Corneal specialists warn of the dangers of systemic immunosuppression

ATHENS — Systemic immunosuppression following corneal transplantation should be administered under strict medical surveillance, according to several corneal specialists speaking here.

"It cannot be just in the hands of ophthalmologists, but needs the cooperation of different specialists," José Güell, MD, said at Cornea Day during the ESCRS Winter Refractive Surgery Meeting. "The lungs, liver and kidneys should be screened preoperatively but also checked periodically after surgery."

Jorge L. Alió

"Patients should know that lifelong immunosuppression is unfortunately unavoidable in some cases, but they should also be aware of the consequences it may produce. Elderly patients are more at risk of severe complications, and women in particular should know that they are going to have fertility problems," noted Jorge L. Alió, MD, PhD, Ocular Surgery News Europe/Asia-Pacific Edition Editorial Board Chairman.

According to Nikolaos Papadopoulos, MD, the main danger is lung aspergillosis. In one patient, a 65-year-old woman treated with oral cyclosporine at the U.S. Food and Drug Administration-recommended dosage, lung aspergillosis was accidentally discovered after a second graft rejection.

"For the needs of general anesthesia, we performed chest X-rays, which showed multiple round shadows in the lungs. Further examination with high-resolution CT scan revealed the typical emphysematous cysts of aspergillosis," Dr. Papadopoulos said.

After a third regrafting, the patient was treated with topical cyclosporine eye drops and showed no sign of rejection at 3 months.

"In this case, we managed to treat the lung condition, but aspergillosis is an extremely severe, life-threatening disease," he said.

Previously, Dr. Papadopoulos said he experienced the extreme side effects of systemic immunosuppressive drugs in three patients. One patient died of lung aspergillosis caused by systemic steroids, another developed septic arthritis of the hip joint following systemic cyclosporine treatment, and the third patient contracted a severe lung virus induced by systemic steroids.

Dr. Papadopoulos said topical immunosuppression might be a viable alternative, especially in the elderly.

"Topical cyclosporine can be as effective as systemic," he said.

Dr. Alió objected, saying that topical cyclosporine cannot be effective for long-term immunosuppression. "It doesn't reach the anterior chamber," Dr. Alió said, noting he prefers to use tacrolimus in a 1% concentration.