How AKC affects the eye
Atopic keratoconjunctivitis (AKC) is a chronic, bilateral inflammation of the eye surface. It mainly affects young adults who already have atopic dermatitis (eczema), asthma, or allergic rhinitis (hay fever), and it is considered the most severe form of eye allergy.[1] It is one of the most serious eye complications of atopic dermatitis.[2]
The inflammation involves the conjunctiva (the thin tissue lining the lids and covering the white of the eye) and the cornea (the clear front window of the eye). Over time it can cause:
- Corneal damage and scarring. Ulcers, new blood vessels growing into the cornea, and scarring can threaten vision.[1]
- Keratoconus. AKC is linked to keratoconus, in which the cornea thins and bulges into a cone.[2] Corneal thinning and keratoconus are seen more often in people with AKC, and severe eye allergy has been reported as a risk factor for corneal hydrops, a sudden swelling of a thinned cornea.[3]
- Other problems. Cataract, blepharitis (lid inflammation), tear problems, infectious keratitis, and glaucoma caused by long-term steroid drops are all recognized complications.[2]
Rarely, a thinned and inflamed cornea can perforate on its own.[3] That is why AKC needs regular care from an eye doctor, not just allergy drops.
How a scleral lens can help in AKC
A scleral lens is a large rigid gas-permeable lens. It rests on the sclera (the white of the eye) and arches over the whole cornea without touching it. Before it goes in, it is filled with sterile, preservative-free saline, which stays over the cornea while the lens is worn.
In AKC, that can do three useful things:
- Shield the cornea. The lens puts a barrier between the cornea and the inflamed eye surface and lids. The researchers behind the main series used scleral lenses specifically to protect the cornea from the ocular surface environment.[4]
- Keep the surface moist. The saline pool bathes the cornea for as long as the lens is in, which can help a dry, damaged surface.
- Sharpen vision. The saline layer smooths over an uneven, scarred, or cone-shaped cornea optically, which can bring a real improvement when glasses no longer help.
Many people with AKC first meet scleral lenses because of keratoconus rather than the surface disease. If that’s you, the lens is doing the same job it does for anyone with a cone-shaped cornea, explained on our keratoconus page. The difference is that the eye surface around it is more fragile and more prone to inflammation, so the fit, the cleaning routine, and the follow-up schedule may need to be more careful than usual.
A scleral lens doesn’t touch the cause of AKC. The allergy and inflammation still need medical treatment, and in the published experience the lens was added once that treatment had the disease under control.[4]
What the research shows
The evidence is small. We found one case series and one case report of scleral lenses in AKC. There are no trials.
A series of 10 eyes. A US team reviewed the records of 10 eyes with advanced AKC whose inflammation was medically controlled and who were fitted with rigid gas-permeable scleral lenses. Over a median follow-up of 20.5 months, redness of the eye surface and corneal surface defects improved in all of them. Median best-corrected vision improved from about 20/90 to 20/35. Every patient gained at least one line on the eye chart, and 9 of the 10 eyes gained two or more lines. The lenses were well tolerated, and the authors reported no complications or infections from lens wear.[4] That is encouraging, but 10 eyes at one center can’t tell you how likely those results are for you.
A case report after a corneal transplant. A 52-year-old man with keratoconus and severe AKC had a full-thickness corneal transplant. Afterward, the surface of the new cornea wouldn’t heal, and a herpes infection of the cornea followed. His team started a scleral lens two weeks after surgery, with design changes to avoid suction and low oxygen, and used the lens’s saline reservoir to deliver an antibiotic. Together with antiviral tablets and other changes to his treatment, the cornea healed and his vision improved to about 20/40. He was still wearing the lens during waking hours, without a recurrence, at 18 months.[5] One case shows what is possible in skilled hands. It isn’t a typical result to expect.
Keratoconus research is relevant too. Many people with AKC wear scleral lenses mainly for keratoconus. In a study of 157 eyes with keratoconus that had worn scleral lenses successfully for at least a year, average vision improved from about 20/63 with glasses to about 20/25 with the lens. Lens problems such as breakage, deposits, and fogging were common, and 9.6% of eyes had a physiological adverse event, including microbial keratitis in 0.6%.[7] That study didn’t single out people with AKC.
