Introduction

If you are experiencing constant eye irritation, redness, swelling, or blurred vision, your concern may be linked to a severe allergic eye disease called atopic keratoconjunctivitis (AKC). This mainly happens to people with eczema, which is a chronic skin condition.¹

When long-term inflammation affects the conjunctiva and cornea, the immune response becomes overactivated similar to what occurs in eczema. This can lead to facial dryness and potentially compromise eye health, as eczema may extend to the skin of the eyelids. AKC can also cause potential eye complications like corneal scarring, cataracts, and permanent vision loss when left untreated.¹

Learning how to spot the signs of AKC comes with understanding eczema first and how the two conditions connect. Read on to learn more about it and how to effectively manage it to protect your vision.

What is atopic keratoconjunctivitis?

AKC is a severe form of eye allergy disease that affects people who have an atopic condition, including eczema. AKC is what you call a ‘year-round disease, ’ meaning that the symptoms appear chronically throughout the year.² 

AKC is distinct from seasonal allergic conjunctivitis (SAC) and vernal keratoconjunctivitis (VKC). SAC is generally mild and temporary, with symptoms like itchy red eyes–often triggered by seasonal allergens such as pollen. VKC tends to present more severe symptoms and typically recurs in a seasonal pattern. In contrast, AKC is persistent and can worsen over time, which is why it is important to spot the difference.³

AKC usually develops in young adulthood to middle age, and it commonly affects men more than women.¹ It is a genetically linked condition that affects both eyes, often triggered by underlying skin inflammation or exposure to environmental allergens. AKC is a chronic condition that remains persistently active, with spontaneous flare-ups that can vary in severity over time.

Symptoms of AKC

• Chronic redness of the eyes
• Constant tearing and intense itching
• Photophobia (sensitivity to light)
• Eyelid eczema, prone to dry and flaky eyes due to repeated rubbing¹ 

AKC involves a mix of genetic factors and an overactive immune system. Symptoms of AKC are caused by a combination of immediate allergic reaction (type I) and a delayed immune response (type IV). When the eyes are exposed to allergens, immune cells, such as mast cells, T-cells, and eosinophils are activated, causing inflammation through cytokine release.⁴ This can damage the cornea and the surrounding tissues.

AKC is a manifestation of eczema for the eyes, it is a condition that threatens your vision and requires long-term treatment.

Eczema (atopic dermatitis) and its systemic nature

Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition that is caused by an immune imbalance. It affects multiple organs in the body, including the eyes. Eczema weakens the whole body, not just the skin, making it easier for external irritants to trigger chronic inflammation, which can present as dry, red, and itchy patches.² This immune dysregulation can spread to the eyelids and conjunctivae, which increases the risk of AKC.²

Common conditions associated with eczema are asthma, allergic rhinitis, and AKC. This is because inflammation can affect the skin and reach other areas, such as the respiratory system and eyes. It can start at any age and will gradually get better with age.² Even when the skin appears well-maintained, eye problems can still occur. Thus, proper diagnosis and treatment is necessary to effectively care for and manage symptoms of AKC. 

Eczema is a condition that affects the skin and the whole body. It needs to be diagnosed correctly to be able to care for the symptoms and manage the allergy, while monitoring your eyes.

The link between AKC and eczema

The relationship between AKC and eczema is the shared immune system and inflammatory activity that affects the skin, especially the eyes. The immune cells overreact to external irritants and allergens, leading to elevated type 1 level hypersensitivity responses. Due to the fact that the skin around the eyes is thin and sensitive, inflammation often spreads to this area, even when eczema elsewhere is under control.⁴

Facial eczema frequently extends to the eyelids, causing them to become more sensitive and attract allergens that will further exacerbate AKC. The resulting itchiness may lead to excessive rubbing, damaging the delicate tissues around the eyes, causing redness, swelling, and irritation. When AKC is triggered, it can progress independently and show visibly as dry patches.⁴

There are genetic factors that weaken a person's natural skin barrier that can also contribute to eye involvement, although more research is needed in this area. Yet, patients who have eczema can still develop AKC.⁴

The dermatological aspect of AKC may occur even when skin symptoms are controlled. The link between both atopic diseases is the immune imbalance. To address both, you would need to manage the symptoms first.

Long-term complications of AKC 

AKC can lead to serious visual impairment that could become permanent if left untreated. Chronic inflammation of the cornea and the conjunctiva leads to tissue damage of the skin barrier around the eyes, causing long-term irritation.⁴

Over time, if the eye is damaged, the surface of the eye will become delicate, leading to a number of outcomes such as:

• Corneal scarring and ulceration: damage to the corneal tissues and persistent scratching worsens the current condition, which can lead to permanent changes in vision⁴
• Keratoconus: the eyeballs bulge outward and distorts vision; it appears cone-shaped. In severe cases, a corneal transplant surgery is needed⁵
• Cataracts (especially posterior subcapsular): it can develop prematurely. Long-term use of steroids can impair vision and cause inflammation⁴
• Secondary infections: the surface of the eye is vulnerable to bacteria. Bacterial keratitis may occur and rapidly cause problems, and emergency care is needed with antibiotics⁶

The extent of damage from these outcomes leads to vision loss. Persistent rubbing due to itching may aggravate corneal damage, which increases the risk of infections. Inflammation can extend further than the cornea, resulting in fibrosis on the eyelids – a process that thickens the inflamed tissues. In AKC, this fibrosis creates an extra layer of tissue, forming a stiff and hard-to-move barrier, making healing difficult. Thickened eyelids may block the oil glands near the lashes from releasing sufficient moisture, worsening dryness. This disruption destabilises the tear shield on the surface of the eye, causing symptoms such as eye irritation, blurriness, and stinging.⁶

