Mousa Al-Madani, MD*
Farid Al-Zawaideh, MD, FRCS(ophth)*
Esmat Ereifej, MD*
Walid Qubain, MD*
Basel Al-Rawashdeh, MD**

* Ophthalmology at King Hussein Medical Center.
** Dermatology at King Hussein Medical Center.

Correspondence to:
Dr. Mousa Al-Madani
Email: mousamad@yahoo.com


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Atopic dermatitis is a recurrent eczematous pruritic skin condition usually beginning in infancy 1. Precise aetiology is unknown, but current theories center on a disordered immune response, especially an imbalance of cytokines, disordered regulation of IgE and T cell mediated hypersensitivity reactions and vascular responses.

Skin manifestations usually occur on the cheeks, hands, and extensor surfaces in children; antecubital and popliteal fossa in adults. Ocular involvement including cataract, keratoconjunctivitis, keratoconus, retinal detachment, herpes simplex keratitis, and ocular motility disturbances have been described 2-4.

In this study we aimed to evaluate the ocular features and their frequency in patients with atopic dermatitis.

A prospective study conducted at King Hussein Medical Center during the period of January 2005 and January 2006. A total number of 64 patients diagnosed to have atopic dermatitis and being followed at the dermatology clinic were enrolled in the study. Patients were evaluated at the ophthalmology clinic. Ophthalmologic examination included Snellen's chart visual examination, anterior segment examination via slit lamp, prior and after staining with fluorescein, intraocular pressure measurement via Goldmann's applanation tonometry, posterior segment examination after mydriasis via indirect ophthalmoscope and Schirmer test.

The mean age for patients was 11.6 years with 1.1:1 male to female ratio. Ocular involvement was evident in 30 patients (46.9%). 83.3% of patients had bilateral eye involvement. The commonest abnormality was blepharitis 40.6% followed by conjunctivitis 31.3%, corneal disease 15.6%, lens opacities 7.8%, and retinal involvement 1.6% (Table 1). Corneal involvement included superficial punctuate keratopathy, ulceration, opacities, pannus, and reactivation of herpes simplex keratitis. 25% of patients were asymptomatic, 14.1% had dry eyes and 6.3% had keratoconus.

Although there are a limited number of studies on the frequency of ocular complications in atopic dermatitis patients, they have been reported in 42.5% of patients 4. Our results showed that 46.9% of atopic dermatitis patient had ocular involvement with the majority having bilateral eye involvement.
The commonest ocular manifestation we found was blepharitis. Atopic blepharitis is one of the major ocular complications of atopic dermatitis 4-5. It has been pointed out that atopic patients have dry skin accompanied by barrier disruption and water deficiency 6.

Conjunctivitis may occur in isolation or may be accompanied by blepharitis or corneal involvement. Atopic blepharoconjunctivitis is a subgroup of patients with atopic dermatitis with chronic allergic conjunctivitis which do not show keratopathy 7-8. Atopic keratoconjunctivitis is a severe chronic allergic conjunctival disease associated with atopic dermatitis and is often associated with corneal complications such as erosion and ulcers 9. The cornea is frequently involved in a variety of ways including punctate epithelial keratitis, macroerosion, and plaques 10. Ten of our patients had corneal pathology, the commonest being superficial punctuate keratopathy (4 patients), ulceration (2 patients), opacities (2 patients), pannus and reactivation of herpes simplex keratitis (1 patient each).

Keratoconus is also reported to accompany atopic dermatitis; 4 patients in our study had keratoconus.
Patients with atopic dermatitis frequently develop cataract and retinal detachment. Previous studies reported that the frequency of cataract in patients with atopic dermatitis was approximately 10-20% 4, 11-12 while that of retinal detachment was 8% 12. The figures we encountered were 7.8% for cataract and 1.6% for retinal detachment. All patients had straight forward surgeries. Cataract associated with atopic dermatitis may be of anterior or posterior subcapsular opacities, mixed or mature usually manifesting in adolescence. Five of our patients had cataract; 3 of them had anterior subcapsular variety and 2 had posterior subcapsular cataract. Retinal detachment is generally caused by breaks in the ciliary body or the retina near the ora serrata 13-14. It had been reported that breaks in the ciliary body developed because of traction resulting from contraction of the lens capsule following cataract surgery 15-16. Only 1 patient in our study had retinal detachment that occurred four months after uneventful cataract surgery.

Nine patients (14.1%) had dry eyes. Dry eyes were diagnosed based on Schirmer test; wetting of less than 5 mm was considered abnormal 17. All these patients were asymptomatic. The other 7 patients who were asymptomatic had blepharitis.

In conclusion, various ocular abnormalities accompany atopic dermatitis. Some patients are rather asymptomatic, hence the importance of referring patients with atopic dermatitis to an ophthalmology clinic.