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Topical cyclosporine is a viable alternative to corticosteroids for treating corneal ulceration
Use of topical cyclosporine avoids complications associated with chronic corticosteroid usage.
WAILEA, U.S.A. — Topical cyclosporine A 0.05% can be a useful adjunct in the management of therapeutic keratoplasty for mycotic keratitis.
“The main reason I feel cyclosporine is a beneficial adjunct is because it allows the clinician to use an agent that is a powerful T-cell immunomodulator without the inherent complications associated with chronic corticosteroid usage,” said Henry D. Perry, MD, a clinical associate professor of ophthalmology at Cornell University School of Medicine in New York City. However, “the dilemma for the clinician is that he or she is treating a form of corneal ulceration that he or she feels is immune mediated. So he or she wants to use a drug to block the immune response, which is usually a corticosteroid. But the problem with corticosteroids is that they can increase collagenolysis.” In addition, “if the patient has underlying herpetic disease, corticosteroids can stimulate a recurrence.”
Dr. Perry, who spoke at the annual Hawaii 2000 meeting here, told Ocular Surgery News that “I’m not saying cyclosporine is better than corticosteroids. I’m simply saying it’s safer.” With respect to fungal corneal ulcers, “corticosteroids are a known exciting agent; in other words, they potentiate the spread of fungal infections.”
Fungal disease case
---Ring infiltrate
secondary to mycotic keratitis.
At the meeting, Dr. Perry shared
the case of a 53-year-old man who presented with a ring infiltrate. “The
differential diagnosis included fungal disease — which is what he had
— herpes simplex, Acanthamoeba and severe bacterial ulcer,” he said.
Although the patient was treated for fungal disease, “he continued to go
downhill, because he had already been on corticosteroids for a month before we
saw him.” Penetrating keratoplasty was eventually performed.
“In the postoperative period, we were able to avoid corticosteroids and treat him just with topical cyclosporine and topical nonsteroidals,” Dr. Perry said. “However, cyclosporine doesn’t reverse vascularity. Because of this, the eye was extremely red and it remained inflamed for about 6 months postoperatively, so there are limitations to the use of topical cyclosporine.” Prescribing corticosteroids, on the other hand, “may decrease the inflammation, but if there are any fungal elements lying around, the corticosteroids may stimulate these elements to invade the recipient tissue.”
Two other drawbacks of topical cyclosporine are that “the formulation requires the use of a compounding pharmacy, and the medication has significant burning on instillation,” said Dr. Perry, chief of corneal service at North Shore University Hospital in Manhasset, U.S.A. Nonetheless, cyclosporine also has been effective in patients with corneal perforation following rheumatoid arthritis. In one patient who had gluing, “the use of topical cyclosporine eventually caused quiescence of a disease. And we were able to remove the glue. The cornea had healed itself under the glue,” Dr. Perry said. “We’ve had approximately four patients with this scenario.”
There have been other reports of success, as well. “Use of topical cyclosporine in patients with rheumatoid corneal melts is well documented,” he said.
Various medications effective
---A patient with
psoriatic corneal abscess that responded positively to topical
cyclosporine.
Dr. Perry has also looked at patients with
staphylococcal marginal keratitis. All three treatments — steroids,
topical bacitracin ointment and topical cyclosporine — proved to be
effective. However, one of the study patients was misdiagnosed and had herpetic
disease. “So it behooves us to think about avoiding corticosteroids and
using cyclosporine or bacitracin in these patients because misdiagnosis is
something that can occur to any of us,” Dr. Perry said.
Other researchers have reported the effectiveness of topical cyclosporine in patients who develop post-scleral necrosis following either phacoemulsification or extracapsular surgery. “These patients respond well to the use of topical cyclosporine,” Dr. Perry said. One of Dr. Perry’s patients was subjected to sensitivity testing, as well. “We found that the patient was allergic to the nylon that was used,” he said.
---Patients with a
psoriatic corneal abscess also can benefit from topical cyclosporine, Dr. Perry
said.
Patients with a psoriatic corneal abscess can also benefit
from topical cyclosporine. “One of our patients had a marked benefit, and
the entire corneal abscess cleared within approximately 2 weeks,” Dr.
Perry said. “The patient returned about 2 years later with another corneal
abscess in the exact same area. We again treated him with topical cyclosporine
and he did well. But again, the corneal abscess recurred. So when he returned
for the fourth time, we decided to leave him on maintenance topical
cyclosporine. The patient has been clear now without any recurrences for the
last 2.5 years.”
In summary, “I think that topical cyclosporine can be a helpful adjunct to us in treating patients with mycotic keratitis in the post-keratoplasty theater, and it also can be helpful to us in the management of noninfectious corneal ulceration,” Dr. Perry said.
 Staphylococcal marginal ulcer. |
 Ulcer after extracapsular cataract extraction. |
For Your Information:
- Henry D. Perry, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 N. Village Ave., Rockville Centre, NY 11570 U.S.A.; +(1) 516-766-2519; fax: +(1) 516-766-3714; e-mail: hankcornea@aol.com.