Topical Tacrolimus 0.03% as Sole Therapy in Vernal Keratoconjunctivitis: A Randomized Double-Masked Study

Management of vernal keratoconjunctivitis: Navigating a changing treatment landscape

Vernal keratoconjunctivitis (VKC) is a chronic, progressive, and potentially sight-threatening form of ocular inflammatory disease that primarily affects children and young adults. Prevalence varies by region, ranging from <2 per 10,000 in the United States to as high as 1,100 per 10,000 in parts of Africa. The rarity of VKC in developed countries can make differential diagnosis challenging, and treatment is often delayed until the disease is advanced, and symptoms are significantly impacting patients' quality of life. Although once viewed primarily as an immunoglobulin E-mediated condition, approximately 50% of patients with VKC do not exhibit allergic sensitization. It is now recognized that the immunopathology of VKC involves multiple inflammatory pathways that lead to the signs, symptoms, and conjunctival eosinophilic and fibroproliferative lesions that are a hallmark of the disease. We examine the evolution of our understanding of the immunopathology of VKC, the expanding VKC treatment armamentarium, the clinical implications of emerging treatment approaches, and future directions for VKC research and practice.

Comparision of efficacy and safety of 0.03% and 0.1% tacrolimus ointment in children with vernal keratoconjunctivitis

Background

Topical immunosuppressants such as tacrolimus in different concentrations are a breakthrough in the management of recalcitrant vernal keratoconjunctivitis (VKC); however, there is a lacks of comparative studies to guide their use in VKC management.

Objective

To compare the efficacy and safety of tacrolimus 0.03% and 0.1% eye ointment in the treatment of recalcitrant VKC.

Design

A retrospective comparative single-centre observational study.

Method

We reviewed records of a total of 48 recalcitrant VKC patients treated with two different strengths of tacrolimus ointment between April 2016 and March 2017. Of these, 39 fulfilled the inclusion criteria and were categorized into two groups, A and B, depending on the use of strength of tacrolimus (0.03% and 0.1%) used, respectively. Group A had 18 patients, while group B had 21 patients. Thirty-six patients, 18 from each group, were finally analysed and compared. Records of patients were explored for the subjective symptoms and objective sign score of the patient at baseline and at each time point. The main outcome measures were composite scoring and comparison of total subjective symptom scores (TSSSs) and total objective sign scores (TOSSs) within and between the groups at each follow-up. Percentage of patient with significant reduction in symptom and sign scores as compared with baseline was considered success of treatment. Chi-square and t-tests were used for comparison of outcomes between both groups.

Results

Mixed variety was most commonly encountered type of VKC. The signs and symptoms were significantly reduced in patients with treatment in both groups (p = 0.001) in all types of VKC. However, in group B, there was significant improvement in the size of papillae (p = 0.04) as compared baseline in contrast to group A. Side effects like burning and stinging in group B were significantly higher as compared with group A.

Conclusions

Both strengths of tacrolimus (0.03% and 0.1%) are effective in all forms of recalcitrant VKC. Papillary component of VKC responds better with higher strength (0.1%) but is associated with more significant side effects. Different strengths of tacrolimus can be used strategically depending upon the severity and clinical type of VKC to intensify outcome and minimize side effects.

Executive summary: Japanese guidelines for allergic conjunctival diseases 2021

Allergic conjunctival disease (ACD) is an inflammatory disease of the conjunctiva that is mainly caused by type I hypersensitivity response to allergens and accompanied by subjective symptoms and other findings induced by antigens. ACD is classified as allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. This article summarizes the third edition of the Japanese guidelines for allergic conjunctival diseases published in 2021 and outlines the diagnosis, pathogenesis, and treatment of ACD. Since the introduction of immunosuppressive eye drops, the treatment strategies for severe ACDs have significantly changed. To clarify the recommended standard treatment protocols for ACD, the advantages and disadvantages of these treatments were assessed using clinical questions, with a focus on the use of steroids and immunosuppressive drugs. This knowledge will assist healthcare providers and patients in taking an active role in medical decision making.

Comparative efficacy of medical treatments for vernal keratoconjunctivitis in children and young adults: a systematic review with network meta-analyses

PURPOSE

To systematically review the literature on the treatment of vernal keratoconjunctivitis (VKC) in children and young adults and conduct comparative efficacy analysis on clinical signs and symptoms using network meta-analyses.

