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Chronic-Atopic Dermatitis

with Keratoconjuctivitis (AKC)General Characteristics

– A chronic, rare disorder seen in associationwith asthma, hay fever and atopic eczemoiddermatitis

– Dermatitis may begin as early as infancy withocular findings more common in older patients

– Most ocular signs develop after several yearsof atopic features; men more frequently

– Many cases improve by 4-5th decade

– Little or no seasonal variation, winter worse

– Differs from VKC by obvious skin/lid signs

Eczema

• Most common on forehead,

cheeks, flexor surfaces of the

arms & legs

• Itching & scratching can be so

intense that skin becomes

erythematous, excoriated,

lichenfied & hypopigmented

Symptoms

– Chronic itching of lid skin, periorbitalarea & conjunctiva, burning,photophobia and tearing

– Mucous discharge

Signs

– Key findings are the eyelids- thickened,red and sore/fissures especially in lateralcanthi with ulcerations plus chronicstaph. blepharitis, ptosis

– Conjunctiva is hyperemic

– Mild to moderate papillary reaction,usually inferiorly

– Inferior fornix scarring withsymblepharon formation

– Corneal involvement: usually inferior

Punctate staining, persistent epithelialdefects, neovascularization andscarring (shield shaped)

Secondary infections: herpes &bacterial

Reported association of keratoconus &pellucids

Reported association with anterior orposterior subcapsular or polar cataractsthat begin as early as 16 years andprogress.

Typical Clinical Profile

• Red, scaly, itchy skin on eyelids and

around eyes that does not respond

well to topical steroid preparations

• Have a “racoon” look

• Significant keratoconjunctivitis / PEK

that is refractory to most all topical

treatment

Clinical Profile

• Proper differential diagnosis is

critical!

• Very frustrating for doctor and

patient because nothing seems to

bring relief…….steroids, tears,

punctal occlusion, anti-allergy drops

all provide limited relief

• There is hope!

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Treatment

• Topical steroids

• Mast cell stabilizer

• Oral antihistamines

• Systemic antibiotics

• Elidel (Pimecrolimus) topicalmedication

•Nonsteroidal

•Exact mechanism is not

understood

Tacrolimus / Pimecrolimus

• Non-steroidal immune modulators

• Blocks t-lymphocyte activation: atopicdisease is caused by abnormal t-cellnumbers and functions

• Inhibits formation of pro-inflammatorycytokines

• Treatment of skin leads to resolution ofocular complications by decreasinginflammatory mediators

Tacrolimus /

Pimecrolimus• Treatment regimen is to apply to skin /

lids BID

• NOT to be used in the eye

• After several months, if treatment has

been effective can reduce to two

applications per week

• No long-term side effects have been seen

• Does not cause skin atrophy or

discoloration like topical steroids can

Treatment

• Restasis can be used

in refractory cases to

help relieve ocular

complications by

mediating T-cell

function

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AKC

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Allergy TreatmentAcute Drug Treatment

– OTC topical vasoconstrictors alone orcombined with antihistamines? Maybe reboundvasodilation, may mask symptoms: Naphcon A,Opcon A, Vascon A, Visine-A

– Acular (Allergan) -Ketorlac tromethamine0.5%: 1 gtt qid, also in PF, New-Acular LS .4%

– Topical NSAIDs - raises the sensory thresholdof peripheral nerve endings such that sensationof itch is reduced

– Note: oral aspirin therapy has been shown touseful in VKC 1g aspirin daily x 6 weeks

Acular, Allergan

• Qid x 1-3 weeks

• Stings upon instillation

• Available PF, unit dose

Alrex (B & L)-lotreprednol etabonate .2%

ophth. susp.

– qid as needed to control itching

– FDA approved for ocular allergy

– Site-specific steroid

– Shaken prior to instillation

Emadine (Alcon)- emedastine

difumarate 0.05% ophth. sol.

–Topical antihistamine approved for

temporary relief of the signs and

symptoms of allergic conjunctivitis

–qid as needed

–Also for treatment of lid myokymia

• Qid for 1 week, then bid for 1-2 weeks

Livostin (Ciba Vision) -

levocabastine 0.05%

–A potent histamine type I (H1)

receptor blocker

–Shaking is required-suspension

–Qid or as needed

–No longer available!

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Oral Antihistamines

• Occasionally used to relieve symptomsof severe allergic conjunctivitis

• Four agents: Allegra 60mg bid & 180mgqd, Claritin 10mg qd OTC, Clarinex 5mg qd, Zyrtec 10mg

• Safe & effective relief from allergysymptoms and are minimally sedating

• May cause ocular dryness- may actuallyexacerbate ocular allergies

Patanol

• Patanol (olpatadine hydrochloride 0.1%,

Alcon)

-Topical antihistamine with some mast cell

stabilizing properties

-1 drop bid

New Patanol 0.2% with qd dosing

Zaditor

• Zaditor ( ketotifen fumarate 0.025%,

Novartis)

-Histamine, mast cell plus inhibits

eosinophilic chemotaxis

-1 drop bid

- Cost is 25% less than Patanol

• Optivar (azelastine hydochloride,B&L) 0.05%

–Mast cell-stabilizer, antihistamine,decreases chemotaxis & eosinophilactivation

–1 gtt bid

–Post nasal metallic taste

• Elestat (0.05%) epinastine

hydrochloride 0.05%) Allergan

bid

Topical Steroids-short course!

–Prednisolone sodium phosphate 1%

–Rimexlone

–Fluorometholone acetate

–Prednisolone acetate 1%

–Loteprednol etabonate: .2 %Alrex/ 0.5% (Lotemax)

• Q2h for 2 days, then qid for 1 week,then bid, then qd