A 28-year-old man with lifelong eczema and asthma has intensely itchy, red eyes all year round, worse in winter. His eyelids are thickened and scaly, and he rubs them constantly. Vision is mildly blurred. Antihistamine drops from the pharmacy barely help.
Examination Findings
Visual acuity: 6/9 both eyes. Both eyes: chronic injection, intense itching, thickened eczematous eyelid skin with Dennie-Morgan folds, papillary reaction of both upper and lower tarsal conjunctivae. Corneas show punctate erosions superiorly with early plaque formation. He has lifelong atopic dermatitis and asthma; symptoms are year-round, worse in winter.
Investigations
Slit-lamp examination documents the papillary reaction, lid eczema and corneal changes — shield-ulcer screening is the priority. The atopic history (dermatitis, asthma) is confirmed. Intraocular pressure is checked at baseline because steroid therapy is likely and these patients are steroid responders. Cataract screening matters too, as atopic patients develop cataracts.
Questions to Think About
- How does this differ from vernal keratoconjunctivitis?
- Why is eye rubbing specifically dangerous in this patient?
- Why must pressure be checked if steroids are prescribed?
Diagnosis
Atopic keratoconjunctivitis in an adult with atopic dermatitis: chronic itchy eyes with eczematous lids, papillary reaction and early shield-ulcer risk.
Reasoning
Reasoning: Chronic year-round intensely itchy eyes with eczematous lids, Dennie-Morgan folds, upper and lower tarsal papillae and superior corneal erosions in a 28-year-old with atopic dermatitis and asthma is atopic keratoconjunctivitis. Age and perennial course distinguish it from vernal disease (children, seasonal). Diagnosis: atopic keratoconjunctivitis, bilateral. Management: typical management includes topical anti-allergic therapy, supervised short steroid courses for flares with pressure monitoring, lubrication, no-rubbing counselling, steroid-sparing agents for chronic disease, and dermatology co-management per local protocol.
Differential Diagnosis
- Vernal keratoconjunctivitis — ruled out: he is 28 (vernal is a disease of children and adolescents) with year-round symptoms and eczema; the age and atopic background define atopic disease.
- Seasonal allergic conjunctivitis — incomplete: simple seasonal allergy lacks the chronic lid eczema, constant course and corneal involvement.
- Blepharitis — incomplete: blepharitis is present, but the intense itch, papillae and eczema history mark an atopic process.
Management
Typical management includes topical anti-allergic therapy with careful short courses of steroids for flares under supervision per local protocol, aggressive lubrication, cold compresses, and strict no-rubbing counselling. Steroid-sparing immunomodulatory drops are considered for chronic disease with specialist input. Dermatology co-manages the eczema. He is told rubbing is reshaping his cornea, that the disease is chronic but controllable, and that pressure checks accompany any steroid use.
Key Learning Points
- Atopic keratoconjunctivitis is the ADULT, year-round cousin of vernal disease — think of it in any itchy-eyed adult with eczema.
- The cornea is at stake: chronic rubbing and inflammation can produce shield ulcers and scarring.
- These patients are steroid responders — pressure must be monitored whenever steroids are used.
- Atopic cataract and keratoconus (from eye rubbing) are associated — examine the lens and topography over time.
- Treating the SKIN (eczema) helps the eyes — dermatology co-management matters.
Red Flags
- A non-healing corneal plaque or ulcer in atopic disease — shield ulcer; urgent specialist care.
- Rising pressure on steroid drops — steroid responder; adjust therapy promptly.
- Increasing irregular astigmatism in a chronic eye-rubber — screen for keratoconus.
Educational content only — not medical advice. Clinical decisions must be made by a qualified professional for the individual patient.