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Majority of high-risk cornea grafts successful with systemic tacrolimus

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A majority of patients who received systemic tacrolimus underwent successful high-risk keratoplasty with grafts surviving at 2 years postop, according to researchers in England.

A. Joseph and colleagues at the Queen's Medical Centre in Nottingham evaluated the effect of systemic tacrolimus on graft rejection in 47 patients undergoing 47 high-risk corneal grafts. Patients were defined as high-risk candidates if they had at least one previous graft failure in the same eye or two quadrants of stromal vascularization, according to the study. All patients took 2 mg of oral tacrolimus on the day of surgery and continued taking a mean 2.5 mg daily until 18 months postop or suture removal.

Tacrolimus is an immunosuppressive macrolide antiobiotic with a mechanism of action similar to cyclosporine, according to the study. The authors had previously confirmed the drug's benefit in preventing graft rejection in a smaller cohort with shorter follow-up, they noted.

In the current study, four patients could not tolerate tacrolimus and were excluded. In the remaining 43 patients, 28 (65%) had graft clarity at a mean 33.7 months' follow-up, the authors found.

Eight patients (18.6%) experienced graft rejection episodes while taking tacrolimus. Despite intensive topical and intravenous steroids, five cases ended in graft failure, the authors said.

"Raised intraocular pressure or hypotony after attempts to control the intraocular pressure was the main cause of graft failure," the authors said. "These patients may have benefited from higher doses of tacrolimus or combination treatment with another immunosuppressive agent."

Four patients (9.3%) experienced rejection episodes after discontinuing tacrolimus treatment, the authors said. They noted that no patient followed for more than 30 months developed a rejection episode, suggesting "some indication on the duration for which immunosuppression may be continued."

The study is published in the January issue of the British Journal of Ophthalmology.