Other options, compared
AKC is usually treated in steps, starting with antihistamine and mast-cell stabilizer drops and moving to steroid drops, calcineurin inhibitors (such as cyclosporine or tacrolimus), and, for severe disease, medicines taken by mouth or injection or surgery.[1] Newer biologic medicines that target specific allergy signals (IL-4 and IL-13) show promise in selected patients.[1]
Cyclosporine can reduce the need for steroid drops. In a UK series of 99 children and young people with AKC, of those who were also using steroid drops when cyclosporine started, 65.2% had stopped the steroids within 12 months. Stinging led 9% of the whole group to stop cyclosporine.[6]
| Option | What it does | Typically suited to |
|---|---|---|
| Antihistamine and mast-cell stabilizer drops | Reduce itch and allergic reaction | Mild disease and maintenance |
| Steroid drops | Calm inflammation quickly | Flares; long-term use risks cataract and glaucoma |
| Cyclosporine or tacrolimus | Long-term control of inflammation | Moderate to severe AKC, to reduce steroid use |
| Systemic or biologic treatment | Treat the immune response throughout the body | Severe or treatment-resistant disease |
| Glasses or corneal rigid lenses | Correct vision | Mild corneal changes |
| Scleral lens | Shields and moistens the cornea; corrects an irregular cornea | Advanced AKC once inflammation is controlled; AKC with keratoconus |
| Corneal transplant | Replaces a scarred or thinned cornea | Advanced scarring or keratoconus; higher risks with ongoing inflammation |
Questions to ask a scleral lens fitter
- How many patients with AKC or other severe eye allergy do you fit?
- Is my eye surface calm enough to start, and how will you coordinate with the doctor treating my AKC?
- What should I do with my lenses during a flare?
- How should I time my drops around lens wear?
- Which cleaning and saline products do you recommend, given my allergies and eczema?
- How often will you check for infection, and what signs should make me remove the lens and call right away?
Common questions
Will a scleral lens stop my AKC flares?
No. A scleral lens doesn't treat allergy or inflammation. In the published series, lenses were fitted only after the inflammation had been brought under control with medicine, and that treatment continued. Think of the lens as protection and vision correction alongside your drops, not instead of them.
Can I wear a scleral lens during a flare?
Ask your eye doctor. The research we found involved eyes whose AKC was medically controlled. During a flare, your doctor may want you to reduce or pause lens wear and step up treatment. Agree a plan for flares in advance.
I have AKC and keratoconus. Is a scleral lens an option?
Often, yes. Keratoconus is a known complication of AKC, and scleral lenses are widely used for keratoconus vision. The AKC itself changes the picture: the surface needs to be calm, and you will need closer checks. See our keratoconus page for how sclerals work on a cone-shaped cornea.
How do I use my eye drops with a scleral lens?
It depends on the drop. Some prescription drops are labeled to be used with contact lenses out, followed by a wait before the lens goes back in. Ask your eye doctor and your fitter to agree a schedule for each of your drops.
Does AKC raise my risk of eye infection with a lens?
AKC on its own is associated with infectious keratitis, so infection is already a concern. Any contact lens adds some risk. Careful cleaning, fresh sterile saline, and prompt checks for a red, painful eye matter more than usual.
Why does my lens film over within minutes when my allergies act up?
Allergic eyes can produce extra mucus and debris that coat the front of the lens or cloud the saline behind it. Wearers often rinse and refill, or clean the lens, more often during flares. Tell your fitter, because a surface coating, a different cleaning routine, or better control of the allergy with your eye doctor may help.
What can I do instead of rubbing my itchy eyes?
Try not to rub, with or without the lens in, because eye rubbing is linked to keratoconus and can irritate an inflamed surface further. Wearers often use a cool compress or chilled preservative-free artificial tears instead. If itching keeps coming back, ask your eye doctor about stepping up allergy treatment.
Could I be allergic to my lens or my solutions?
It's possible. Wearers who react often trace it to a solution, drop, or preservative rather than the lens itself, though reactions to lens materials have been reported. Tell your fitter, and work out the cause by changing one thing at a time with their agreement.
My eyelid eczema is flaring. Does that affect my lenses?
It can, because itchy, inflamed lids make rubbing more likely and can irritate the eye surface. Ask your eye doctor or dermatologist which treatments are safe to use on the eyelids. Keep creams off your fingers and lenses when you handle them.