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    Managing treatment options for atopic keratoconjunctivitis

    Corticosteroid therapy, calcineurin inhibitors, off-label dermatologic drug may offer relief


    Recommended treatment

    The recommended treatment for AKC is a stepwise approach based on disease severity in both the conjunctiva and cornea, as well as the potential for sight-threatening complications. Antihistamines and mast cell stabilizers may be helpful for cases with a milder form of disease in which the primary symptom is itching.

    If the disease has progressed to moderate conjunctival inflammation (particularly if conjunctival thickening is affecting the cornea), corneal epithelial involvement, or corneal neovascularization, corticosteroid therapy is recommended. For patients requiring chronic corticosteroid therapy, consider topical calcineurin inhibitors such as tacrolimus or cyclosporine.

    “In the most severe cases you may have to resort to use of systemic calcineurin inhibitors or corticosteroids,” Dr. Pflugfelder said. “In my career, I’ve only had to do this in a handful of patients, but in some cases it’s definitely required to prevent the patient from going blind.”

    Calcineurin inhibitors have been reported to improve both signs and symptoms of AKC. They suppress T-cell activation by preventing calcineurin phosphatase activity on the nuclear factor of activated T-cells, which is required for full T-cell activation in cytokine production.

    “Use of these medications limits T-cell activation in cytokine production, particularly cytokines like IL13, produced by TH2 cells,” he said.

    There is no approved tacrolimus therapy in the United States for the treatment of AKC, but it can be formulated.

    Another option is off-label use of tacrolimus 0.03% dermatologic ointment. It should be placed on the eyelid margin, but he suggested asking patients to also place it into the inferior fornix before bedtime.

    These chronic patients who need topical steroids to control disease could also use topical cyclosporine 0.05% (Restasis, Allergan) frequently, up to eight times a day, he suggested.

    Patients with eyelid margin changes, particularly cicatricial entropion, often benefit from a prosthetic replacement of the ocular surface ecosystem (BostonSight PROSE, BostonSight).


    Stephen C. Pflugfelder, MD

    E: [email protected]

    This article was adapted from Dr. Pflugfelder’s presentation during Cornea Subspecialty Day at the 2016 meeting of the American Academy of Ophthalmology. Dr. Pflugfelder is a consultant and advisor for Allergan and Shire.

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