Cyclosporine A 1% an alternative to corticosteroids for treating subepithelial infiltrates

A study found that cyclosporine A eye drops were successful in patients who could not be tapered from corticosteroid eye drops.

Cyclosporine A 1% eye drops for the treatment of subepithelial infiltrates after adenoviral keratoconjunctivitis were shown in a study to be an effective alternative to corticosteroid eye drops.

Twelve eyes of seven patients were initially responsive to corticosteroid eye drops but were resistant to tapering. The subsequent introduction of cyclosporine A (CSA) eye drops allowed the corticosteroid therapy to be tapered, and all eyes were maintained on cyclosporine A eye drops once per day or less.

Patients were followed for a mean of 13 months (range: 4 to 28 months).

Lead author Bennie H. Jeng, MD, an associate professor of ophthalmology at the University of California, San Francisco, first encountered a handful of patients with symptomatic corneal subepithelial infiltrates occurring as a sequelae of adenoviral keratoconjunctivitis while in fellowship training.

He and co-author Douglas S. Holsclaw, MD, a mentor of Dr. Jeng’s and a clinical faculty member at the University of California, San Francisco, “just couldn’t get these patients off of steroids,” Dr. Jeng told Ocular Surgery News. “Patients can go on and off steroids for years.” In addition, there are steroid-related complications, namely glaucoma and cataracts, especially if patients keep going back on steroids.

Treatment with cyclosporine A 1%

During Dr. Jeng’s fellowship, Dr. Holsclaw started a patient on cyclosporine A eye drops, which seemed to work.

“Cyclosporine is a steroid-sparing agent, which is safer to use topically for prolonged periods of time,” Dr. Jeng said. In fact, a few patients were completely weaned from steroids.

The study authors speculated that subepithelial infiltrates and their associated symptoms can resolve with the use of topical corticosteroid eye drops because the pathogenesis of subepithelial infiltrates involves an immunologic host reaction, according to Dr. Jeng.

After completing his fellowship, Dr. Jeng spent 5 years at the Cleveland Clinic, where he continued to use cyclosporine A to successfully treat patients who had subepithelial infiltrates.

The study

Among the patients in the study, which was published in Cornea, the mean duration of topical corticosteroid use before starting cyclosporine A eye drops was 2.79 years.

“One patient had been on steroids for 7.5 years before being referred in,” Dr. Jeng said. “I think CSA is almost completely effective. However, the question remains: Can you get patients off CSA completely? Regardless, I’d prescribe CSA over steroids, indefinitely, any day of the week.”

Most study patients were kept on a low dose of cyclosporine A; the rest of the patients were successfully taken off cyclosporine A completely. No adverse events were detected for either group of patients.

Since submitting the study paper for publication about 1 year ago, Dr. Jeng has treated an additional 10 to 15 patients with cyclosporine A, achieving a success rate that parallels the study.

During flare-ups, Dr. Jeng’s patients are treated concurrently with steroids four times a day and cyclosporine A four times a day.

“We then taper off the steroids over 3 to 4 weeks, while maintaining CSA four times a day,” he said.

At that point, tapering of cyclosporine A begins. Every 2 weeks, the number of daily drops is reduced by one. “When patients are down to one drop a day, we then usually taper further to once every other day and then try to stop completely,” Dr. Jeng said. “However, if the patient flares up again, the tapering begins again, and we may eventually switch to a less potent formulation of CSA to try to wean the patient even lower.”

Cyclosporine A 1% must be obtained through a compounding pharmacy.

“Even though using CSA 1% may pose a logistical hurdle because of the need for a compounding pharmacy, I encourage clinicians to try this therapeutic regimen because they may be pleasantly surprised at the results,” Dr. Jeng said. “Some patients who have been recalcitrant to tapering off of steroids for over 5 years have been able to be weaned to once per day or less of CSA.”

Dr. Jeng has observed no patient compliance concerns with cyclosporine A. “I think this is because patients have been through the ringer using steroids,” he said.

Some researchers have proposed bypassing steroids altogether and starting patients on cyclosporine A. “Results are mixed, though, as to efficacy,” Dr. Jeng, who has no experience with such a protocol, said. – by Bob Kronemyer

Reference:

• Jeng BH, Holsclaw DS. Cyclosporine A 1% eye drops for the treatment of subepithelial infiltrates after adenoviral keratoconjunctivitis. Cornea. 2011;30(9):958-961.

• Bennie H. Jeng, MD, can be reached at 10 Koret Way, K-304, San Francisco, CA 94143; 415-206-8304; email: jengb@vision.ucsf.edu.
• Disclosure: Dr. Jeng has no relevant financial disclosures.