MISLEADING UNILATERAL ATOPIC KERATOCONJUNCTIVITIS: NAVIGATING TREATMENT AND MANAGEMENT CHALLENGES

To illustrate the response and efficacy of triamcinolone acetonide supratarsal injection in a patient with atopic keratoconjunctivitis (AKC), neurotrophic keratitis, and severe corneal damage. The patient was previously diagnosed and treated for herpes keratoconjunctivitis.

Corneal Department, Fondation Adolphe Rothschild Hospital, Paris, France.

A 72 year old male patient presented to our ophthalmology emergency department for red eye and photophobia in the left eye. At clinical examination, a visual acuity of counting fingers, 26 mmHg intraocular pressure, a large epithelial defect, superficial corneal neovascularization, and mild anterior chamber inflammation were found in the affected eye. Major tarsal conjunctiva inflammation was also noticed; he was known with a history of AKC and atopic dermatitis. Notably, the fellow eye presented no conjunctival redness, et solely minor papillary conjunctivitis. The patient was already under lubricants and Valaciclovir 3g per day for presumed herpetic keratouveitis. Oral doxycyclineand periocular steroid injections were introduced, and an amniotic membrane graft (AMG) was realized for the refractory epithelial defect. A more severe anterior chamber inflammation started to occur as mild hyphema as long as a persistent epithelial defect. All those treatments, combined to local cyclosporine remained ineffective for the ocular surface’s inflammation and a corneal plaque started to appear. A severe AKC and neurotrophic keratitis were finally incriminated. We decided to perform a new AMG and a supratarsal triamcinolone acetonide injection after corneal plaque scraping . Remarkable epithelization and disparition in inflammation were noticed immediately after this procedure. Short time after the oral antivirals were suspended. Tacrolimus 0.1% hydrate ophthalmic suspension was quickly introduced for both eyes. Three months later, a minor recurrence of conjunctival inflammation was noted, well alleviated by dexamethasone phosphate drops b.i.d. One month after, the fellow eye presented a similar outbreak with major papillary conjunctivitis and corneal ulcer, immediately and successfully treated with dexamethasone sub-conjunctival injection. Patient was referred to his dermatologist for systemic therapy.

In this situation of unilateral outbreak of AKC, not only treatment but the diagnosis itself may be challenging. Triamcinolone acenoide supratarsal injection may be a very effective treatment in patients suffering from the more severe cases of AKC and subsequent fellow eye involvement should make us consider systemic therapy.