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Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 57-59

Atopic keratoconjunctivitis: A classical presentation and the emerging role of tacrolimus in its management

1 Department of Ophthalmology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India
2 Department of Dermatology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India

Date of Submission03-Oct-2016
Date of Acceptance08-Dec-2016
Date of Web Publication12-Jul-2017

Correspondence Address:
Elfride Farokh Sanjana
Department of Ophthalmology, Pondicherry Institute of Medical Sciences, Kalapet - 605 014, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-3069.210343

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We describe a rare and classical presentation of atopic keratoconjunctivitis that responded well to tacrolimus skin ointment. Furthermore, the emerging role of tacrolimus in the treatment of atopy is also highlighted briefly.

Keywords: Atopy, shield ulcer, tacrolimus ointment

How to cite this article:
Ninan RS, Sanjana EF, Prasanth HR, Kuruvila S. Atopic keratoconjunctivitis: A classical presentation and the emerging role of tacrolimus in its management. J Curr Res Sci Med 2017;3:57-9

How to cite this URL:
Ninan RS, Sanjana EF, Prasanth HR, Kuruvila S. Atopic keratoconjunctivitis: A classical presentation and the emerging role of tacrolimus in its management. J Curr Res Sci Med [serial online] 2017 [cited 2023 May 30];3:57-9. Available from: https://www.jcrsmed.org/text.asp?2017/3/1/57/210343

  Introduction Top

The term atopy refers to the state of hypersensitivity in individuals who are prone to allergic disorders. It affects around 10%–20% of the population, with hay fever, allergic asthma, and atopic dermatitis being the most common presentations. In the eye, common manifestations include atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC), giant papillary conjunctivitis, symblepharon, trichiasis, and  Meibomitis More Details. There is a tendency for recurrence in atopic disorders.

This case presented with a shield ulcer, a classical ocular manifestations of AKC. The ulcer responded well to tacrolimus, highlighting its effectiveness as a steroid-sparing agent in the management of the condition.

  Case Report Top

A 30-year-old man under treatment for atopic dermatitis presented with diminished vision in both eyes for 15 days which was sudden in onset, progressive, associated with redness, pain, photophobia, and burning sensation in both eyes. There was no history of trauma. On examination, best-corrected visual acuity was 6/60 in the right eye and 6/24 in the left eye. Lids were erythematous, congested with papillae present in the palpebral conjunctiva.

Right eye cornea showed an opacity of 4 mm × 4 mm in the paracentral cornea, involving only the anterior stroma. Fluorescein stain was negative, implying an intact corneal epithelium [Figure 1]. Surrounding the lesion were numerous punctate epithelial erosions [Figure 2]. Corneal sensations were reduced.
Figure 1: Anterior stromal opacity (right eye)

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Figure 2: Punctate epithelial erosions (right eye)

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Left eye showed an opacity of 3 mm × 3 mm in the paracentral cornea, involving the anterior stroma with an overlying central 1 mm × 1 mm area of epithelial defect which took up fluorescein stain. Rest of the cornea revealed florid punctate epithelial erosions [Figure 3]. Corneal sensation was reduced.
Figure 3: Epithelial defect (left eye)

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A provisional diagnosis of shield ulcer secondary to AKC was made.

The patient was started on treatment with moxifloxacin and loteprednol combination eye drops 0.5% four times a day, olopatadine eye drops, an antihistamine two times a day and tear substitute every 2nd hourly, and tacrolimus eye ointment two times a day.

Over a period of one week, the patient had resolution of symptoms, decrease in size of lesion, and resolution of punctate epithelial erosions [Figure 4] and [Figure 5].
Figure 4: View of healed right eye after 1 week

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Figure 5: View of healed left eye after 1 week

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  Discussion Top

Atopy refers to hypersensitivity in patients who have a hereditary predisposition to allergic disease. Atopic disorders are mainly Type 1 hypersensitivity reactions. The various atopic diseases include bronchial asthma, atopic dermatitis, urticaria, seasonal and perennial rhinitis, nonhereditary angioedema, and food allergies. VKC and AKC are thought to involve a more complex interaction between the immune and inflammatory systems of the body. The mechanism by which ocular surface disease occurs involves various stages including presentation of the antigen to the mucosal surface, sensitization of the body against the allergen through the production of IgE antibodies, subsequent contact with the allergen and binding of the allergen to the IgE antibody on the mast cells, and its subsequent degranulation and recruitment of leukocytes. The resulting changes including congestion and increased vascular permeability are thought to cause the ocular surface changes seen in the above conditions.[1]

AKC is usually seen in adults with a peak incidence in the 30–50 years' age group.

