Referral Criteria for Atopic Keratoconjunctivitis According to NICE-Aligned Guidelines
Patients with atopic keratoconjunctivitis should be promptly referred to an ophthalmologist when there is visual loss, moderate to severe pain, corneal involvement, conjunctival scarring, lack of response to therapy, or recurrent episodes. 1, 2
Immediate Ophthalmology Referral Required
The following situations mandate urgent specialist evaluation:
- Visual loss or any visual symptoms - This is a sight-threatening emergency requiring immediate ophthalmologic assessment 1, 2
- Moderate or severe pain - Indicates potential corneal complications that require specialist management 1
- Corneal involvement - Including ulceration, scarring, or pannus formation, as these can lead to permanent visual disability 1, 2
- Severe, purulent discharge - May indicate secondary bacterial infection requiring intensive treatment 1
- Conjunctival scarring - Progressive scarring requires specialist intervention to prevent further complications 1
Referral for Treatment Failure or Complications
Additional indications for ophthalmology referral include:
- Lack of response to standard therapy - When topical mast cell stabilizers, antihistamines, and short-term corticosteroids fail to control symptoms 1, 2
- Recurrent episodes - Frequent flares despite appropriate primary care management warrant specialist evaluation 1
- Need for prolonged corticosteroid therapy - Patients requiring repeated or extended courses of topical steroids need specialist monitoring for glaucoma and cataract development 1, 2
- History of immunocompromise - These patients are at higher risk for complications and require specialist co-management 1
Multidisciplinary Referral Considerations
Dermatology consultation is often helpful for managing the associated atopic dermatitis component, as AKC is frequently associated with severe atopic dermatitis requiring coordinated care 1, 3, 2
Allergist referral may be indicated for patients with severe atopy who may benefit from environmental allergen control and systemic antihistamine therapy 1, 4
Key Clinical Pitfalls to Avoid
- Do not delay referral when corneal signs are present - Even subtle corneal changes can progress rapidly to vision-threatening complications 2
- Do not continue topical corticosteroids long-term without specialist supervision - This risks steroid-induced glaucoma and cataracts, which are common complications in AKC 1, 2
- Do not dismiss ocular symptoms in patients with atopic dermatitis - AKC can occur as a sole manifestation of atopy even without prominent skin findings 4
Management Coordination
All treatment for atopic keratoconjunctivitis should be managed in conjunction with an ophthalmologist to prevent permanent vision loss from complications including cataracts, keratoconus, infectious keratitis, and steroid-induced glaucoma 2
Most patients can be treated in an outpatient setting, but the threshold for specialist referral should be low given the sight-threatening nature of this condition 1, 2