Tacrolimus Ointment 0.03% for Treatment of Refractory Childhood Phlyctenular Keratoconjunctivitis

Treatment of Steroid-Resistant Nodular Episcleritis With Tacrolimus: A Case Report

A 46-year-old male, with no chronic medical illness, complained of pain, tearing, and redness for one-month duration, with no photophobia, discharge, or decrease in visual acuity. Examination revealed a small, painful, red swelling in the left sclera. Slit-lamp examination using a narrow bright slit beam revealed edema of the episcleral layer and injection of the superficial episcleral blood vessels. The rest of the anterior segment exam and fundoscopy were normal. The laboratory investigations and systemic workup were normal. The patient was initially treated with prednisolone acetate (Pred Forte) 1% every three hours per day for one week, and then four times per day for another week, and tapered gradually over eight weeks with systemic nonsteroidal anti-inflammatory drugs (NSAIDs) as diclofenac sodium for eight weeks with mild improvement of clinical symptoms, but the size of the lesion remained without any change and the patient started to have a relapse of symptoms at the end of the course. Topical tacrolimus drops of 0.1% concentration were prepared in the pharmacy under complete sterile precautions and were used four times per day for the following six weeks duration instead of the initial therapy (steroids and NSAIDs). Tacrolimus drops were then tapered gradually over another six weeks duration. The patient showed dramatic suppression of inflammation and exceptional remission of symptoms with complete resolution of the episcleritis. Topical tacrolimus is very effective in the treatment of nodular episcleritis, which is resistant to steroid therapy. Patients with nodular episcleritis suffer from prolonged bouts of inflammation that are characteristically more painful than the diffuse type and may be associated with other systemic diseases. The case is steroid-resistant nodular episcleritis, which did not respond to the usual treatment and showed a good response to treatment with tacrolimus, which was first introduced in episcleritis. Tacrolimus is being used in other ocular diseases, but its use in episcleritis is unique.

Pediatric Phlyctenular Keratoconjunctivitis at a Tertiary Care Center in the United States

PURPOSE

The aim of this study was to evaluate characteristics and outcomes of pediatric phlyctenulosis at a tertiary care center in the United States.

METHODS

A retrospective cohort study of phlyctenulosis diagnosis in patients younger than 18 years was conducted. Demographics, presenting features, treatment regimens, and outcomes were analyzed.

RESULTS

Seventy patients (95 eyes) with phlyctenulosis were identified. Fifty-four patients (77.1%) were Hispanic, which was greater than the center's proportion of pediatric patients identifying as Hispanic (53.8%, P < 0.0001). Common comorbidities included adjacent external/lid disease (82.9%), allergic/atopic disease (18.6%), and viral infections (8.6%). Nine patients had tuberculosis testing which was negative in all cases. Five patients had vitamin A testing which revealed deficiency in 1 patient. Treatment regimens were diverse and included varying combinations of topical and systemic medications. Complications included corneal scarring (27.4%), corneal neovascularization (40.0%), amblyopia (16.8%), corneal perforation (3.2%), and severe limbal stem-cell deficiency (1.1%). 26.3% of affected eyes had final visual acuity worse than 20/40. Differences in rates of corneal complications between Hispanic and non-Hispanic patients were not statistically significant, although severe corneal complications including perforation occurred only in the Hispanic group.

CONCLUSIONS

This study presents a modern cohort of phlyctenulosis at a tertiary center in the United States and includes a larger proportion of Hispanic patients than expected. Phlyctenulosis carries high corneal morbidity and may frequently result in reduced visual acuity. Similar rates of corneal complications were seen in Hispanic versus non-Hispanic patients, but severe corneal complications were seen only in the Hispanic group.

A comparative study between ciclosporine A eye drop (2%) and tacrolimus eye ointment (0.03%) in management of children with refractory vernal keratoconjunctivitis

PURPOSE

To compare the effects of ciclosporine A (2%) eye drop and tacrolimus (0.03%) eye ointment on children with vernal keratoconjunctivitis (VKC) who were not responding to corticosteroid eye drops.