METHODS

We systematically searched the databases PubMed/MEDLINE, EMBASE, Cochrane Central and Web of Science on 21 October 2019 for randomized controlled trials (RCT). Studies considered had patients with VKC < 20 years of age randomized into either intervention (any medical intervention) or comparator (active treatment, placebo treatment or non-treatment control), where pre-defined outcomes (data from ≥2 weeks and as close as possible to 2 months) of symptoms (itching, tearing, photophobia and foreign body sensation) and signs (hyperaemia, punctate keratitis, Horner-Trantas dots and macropapillae) were reported. Risk of bias within studies was evaluated using the Cochrane risk of bias tool. Comparisons were made using network meta-analyses.

RESULTS

We identified 39 studies with data on 2046 individuals. Twenty-three studies were eligible for quantitative analyses. None were systemic therapy. Temporal trend analysis showed that an initial focus on topical mast cell stabilizers turned to a focus on calcineurin inhibitors and a more diverse variety of pharmacological strategies. Studies varied in population, treatment duration and quality. The quantitative analysis revealed that efficacy of different therapies differed substantially across important clinical signs and symptoms, but there was a general trend of superior efficacy when using topical corticosteroids with stronger efficacy of the more potent corticosteroids.

CONCLUSION

We provide an overview of RCTs comparing the efficacy of treatments for VKC in children and young adults, which we find differs across symptoms and signs. Overall, we saw a general trend of superior efficacy with topical corticosteroids. However, our findings highlight the need for better studies, consensus on core outcomes and potential for individualized therapy.

Combination of 0.05% Azelastine and 0.1% Tacrolimus Eye Drops in Children With Vernal Keratoconjunctivitis: A Prospective Study

Aims: To compare the efficacy of the combination of 0. 05% azelastine and 0.1% tacrolimus eye drops with 0.1% tacrolimus monotherapy in pediatric patients with vernal keratoconjunctivitis (VKC). Methods: Prospective study. Seventy-six patients with VKC were randomized 1:1 into monotherapy group with 0.1% tacrolimus or combination therapy group with 0.1% tacrolimus and 0.05% azelastine. The Ocular Surface Disease Index (OSDI) scores and the signs of conjunctival hyperemia, corneal involvement, and palpebral conjunctiva papillae were assessed at baseline and at 1, 2, and 6 weeks after treatment. Results: Two groups were comparable in age, sex, duration of VKC, OSDI, and clinical signs of VKC at baseline. Significant improvements in OSDI score and clinical signs were observed in both groups at all follow-up visits (all p < 0.001), compared with baseline. The combination therapy group showed a larger decrease in OSDI score from baseline (10.30 ± 0.9) compared with monotherapy group (7.30 ± 0.7, p =0.0085) at 1 week. Greater improvements in conjunctival hyperemia and conjunctival papillae were identified in the combination therapy group, compared with in the monotherapy group, at all follow-up visits (all p < 0.05). The corneal involvement scores in the combination group is significantly lower than the monotherapy group at 2 weeks after the treatment (p = 0.0488). No severe adverse effect was found in either group during the study. Conclusions: Compared with a monotherapy of 0.1% tacrolimus, the combination of 0.05% azelastine and 0.1% tacrolimus eye drops lead to faster and greater improvements in clinical signs and symptoms of vernal keratoconjunctivitis in pediatric patients.

Is Interferon α-2b 1 MillionIU/mL Truly Better Than Tacrolimus 0.03% for Steroid-Resistant VKC ?: Our 2-Year Experience at a Tertiary Health-Care Centre

Purpose

To compare the efficacy of eye-drop interferon (IFN) α-2b 1 millionIU/mL with eye-ointment tacrolimus 0.03% in refractory vernal keratoconjunctivitis (VKC).

Materials and Methods

Fifty patients with VKC refractory to conventional treatment with topical corticosteroids and antihistamines after 4 weeks of regular use were selected retrospectively. Patients were divided into two groups depending on whether they received eye-ointment tacrolimus 0.03% three times a day or eye-drop IFN alpha-2b 1 millionIU/mL three times a day and were followed up for 24 months. The main outcome measures were total subjective symptom score (TSSS) and total objective ocular score (TOSS).

Results

Mean baseline TSSS was 7.24±1.98 in Group A (tacrolimus group) and 7.84±1.82 in Group B (IFN group), and it reduced to 1.12±0.83 in Group A and 0.62±0.41 in Group B at 6 months, which was statistically significant compared to the baseline score (p<0.05) as well as between the two groups. Mean baseline TOSS was 6.72±2.07 in Group A and 6.56±2.04 in Group B, and it improved to 1 month onwards to 1.52±0.87 in Group A and 1.0±0.71 in Group B at 6 months, which was statistically significant compared to the baseline score (p<0.05) as well as between the two groups. Side effects like stinging and burning sensations were seen in the tacrolimus group only.