Patients present with symptoms of pruritus, burning sensation of lids, and lacrimation. It is usually a bilateral disease with majority of the patients having associated lid lesions such as eczema, blepharitis, trichiasis, and meibomitis. Conjunctival involvement presents with hyperemia and giant papillae, with symblepharon and blepharoconjunctivitis occurring in long-standing cases. Corneal lesions consisting of punctate epithelial erosions, intraepithelial microcysts, corneal neovascularization, shield-shaped anterior corneal scars and epithelial defects are important causes of morbidity.[2]

Keratoconus is a degenerative disorder of the cornea leading to corneal thinning and protrusion, and has been associated with VKC and AKC. In patients with atopy, a more rapid progression with earlier need for surgical intervention and more frequent complications have been reported.[3],[4]

This patient also presented with symptoms of watering, redness, pain, burning sensation with examination findings of erythematous lids, papillary conjunctivitis, and shield ulcer.

Treatment options include avoidance of the allergen, cold compresses, lubricants in the form of artificial tears, vasoconstrictors, mast cell stabilizers, and nonsteroidal anti-inflammatory drugs. While these can relieve the symptoms, resolution is seldom achieved with the above options. Topical steroids are effective in treating the inflammatory condition, but long-term steroid therapy can cause complications such as raised intraocular pressure, cataract formation, and infection by opportunistic organisms.

Newer treatment options include immunomodulators such as cyclosporine and immunosuppressive macrolide such as tacrolimus.

Tacrolimus is an immunosuppressive macrolide, isolated from Streptomyces tsukubaensis. It is used in prevention of allograft organ rejection and is effective in atopic dermatitis. It is also effective in refractory ocular surface inflammatory diseases. It is 30 times more potent than cyclosporine.[5] It acts by being a competitive blocker for calcineurin preventing T-cell activation of inflammatory cytokine pathways. This effect also applies to B-cells and mast cells. Its main side effects include renal toxicity and hypertension, but these are minimal when applied topically. When applied topically, it can cause burning sensation and recurrent herpetic lesions. Studies have reported its efficacy in peripheral ulcerative keratitis and AKC. Therapy with tacrolimus has to be continued for 3–6 months. The drug is well tolerated for long periods of time with minimal risk of adverse effects associated with long-term steroid usage including cataract formation and raised intraocular pressure.[5]

Similar results with tacrolimus were obtained in a study conducted on patients with AKC and atopic eyelid disease.[6],[7]

Thus, both tacrolimus and cyclosporine are efficacious steroid-sparing agents in the treatment of AKC.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Foster CS, Calonge M. Atopic keratoconjunctivitis. Ophthalmology 1990;97:992-1000.  Back to cited text no. 1
Tuft SJ, Kemeny DM, Dart JK, Buckley RJ. Clinical features of atopic keratoconjunctivitis. Ophthalmology 1991;98:150-8.  Back to cited text no. 2
Leonardi A, De Dominicis C, Motterle L. Immunopathogenesis of ocular allergy: A schematic approach to different clinical entities. Curr Opin Allergy Clin Immunol 2007;7:429-35.  Back to cited text no. 3
Ondas O, Keles S. Central corneal thickness in patients with atopic keratoconjunctivitis. Med Sci Monit 2014;20:1687-90.  Back to cited text no. 4
Miyazaki D, Tominaga T, Kakimaru-Hasegawa A, Nagata Y, Hasegawa J, Inoue Y. Therapeutic effects of tacrolimus ointment for refractory ocular surface inflammatory diseases. Ophthalmology 2008;115:988-92.e5.  Back to cited text no. 5
García DP, Alperte JI, Cristóbal JA, Mateo Orobia AJ, Muro EM, Valyi Z, et al. Topical tacrolimus ointment for treatment of intractable atopic keratoconjunctivitis: A case report and review of the literature. Cornea 2011;30:462-5.  Back to cited text no. 6
Rikkers SM, Holland GN, Drayton GE, Michel FK, Torres MF, Takahashi S. Topical tacrolimus treatment of atopic eyelid disease. Am J Ophthalmol 2003;135:297-302.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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