METHODS

A prospective comparative study was carried out on children who were diagnosed with refractory VKC at the ophthalmology clinic in Benha University, Delta area, Egypt, during the period from October 2019 to February 2020.

RESULTS

Fifty-nine patients completed this study. Regarding the individual symptom score, redness, burning, photophobia, and foreign body sensation were significantly reduced in the tacrolimus group compared to those in the ciclosporine A group during the 1st week (p < 0.05). Moreover, the tacrolimus group showed a statistically significant reduction in burning and foreign body sensation at the 4th week (both p = 0.032), and in redness and burning sensation at the 12th week compared to those in the ciclosporine A group (p = 0.005 and 0.048, respectively). The tacrolimus group showed significantly lower mean scores for tarsal conjunctival papillary hypertrophy at the 1st week and 12th week (p = 0.037 and 0.046, respectively), and for punctate erosion and cobblestone papillae at the 1st week (p = 0.029 and 0.037, respectively) than the ciclosporine group. Failure of treatment was observed in 6 patients (19.35%) in the ciclosporine A group and in 5 patients (17.85%) in the tacrolimus group. No serious side effects were detected in any group.

CONCLUSION

A higher reduction in inflammatory symptoms and signs as well as compliance with tacrolimus 0.03% eye ointment than with ciclosporine A 2% eye drops was observed. Moreover, long-term medication for refractory cases is needed to control inflammation. Overall, our finding suggested that ciclosporine A eye drops and tacrolimus eye ointment could be considered as corticosteroid-sparing drugs in the management of children with refractory VKC.

The Therapeutic Effects of a 0.03% Tacrolimus Ointment on Childhood Phlyctenular Keratitis

Purpose: We explored the therapeutic effects of a 0.03% tacrolimus ointment (Protopic) on steroid-resistant phlyctenular keratitis in children. Methods: We enrolled seven eyes of five children with recurrent phlyctenular keratitis despite 3 months of steroid treatment. The topical steroids were tapered and the patients treated with a combination of 0.03% tacrolimus and 0.3% ofloxacin ointment. The logarithm of minimal angle of resolution (logMAR) visual acuity, corneal neovascularization status, and changes in corneal opacity between the baseline and final visit were checked on anterior photographs using Image J software. Results: The average patient age was 6.8 ± 3.0 years (range, 3-9 years) and the treatment duration 8.0 ± 2.0 days (range, 5-10 days). The baseline logMAR visual acuity was 0.42 ± 0.32 and the final value 0.19 ± 0.22. Visual acuity thus improved significantly after treatment (p = 0.026). Corneal neovascularization and phylctenulosis improved in all seven eyes; the fibrotic corneal opacity decreased in two eyes. Conclusions: Topical 0.03% tacrolimus ointment may usefully treat steroid-resistant phlyctenular keratitis of childhood.

Long-term results of topical 0.02% tacrolimus ointment for refractory ocular surface inflammation in pediatric patients

BACKGROUND

No studies have been reported on the efficacy and safety of long-term (≥12 months) use of topical tacrolimus for refractory ocular surface inflammation in pediatric patients.

METHODS

Medical records of pediatric patients who were prescribed topical 0.02% tacrolimus ointment for refractory ocular surface inflammation between January of 2010 and March of 2018 were reviewed retrospectively. Changes in ocular surface signs during slit-lamp examination, clinical symptoms and concurrent steroid use were graded with a scoring system. The presence of side effects was also assessed. The changes in disease severity and patient symptoms were compared between baseline and after the treatment.

RESULTS

Among 72 patients (55% males, mean age 10.8 ± 3.9 years, range 3 to 17 years), 25 patients (48% males, mean age 11.4 ± 3.9 years) fully recovered, resulting in discontinuance of the ointment treatment before 12 months. Six patients experienced intolerable burning sensation, which required treatment cessation. Cessation days of those who quit were 1,5,14,20,26, and 35 days. Seven patients were lost during follow-up. Thirty-four patients (56% males, mean age 11.2 ± 4.2 years, range 3 to 17 years) were treated with tacrolimus ointment for over 12 months (average 23.1 ± 19.1 months, range 12 to 98 months). During the follow-up period, all patients showed improved clinical signs and symptoms, and no adverse reaction was noted.

