Atopic Dermatitis Causing Late Keratoconus Progression, A Case Report

Keratoconus is a bilateral and asymmetric disease which results in progressive thinning and steepening of the cornea leading to irregular astigmatism and decreased visual acuity. Although the majority of patients usually stabilize after the third decade of life, few may develop further progression. Continuous eye rubbing and atopic disease can be powerful triggers in these cases.  Continuous monitoring of these subset of patients, detecting early progression, is of high importance. Our purpose is to highlight a case of late keratoconus severe progression in a patient with atopic disease and its management.

Hospital Garcia de Orta

37-year-old female with prior history of untreated atopic dermatitis and keratoconus, arrived to our department complaining of visual loss in her left eye (OS). She had penetrating keratoplasty in her right eye for keratoconus management 10 years ago, and she was wearing scleral lens in both eyes.

The onset of symptoms occurred simultaneously to dermatitis exacerbation and corneal rubbing, mainly in OS.

Since her last appointment, one year before, a marked decrease in her left best corrected visual acuity (BCVA) from 6/10 to 1/10 was noted.

Corneal tomography pointed out a significant shift in several contemporary parameters used to evaluate keratoconus progression, namely: Kmax increase of 7.3D and 10% decrease in central corneal thickness. Regarding the most recent Belin ABCD progression display, all four parameters had a significant increase, crossing all the continuous red lines (KC95%).

The diagnosis of progression was made and corneal cross-linking with individualized fluence (sub 400 protocol) was performed.

Along with keratoconus treatment, the patient was referred to a dermatology appointment and started proper topical immunosuppressive therapy (tacrolimus 0,1%) with good control of the atopic disease, halting further eye rubbing and additional progression.

One month after surgery central haze was noted but six months later corneal clarity was re-established. At one-year follow up, there was no evidence of progression and her BCVA returned to 6/10 with scleral lens.

Although most cases of keratoconus stabilize third decade of life, some patients show evidence of progression. Keratoconus-related complications and disease progression in more advanced years can be associated with a prior history of eczema, such as our patient, and frequent eye rubbing. For that reason, these patients should be monitored more often and a multidisciplinary approach with dermatology or immunoalergology specialist should be part of the treatment plan to guarantee better and definite results.