Conclusion

Our study suggests that while both eye-drop IFN α-2b 1 millionIU/mL and eye-ointment tacrolimus eye ointment 0.03% are both safe and effective steroid-sparing agents in steroid-resistant VKC. IFN α-2b results in greater improvement in subjective symptoms and objective signs, has fewer side effects in long term and is better tolerated as compared to tacrolimus.

Efficacy of medical treatments for vernal keratoconjunctivitis: A systematic review and meta-analysis

BACKGROUND

Vernal keratoconjunctivitis (VKC) is a severe type of allergic conjunctivitis for which treatment strategies are still under debate.

OBJECTIVES

This study sought to conduct a systematic review and meta-analysis to evaluate the efficacy of medical treatments for VKC.

METHODS

The PubMed, Cochrane Library, Embase, and ScienceDirect databases were searched to assess the efficacy of treatments for VKC. Random-effect meta-analyses on changes in clinical scores of symptoms and signs between baseline and after treatment, stratified on treatment classes, were computed. Meta-regressions were searched for potential influencing parameters.

RESULTS

Included were 45 studies (27 randomized controlled trials and 18 prospective cohort studies), 1749 patients (78% were men; mean age, 11.2 years), and 12 different treatment classes. Mast cell stabilizers (MCSs; usually considered as first-line therapy), cyclosporine, and tacrolimus were the most studied drugs (in three-quarters of studies). Overall, all clinical scores improved. Total symptom and sign score decreased for MCSs (effect size, -3.19; 95% CI, -4.26 to -2.13), cyclosporine (effect size, -2.06; 95% CI, -2.72 to -1.40), and tacrolimus (effect size, -2.39; 95% CI, -3.36 to -1.43). No significant differences were shown depending on treatment classes, concentration, age, sex, baseline activity scores, and atopy. Sensitivity analyses demonstrated similar results.

CONCLUSIONS

This study confirms the efficacy of MCSs in the treatment of VKC. Efficacy of cyclosporine and tacrolimus did not differ, suggesting that tacrolimus is a good alternative to cyclosporine for severe cases of VKC. Further studies are needed to compare other drugs and their precise place in treatment strategy.

Role of combined immunomodulator therapy in severe steroid intolerant vernal keratoconjunctivitis

PURPOSE

To describe the role of combined topical cyclosporine (CsA) 0.1% and tacrolimus 0.03% in cases with severe steroid intolerant vernal keratoconjunctivitis (VKC).

METHODS

Medical records of patients with acute exacerbation of VKC and steroid intolerance referred from glaucoma to cornea clinic were reviewed from March 2017 to December 2018. Eleven patients (22 eyes), (nine with steroid-induced glaucoma, two with steroid-induced cataract and glaucoma) were found. All were started on topical CsA 0.1% QID. Due to suboptimal response at 2 weeks, topical tacrolimus 0.03% BD was also included.

RESULTS

The mean total subjective score at presentation was 13 ± 1.4, which reduced to 11.2 ± 1.3 at 2 weeks of topical CsA therapy and further reduced to 5 ± 0 at 2 weeks of combination therapy (p < 0.001). The mean total objective score at presentation was 9.4 ± 1.4 that reduced to 8.0 ± 1.3 at 2 weeks of topical CsA therapy and further reduced to 4.3 ± 1.6 at 2 weeks of combination therapy (p < 0.001). Similar results were obtained in a sub-group analysis including the worse eye or right eye of the cases only. The absolute change in the total subjective and objective score was much more with combination therapy. Photophobia and conjunctival hyperemia resolved within 4 weeks of combined therapy. No recurrence was observed till 6 months follow-up.

CONCLUSIONS

Combined use of cyclosporine and tacrolimus may lead to rapid resolution of symptoms and reduced recurrence rate in cases with severe VKC where steroid has to be avoided.

Clinical efficacy assessment in severe vernal keratoconjunctivitis: preliminary validation of a new penalties-adjusted corneal fluorescein staining score

Introduction and objective: Vernal keratoconjunctivitis (VKC) is a rare allergic eye condition that occurs in children and is characterised by a combination of debilitating symptoms. Repeated use of topical corticosteroid rescue therapy is often necessary in severe forms. This study aims to assess the validity of a new composite endpoint: the penalties-adjusted corneal staining score (PACS-S) proposed as primary endpoint in VEKTIS trial evaluating the efficacy of a new corticosteroid-sparing treatment, VERKAZIA® (ciclosporin 1 mg/ml eye drops), in severe VKC patients. Methodology: This research comprised a systematic literature review to identify efficacy endpoints being proposed in clinical trials for pediatric patients with severe VKC, followed by a remote expert advisory board assessing the validity of the PACS-S. Results: While no agreed or validated endpoint for assessing efficacy in VKC was identified when VEKTIS trial started, the experts' board acknowledged a high face validity of PACS-S as a subjective integrated measure matching the current clinical practice. A fair external validity was considered with regards to VEKTIS trial secondary endpoints. Conclusion: PACS-S appears to be a reliable, valid and clinically meaningful primary endpoint that allows significant improvement over existing endpoints in severe VKC trials. Additional research is needed to validate this endpoint.