CONCLUSIONS

Long-term maintenance of topical tacrolimus 0.02% ointment is safe and effective in improving refractory ocular surface inflammation in pediatric patients.

Superior limbic keratoconjunctivitis: a comprehensive review

Superior limbic keratoconjunctivitis (SLK) is characterized by chronic inflammation of the superior limbus and superior bulbar and tarsal conjunctivae. Patients also often have fine punctate staining of the limbus and adjacent area, superior limbic proliferation seen as thickening of the limbal epithelium and surrounding conjunctiva, and occasionally filaments at the superior limbus and upper cornea. SLK frequently presents with ocular irritation, foreign body sensation, and photophobia. SLK can be associated with other ocular and non-ocular conditions, such as thyroid disease. Although the pathogenesis of SLK is still unknown, it is thought to be related to mechanical injury, tear film instability, or an autoimmune/inflammatory etiology. Many patients with SLK can be asymptomatic or have symptoms that resolve or remit spontaneously. For symptomatic SLK, patients are managed medically with treatments such as lubricants, topical anti-inflammatory or immunomodulatory medications, punctal occlusion, and bandage contact lenses. Patients with symptoms refractory to medical management may need surgical interventions. We detail the current literature on the epidemiology, clinical manifestations, associated conditions, histopathology, pathogenesis, and treatment of SLK.

Surgical management of peripheral corneal thinning disorders

The peripheral corneal thinning disorders are associated with degenerative, autoimmune, or infective causes. Corneal thinning can subsequently affect the visual acuity either by inducing severe astigmatism or by progressive involvement of the central cornea. In addition to this, the integrity of the eye is at risk. Medical management is necessary to address the underlying inflammatory or infectious causes; however, most of the cases require surgical intervention for tectonic support or for visual rehabilitation in patients with severe astigmatism. Preoperative investigations help in mapping the corneal curvature and thickness, thereby facilitating planning of treatment. Routine corneal transplantation techniques do not yield good results in peripheral corneal thinning disorders. Various surgical modifications have been described to manage these challenging cases. We review the available literature on causes and management of peripheral corneal thinning disorders.

Topical Tacrolimus 0.03% for Maintenance Therapy in Steroid-Dependent, Recurrent Phlyctenular Keratoconjunctivitis

PURPOSE

To evaluate the efficacy of topical tacrolimus 0.03% as steroid-free maintenance therapy in young patients with severe, recurrent phlyctenular keratoconjunctivitis (PKC).

METHODS

The medical records of 6 eyes of 5 patients (4 children and 1 young adult) with recurrent, steroid-dependent PKC were reviewed. The patients were treated with combined application of topical steroids and tacrolimus 0.03% in the active phase and maintained on topical tacrolimus alone after remission.

RESULTS

The clinical signs, symptoms, and visual acuities resolved in all patients after 25.2 ± 16.9 days of combined treatment with steroids and tacrolimus. After disease remission, the patients were maintained on topical tacrolimus 0.03% once daily alone for 8.4 ± 4.7 months, and no recurrence occurred during 10.6 ± 1.9 months of follow-up. Tacrolimus was successfully discontinued in 2 patients without further recurrence. There were no ocular side effects related to the use of topical tacrolimus.

CONCLUSIONS

Topical tacrolimus 0.03% was effective in maintaining long-term remission in patients with recurrent, steroid-dependent PKC.

