The Impact of the Onset Time of Atopic Keratoconjunctivitis on the Tear Function and Ocular Surface Findings Tatsuya Onguchi, MD, Murat Dogru, MD, Naoko Okada, PhD, Naoko Asano Kato, MD, Mari Tanaka, MD, Yoji Takano, MD, Kazumi Fukagawa, MD, Jun Shimazaki, MD, Kazuo Tsubota, MD, and Hiroshi Fujishima, MD PURPOSE: To investigate the tear and ocular surface findings between controls, children, and adults with atopic keratoconjunctivitis (AKC). DESIGN: Prospective comparative study. METHODS: Twenty eyes of 10 childhood-onset, 10 eyes of five adult-onset, AKC adult patients, and 12 eyes of six children with infantile-onset AKC, 14 eyes of seven normal adults and seven normal children were recruited. Corneal aesthesiometry, Schirmer test, tear film break-up time (BUT), vital staining, and conjunctival impression cytology were performed. RESULTS: The Schirmer and Rose Bengal scores in child- hood-onset adult AKC patients were considerably worse than adult-onset adult AKC patients, pediatric subjects, and the controls (P < .05). The same significant relation was observed in impression cytology parameters. CONCLUSIONS: Ocular surface disease in childhood-onset adult AKC patients was characterized by greater ocular surface epithelial damage. Prolonged inflammation may be important in the evolution and progression of ocular surface disease in patients with longstanding active AKC. (Am J Ophthalmol 2006;141:569 –570. © 2006 by Elsevier Inc. All rights reserved.) A TOPIC KERATOCONJUNCTIVITIS (AKC) IS A COMMON presentation of atopic dermatitis (AD) occurring in 25% to 40% of the US population. 1,2 We previously described tear instability, goblet cell loss, and conjunctival squamous metaplasia in AKC. 3 Reportedly, childhood-onset asthma relapsing into adulthood resulted in a more severe form of respiratory disorder. 4 We studied the tear function and ocular surface in adult AD patients with childhood- or adult-onset ocular and skin disease and compared the results with children having infantile-onset AKC and healthy adult and pedi- atric controls. Twenty eyes of 10 childhood-onset (five males; five females, mean age: 28.5  6.7 years), 10 eyes of five adult-onset adult AKC patients (four males; one female, mean age: 27.8  4.4 years) and 12 eyes of 6 children with AKC (six males; no females, mean age: 9.7  3.4 years), 14 healthy eyes of seven adults (five males; two females, mean age: 34  5.4 years), and seven children (five males; two females, mean age: 7.1  1.5 years) were recruited. Informed consent and ethic committee permission were obtained. No patient and controls had any ocular or systemic disease, drug, or contact lens use. Patients resis- tant to the same treatment of topical ketotifen fumarate 0.025% four times a day and betamethasone 0.01% four times a day for 2 weeks were included. None was being treated with cytotoxic immunosuppressant or systemic corticosteroids during the study. All patients had radioal- lergosorbent tests to confirm their allergic status. Corneal aesthesiometry, Schirmer test-I, tear film break-up time (BUT), fluorescein and Rose Bengal vital staining, con- junctival impression, and brush cytology were performed. Impression cytology samples underwent periodic acid Schiff and immunohistochemical staining with MUC5AC antibodies (Abcam, England). Goblet cell densities and Nelson’s squamous metaplasia grades were calculated un- der light microscopy. Upper palpebral conjunctival brush cytology samples were used to study the inflammatory cell numbers and MUC5AC mRNA expression by real time quantitative RT-PCR. Adult patients had higher percentages of conjunctivo- corneal complications compared with children with AKC. Corneal sensitivity significantly related to the time of onset of disease. Tear stability was considerably worse in adult AKC patients compared with pediatric cases and controls. The mean Schirmer and Rose Bengal scores were considerably worse in adults with childhood-onset AKC. The mean fluorescein scores were remarkably worse in adults and children with AKC compared with controls (Table 1). Considerably higher squamous metaplasia and goblet cell loss were observed in adults with childhood- onset AKC (Table 2). MUC5AC antibodies staining showed positive staining both in adult and children eyes with AKC and in all control eyes. MUC5AC mRNA expression was appreciably downregulated in adult AKC patients compared with pediatric cases (AJO online site). Brush cytology showed numerous inflammatory cells in children and adults with AKC and none in the controls (data not shown). These results suggest that dry eye is an important feature in AKC and is more pronounced in adults with childhood-onset disease compared with adults with disease onset after puberty and the pediatric patients. Supplemental Material available at AJO.com. Accepted for publication Sep 27, 2005. From the Tokyo Dental College Ichikawa General Hospital, Depart- ment of Ophthalmology, Ichikawa, Japan (T.O., M.D., J.S.); and the Keio University School of Medicine, Department of Ophthalmology, Tokyo, Japan (T.O., M.D., N.O., M.T., Y.T., K.F., K.T., H.F.). This work was supported by a research grant of the Japan Society for the Promotion of Science (JSPS Grant 02261). Presented in part at the 28th Japan Cornea Congress, February 19 to 21, 2004, Yonago, Japan. Presented at the 2004 ARVO Meeting, April 29th, 2004, Fort Lauderdale, Florida. Inquiries to Tatsuya Onguchi, MD, Department of Ophthalmology, Tokyo Dental College, 5-11-13, Sugano, Ichikawa, Chiba, Japan 272- 8513; e-mail: ongucci@yahoo.co.jp © 2006 BY ELSEVIER INC.ALL RIGHTS RESERVED. 0002-9394/06/$32.00 569