3.14 Keratoconjunctivitis, Atopic

eyes.nhs.scot/
Eyecare Guidelines/
Section 3 - Conjunctiva/
3.14 Keratoconjunctivitis, Atopic

Date of last review:

19/12/2025

Date of next review:

19/12/2027

Date of publication:

19/1/2026

This is a GOS Specialist Supplementary condition and should be managed by community optometrists in line with national guidance⁽⁸⁾. This guideline should be read in conjunction with ‘Supporting information’ guidance [link to Supporting Information page]

Differential diagnosis ⁽¹⁾

Vernal Keratoconjunctivitis (VKC) – especially in children (distinction from atopic keratoconjunctivitis (AKC) may be unclear)
Giant Papillary Conjunctivitis (GPC) – often contact lens-related
Toxic Keratoconjunctivitis

Possible management by optometrist

Advice

Allergen avoidance – e.g. pets, carpets, bedding materials; consider air filters ⁽¹⁾
Recommend simple over the counter antihistamine with advice from pharmacist if needed ^(1,7)
Severe corneal complications are common and potentially sight-threatening - maintain a low threshold for referral ⁽¹⁾
AKC often requires multidisciplinary management and ongoing use of topical anti-inflammatory eye drops/intermittent use of systemic medication ⁽¹⁾

Treatment

Mild cases:

Lid hygiene and treatment of associated staphylococcal blepharitis ⁽¹⁾
Ocular lubricants for symptomatic relief as required (drops/gel for use during the day ± unmedicated ointment for use at bedtime)⁽¹⁾. Refer to local formularies for suitable options⁽⁶⁾
Cool compresses ⁽¹⁾
Ocular lubricants for symptomatic relief (drops for use during the day, unmedicated ointment for use at bedtime) ⁽¹⁾
Topical mast-cell stabiliser or dual-acting antihistamine/mast-cell stabilizer ⁽¹⁾

Typical adult dosage/duration

(Blue text = IP, black text = non-IP)

Sodium cromoglicate 2% eye drops ^(1,5) (P): One drop ⁽⁷⁾, four times daily ^(2,3)
Olopatadine 1mg/ml eye drops ^(1,5) (POM, off-label): One drop twice daily, max duration 4 months ^(2,3)

NB.Sodium Cromoglicate is available as GSL for the symptoms of hayfever and via Pharmacy First for allergic eye conditions. The supply of Olopatadine (Opatanol) 1mg/ml is available via Pharmacy First for non-IP optometrists, in cases of seasonal allergic conjunctivitis (SAC) only for patients who have had treatment failure or who remain symptomatic despite use of at least one other allergy treatment for ocular symptoms available over the counter (Pharmacy First Scotland - Hayfever | National Services Scotland).

Regimens should be adjusted according to severity and patient factors (e.g, age, weight, pregnancy, renal function). Prescribing should follow local formulary and local/national guidance where available ⁽⁷⁾.

In cases of known sensitivities, please consult local formularies for alternative options⁽⁷⁾.

Further management options

Normally no referral ⁽¹⁾ GOS Specialist Supplementary Stage 1 where appropriate* ⁽⁸⁾
- Mild cases: Initial treatment with mast cell stabilisers or dual acting agents; no referral unless symptoms persist. Routine referral if topical agents fail ⁽¹⁾
If required, GOS Specialist Supplementary Stage 2* treatment should be provided by a local IP optometrist/OMP who is registered and qualified to carry out GOS Specialist Supplementary Stage 2 management; intra-referral (practice to practice) should take place to facilitate this ⁽⁸⁾
Treatment may be provided within available locally enhanced schemes, or by community IP optometrists/OMPs, as appropriate (outwith GOS Specialist Supplementary) ⁽⁷⁾
Severe corneal involvement (e.g. macro-erosion, plaque): Urgent referral to ophthalmology ⁽¹⁾
Mild cases without active corneal involvement: Consider routine referral to ophthalmology ⁽¹⁾

*Treatment should be provided in line with “Annex C of the Statement” ⁽⁸⁾ https://www.eyes.nhs.scot/for-professionals/legislation/

Possible management in secondary care or local/community pathways where available ^(1,8)

See Further management options
AKC often requires input from: Ophthalmology/Dermatology/ Immunology
- Treatment may include:
  - Topical steroids (with monitoring)
  - Topical/systemic antibiotics (for lid disease)
  - Topical immunomodulators (e.g. ciclosporin, tacrolimus)
  - Management of facial eczema and blepharitis
  - Surgical intervention (e.g. for atopic cataract)

College of Optometrists Clinical Management Guideline⁽¹⁾

Atopic keratoconjunctivitis (AKC) - College of Optometrists *

*With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

Disclaimers

CEG disclaimer for guidelines awaiting update:

The Eyecare Guidelines area of the eyes.nhs.scot website (“Website”) is intended as a reference source for education and clinical decision support and is intended for use by ophthalmic healthcare professionals working in Scotland.

As such, the Eyecare Guidelines are not intended for use by the general public and do not replace the advice of a healthcare professional. Members of the public should seek advice directly from their optometrist.

Before reading the Eyecare Guidelines or making any management decisions based upon them, all users should read the ‘supporting information’ page which gives more detail around the content of the Guidelines and useful website links [link to Supporting Information page].

Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation, and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways.

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Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways. 

Updating the Eyecare Guidelines requires a continuous process; the date of the last review for each guideline will be clearly noted on each guideline. Users must consider these dates before using the guidance.

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