Rapid Onset Of Bilateral Band Keratopathy In Severe Atopic Dermatitis

Case report of rapid onset epithelial defects and band keratopathy in a man with uncontrolled atopic dermatitis. Discussion of differentials, initial management and aetiology, including possible pathophysiology in the context of severe atopic disease and use of topical emollients, with discussion of implications for dermatological management of atopic disease involving the face and periocular areas.

Tertiary referral centre.

A 35-year-old male, non-contact lens wearing patient presented with a unilateral red, painful eye diagnosed initially as corneal abrasion attributed to eye rubbing. Findings were associated with a flare up of his facial atopic dermatitis, which he had been suffering from for several years. Symptoms failed to improve on chloramphenicol ointment 1%, and he returned a few days later, when a hazy appearance to the abrasion was noted. A corneal scrape was undertaken to exclude microbial keratitis and the patient was started on hourly guttae moxifloxacin 0.5%. Scrapes were negative for microbial growth and an epithelial defect then developed in the fellow eye. A presumptive diagnosis of atopic keratoconjunctivitis with persistent epithelial defects was made and he was commenced on preservative-free dexamethasone 0.1% drops, tacrolimus 0.1% ointment to the lid margins and oral lymecycline 408mg. Ongoing pain prompted siting of therapeutic contact lenses bilaterally. Surface pH was tested and revealed to be 8-9. Around two months following presentation, stromal calcium deposition was noted and band keratopathy (BK) was diagnosed. This was treated with ethylenediaminetetraacetic acid (EDTA) chelation with permitted healing of both epithelial defects. Whilst awaiting dermatology input his facial eczema flared up and this was associated with early recurrence of BK; the patient reported liberal application of ‘Balneum Plus’ cream peri-ocularly, containing urea 5% and lauromacrogols.

Band keratopathy (BK) may present with pain and photophobia, mimicking other conditions such as corneal abrasion and microbial keratitis. Atopic dermatitis can be associated with BK due to tear film insufficiency and meibomian gland dysfunction. Skin emollients, such as those containing cetostearyl alcohol, can cause ocular surface toxicity. We postulate urea-containing emollients may drive calcium precipitation in the cornea as urea dissolves in tears, increasing surface pH. Patients should be advised to avoid use of such emollients around the eyes. Early chelation and aggressive management of atopic dermatitis including systemic therapy, promotes corneal epithelial healing and reduces the risk of sight-threatening complications.