Severe cases of AKC causes the eyelid and eyeball to stick together, a complication known as symblepharon. The conjunctiva which is a clear, thin tissue that covers the white part of your eye and lines your eyelid can become scarred, impairing the ability to blink smoothly. This may also alter the eye anatomy, making it difficult to treat. Simple interventions such as applying eye drops becomes difficult, alongside any related surgeries.⁷

Diagnosis and differential diagnosis 

Clinical history and a thorough assessment are needed to diagnose AKC. This provides a clear understanding of the patient's needs and possible atopic background of other conditions like eczema, asthma, or allergic rhinitis. When presented with eczema, chronic eye symptoms, and long-term allergies, it is safe to assume that the person will have AKC.

Ophthalmologists typically conduct a slit-lamp examination during diagnosis. The tool functions like a microscope, allowing for detailed observation of the eye. It can reveal tiny red bumps on the inner surface of the eyelid, assessing the severity of inflammation, detecting corneal abrasions, and identifying the growth of new blood vessels in areas of the eye that are normally transparent. These signs are typically due to chronic irritation.⁶

AKC shares similar symptoms to other eye conditions, so it is crucial that doctors rule out other problems: 

• Vernal keratoconjunctivitis (VKC) - seasonal and severe, larger red bumps along the eyelid⁴
• Seasonal allergic conjunctivitis (SAC) - mild and only present when pollen levels are high, like hayfever⁴
• Infectious conjunctivitis - contains a somewhat clear discharge. It is similar to pink eye
• Dry eye syndrome - causes irritation and a burning sensation

The doctor may conduct allergy tests and check tear quality in order to make a more accurate diagnosis. An eye biopsy can also be conducted, where a sample of tissue from the surface of the eye is taken to observe for signs of an allergic reaction.⁴ Early signs typically lead to early treatment which decreases the risk of permanent visual damage. 

Treatment and management

The effective treatment of AKC requires a dual-targeted strategy that addresses both eczema and ocular inflammation. This treatment approach focuses on controlling the irritating symptoms, preventing flare-ups, and protecting the eyes from any bacteria and external physical irritants.⁴ 

For milder symptoms, doctors recommend:

• Topical antihistamines: to reduce redness and itchiness
• Cold compress/shower: to prevent overheating and soothe swelling
• Mast cell stabiliser: for allergic reactions
• Lubricating eye drops: to reduce dryness and irritation⁴

For moderate symptoms: 

• Topical corticosteroids: short-term use to reduce inflammation, but it may have some side effects when used irresponsibly⁴
• Calcineurin inhibitors e.g., tacrolimus ointment for eyelids to soothe irritation⁴
• Oral antihistamines: for allergies

For severe cases:

• Systemic immunosuppressants or biologics under special supervision⁶

The following should be done to manage and prevent the symptoms effectively: 

• Wear protective eyewear in dusty environments to prevent bacteria from entering the eyes
• Avoid wearing contact lenses, as the moisture can attract dirt 
• Avoid excessive eye rubbing, even gently, as this can exacerbate eye irritation⁸ 
• Attend regular check-ups with a dermatologist and ophthalmologist to monitor your eye healing journey and to adjust any part of the treatment if necessary, even in the absence of eye symptoms 
• Practice good hygiene by ensuring thorough washing of hands before touching your eyes and mouth

Patient education and prevention strategies

Being informed about AKC and its link to eczema is an important first step in managing your condition. Understanding the relationship can help you identify and avoid common triggers like pollen, pet hairs, dust, smoke, and other irritants that can exacerbate eye symptoms. 

The following should be done to reduce inflammation and control symptoms:

• Use prescribed eyedrops regularly⁸
• Manage eczema to reduce flare frequency 
• Early eye screening for people with eczema to reduce the risk of AKC and other eye conditions⁸
• Using prescribed fragrance-free skincare for eczema or AKC, these products typically maintain high levels of hydration
  

Summary

AKC is a chronic eye condition that affects people who have a history of eczema. It is characterised by persistent inflammation of the cornea and conjunctiva, often presenting with irritation, redness, and intense itchiness. If diagnosed too late and left untreated, serious complications like cataracts, keratoconus, and vision impairment can occur, largely due to an imbalance in the immune system.

Early recognition of AKC, coupled with skin and eye treatment is essential. Treatment typically includes the use of anti-inflammatory medications, allergy avoidance, and eyelid care. The key to preserving eye health in atopic patients is learning early on how to maintain and educate yourself to control the condition and stop damage to the eyes.

FAQs 

Can eczema affect the eyes?

Yes. Eczema around the face or eyes increases the risk of developing AKC due to the immune system becoming overly stressed due to flare-ups, itchiness, dryness, and other discomforting symptoms.

Is atopic keratoconjunctivitis permanent?

No. It is not a permanent condition. It may seem like it is long-term, but symptoms typically lessen with age. As long as treatment is stable and regular check-ups are conducted then your vision will be protected.

How can AKC be diagnosed?

AKC is determined by the patient's medical history, eye symptoms, and the slit-lamp examination. These are performed by an eye doctor to look for inflammation and damage that are not as visible to the naked eye.

Do topical steroids for AKC damage the eyes?

Topical steroids are used to reduce inflammation in the eye. If there is an overdose or used for long periods, side effects will occur. This includes increased eye pressure, cataracts forming, or the area of the cornea thinning. It is recommended by doctors to use steroid eye drops under careful supervision.