Omalizumab is a monoclonal IgG1 antibody binding to the Fc part of circulating IgE, thus impeding IgE from binding to the FcεRI receptors of mast cells, eosinophils, basophils. It is indicated for children with severe, difficult to treat asthma. Other uses include chronic spontaneous urticaria and allergic keratoconjunctivitis (AKC). This study presents the clinical outcome of children with severe AKC treated with omalizumab in a tertiary children’s hospital. 

The AKC registry of our hospital was retrospectively accessed and all patients receiving omalizumab for allergic conjunctivitis between 2013-2023 were identified. For each patient the following data were documented: sex, age at diagnosis, age at initiation of treatment, duration of treatment, presenting symptoms, allergic sensitizations, follow-up, outcome. 

A total of four children were identified (4 boys) with median age at diagnosis 10.5 years (range 5-11). Among them, three had asthma and/or allergic rhinitis and one had no other allergic manifestations. Two had sensitizations to perennial and seasonal aeroallergens. The remaining two patients had no detectable sensitizations (via skin prick tests and specific IgE); yet one had seasonal symptom flare-ups.  

All patients received omalizumab for ACK, unresponsive to first-line topical medications. Pre-omalizumab Bonini grading of ACK lesions was Grade 3 in 3 cases and Grade 4 in 1. Median age at initiation of omalizumab was 11.5 years (range 10-12) and median duration of treatment is 3.5 years (range 2-5) to date.

All children showed improvement in ophthalmologic follow-up, with median time to improvement 2.5 years (range 1-4). Two patients showed regression in Bonini grading (Grade 2B and 2A respectively, compared to Grade 3 pre-treatment). Two boys with pre-treatment ACK Grades 3 and 4, respectively, did not change category. Notwithstanding, all showed decline in topical medication doses; topical corticosteroids were discontinued in three patients and reduced in the child with Grade 4 ACK. Dosing of all remaining agents was downregulated.

Omalizumab administration for ACK led to significant improvement in children refractory to prior treatment options. Further data is needed on the diagnostic and therapeutic approach of unresponsive cases.