltiazem, aminoglycosides, acyclovir, amphotericin B, and clarithromycin may increase cyclosporine toxicity; acute renal failure, rhabdomyolysis, myositis, and myalgias increase when taken concurrently with lovastatin |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Frequently evaluate renal and liver functions by measuring BUN, serum creatinine, serum bilirubin, and liver enzymes; may increase risk of infection and lymphoma; reserve IV use only for those who cannot take PO |
| Media file 1: Atopic keratoconjunctivitis. Limbal Trantas dots. | |
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| Media file 2: Atopic keratoconjunctivitis. Corneal shield ulcer. | |
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| Media file 3: Atopic keratoconjunctivitis. Symblepharon. | |
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Keratoconjunctivitis, Atopic excerpt
Article Last Updated: Sep 29, 2006