Observer-masked trial comparing efficacy of topical olopatadine (0.1%), bepotastine (1.5%), and alcaftadine (0.25%) in mild to moderate allergic conjunctivitis

Purpose:

With increasing environmental pollution, the incidence of allergic conjunctivitis is increasing. Newer anti-allergic medications with combined anti-histaminic and mast cell stabilization action can help reducing the use of topical steroids for milder form of disease. There is no study directly comparing olopatadine (0.1%), bepotastine (1.5%), and alcaftadine (0.25%) for mild to moderate allergic conjunctivitis cases. Hence, we decided to methodically study the efficacy of three topical medications.

Methods:

Prospective, observer-masked clinical trial enrolled 45 patients with 15 patients in each of the three groups. Patients with mild to moderate allergic conjunctivitis were sequentially assigned to respective groups, and relief of symptoms and signs were noted upto 1-month follow-up.

Results:

All three topical medications faired almost equally in resolving symptoms of the patients with mild to moderate allergic conjunctivitis, and most of them reported complete relief after 1 week of use of medication. Few cases with limbal or palpebral papillae reported symptomatic relief after use of medication, but the resolution of these signs was not noted in all three groups.

Conclusion:

We concluded similar efficacy of three medications in relieving symptoms and inefficacy in regressing palpebral and limbal papillae in cases of allergic conjunctivitis.

Comparative Evaluation of Tacrolimus Versus Interferon Alpha-2b Eye Drops in the Treatment of Vernal Keratoconjunctivitis: A Randomized, Double-Masked Study

PURPOSE

Vernal keratoconjunctivitis (VKC) is a bilateral, chronic, external ocular inflammatory disorder that mainly affects patients in their first or second decade. This study was designed to compare tacrolimus and interferon alpha-2b (IFN alpha-2b) eye drops in the treatment of VKC.

METHODS

In this randomized, double-masked clinical trial, 40 consecutive patients with VKC were sent to a referral eye hospital in a tropical region southeast of Iran. Patients were randomly assigned to receive either 0.005% tacrolimus or IFN alpha-2b (1,000,000 units/cc). Chi-square and t tests were used for comparison of outcomes between both groups.

RESULTS

Mean ± SD age was 11.1 ± 5.2 years. Thirty-one patients (77.5%) were male. The mean duration of disease was 3.4 ± 2.9 years. In this study, the signs and symptoms were significantly reduced in patients after treatment in both groups (P = 0.0001). In the tacrolimus group, all patients responded to treatment whereas only one subject in the IFN group failed to respond (P = 0.99). Side effects in both groups were mild and tolerable.

CONCLUSIONS

This study indicated that both 0.005% tacrolimus and IFN alpha-2b are effective and appear to be safe in treatment of recalcitrant VKC.

Effect of Topical Tacrolimus in the Treatment of Thygeson's Superficial Punctate Keratitis

PURPOSE

To evaluate topical tacrolimus ointment for treating Thygeson's superficial punctate keratitis (Thygeson SPK).

DESIGN

Retrospective interventional case series.

METHODS

setting: Institutional practice.

PATIENT POPULATION

The medical records of 14 patients (9 women; age range, 9-65 years) with Thygeson SPK were reviewed retrospectively. Diagnosis was based on the history and clinical examination.

INTERVENTION

Patients were treated with tacrolimus 0.03% eye ointment instilled into the lower fornix twice daily for the first 2 weeks, followed by nocturnal application. The clinical signs and symptoms were assessed after 1 month of treatment. The drug was tapered with disease improvement.

MAIN OUTCOME MEASURE(S)

Treatment efficacy and side effects.

RESULTS

All patients had bilateral disease (average duration, 6 years). All patients, except 2 who used the medication irregularly, had improved visual acuity (VA), symptoms, and signs as long as the medication was applied. Before treatment 28.57% of patients had VA between 20/30 and 20/50, with improvement after treatment to 20/25 or 20/20. Attempts to withdraw the medication resulted in recurrent disease, and, therefore, treatment was not curative during the study period. No significant local medication side effects were reported.

CONCLUSION

Tacrolimus eye ointment 0.03% was effective for controlling Thygeson SPK for a long period with good patient tolerance and no noticeable local or systemic side effects. During the average 6-year follow-up, treatment was not curative. Randomized studies are difficult to conduct because of the disease rarity.