Topical tacrolimus in anterior segment inflammatory disorders

Immune mediated inflammatory anterior segment diseases are variable and their management requires intense immunosuppression. Treatment with topical steroids is associated with serious ocular side effects. In order to overcome the potentially blinding complications of topical steroids, immunomodulatory drugs are being used more frequently. Tacrolimus is a calcineurin inhibitor that induces suppression of T lymphocytes activity and reduction of ocular inflammation. Tacrolimus was recently investigated for application in various anterior segment inflammatory disorders. In this review, we will discuss the therapeutic application of topical tacrolimus as a steroid-sparing agent in treating T cell mediated anterior segment inflammation.

Therapeutic Effect of 0.1% Topical Tacrolimus for Childhood Interstitial Keratitis Refractory to Cyclosporine

PURPOSE

To report our findings in a case of childhood refractory interstitial keratitis successfully treated with 0.1% topical tacrolimus.

METHODS

A 12-year-old boy presented with a 3-year history of interstitial keratitis. For the recurrent interstitial keratitis he had been treated with topical and systemic acyclovir, steroids, and topical cyclosporine for 3 years. Our examinations revealed severe stromal infiltrates and neovascularization. Treatment was changed from topical 0.5% cyclosporine to topical 0.1% tacrolimus combined with topical acyclovir and betamethasone.

RESULTS

After 2 weeks of treatment with topical tacrolimus, the degree of stromal infiltrates decreased. Although the improvements were slow, the stromal infiltrates resolved somewhat, and neovascularization and topical acyclovir and betamethasone were tapered and stopped in 18 months. Since then, the patient has not shown any recurrence for 9 months without medication.

CONCLUSION

Our findings indicate that topical tacrolimus should be considered for treating refractory interstitial keratitis in children.

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.

Long-term result of maintenance treatment with tacrolimus ointment in chronic ocular graft-versus-host disease

PURPOSE

To investigate the efficacy and safety of long-term maintenance treatment with tacrolimus ointment in chronic ocular graft-vs-host disease (GVHD) with ocular surface inflammation.

DESIGN

A retrospective interventional consecutive case series.

METHOD

Long-term maintenance treatment (≥6 months) with topical 0.02% tacrolimus ointment was applied to patients with chronic ocular GVHD with ocular surface inflammation (at least grade 2 inflammatory score). We evaluated the inflammatory score, steroid score and steroid use period of total duration, and numbers of inflammatory aggravations before and after tacrolimus treatment. The clinical outcomes were assessed by symptom score, ocular surface staining, Schirmer I test, tear break-up time (TBUT), and classification of chronic GVHD conjunctivitis at the initial and final examinations.

RESULTS

Thirteen patients (24 eyes) were treated with tacrolimus ointment for up to 20 months (average 12.2 months). The ocular surface inflammatory score decreased from 2.8 to 0.6 (P = .001) within 2-8 weeks after starting tacrolimus ointment treatment. The numbers of inflammatory aggravation and the need for steroid treatment also decreased after initiating tacrolimus treatment. At the final follow-up, all patients reported improvement in clinical outcomes, compared to initial findings. Except for blurred vision or mild burning sensation, there were no reported side effects.

CONCLUSION

Considering the chronic course of GVHD, long-term maintenance treatment with tacrolimus ointment could be useful and safe to locally treat ocular surface inflammation in chronic ocular GVHD.

Topical 0.03% tacrolimus for subepithelial infiltrates secondary to adenoviral keratoconjunctivitis

OBJECTIVE

To determine the safety and efficacy of topical 0.03% tacrolimus ointment treatment for subepithelial corneal infiltrates (SEIs).

METHODS

This prospective non-controlled interventional case series included patients with SEIs who had been previously treated with topical corticosteroids with either no improvement or the medication being withdrawn due to associated intraocular pressure (IOP) elevation. The patients were treated with 0.03% tacrolimus ointment twice daily for 22 weeks (including a 1-month washout). The objective data were best-corrected Snellen visual acuity (BCVA), IOP, and full ocular examination results, including SEI severity and the Schirmer test. The subjective data were the patients' responses to a questionnaire at all follow-up visits.

RESULTS

The patients consisted of five males (45%) and six females (55%) (mean age 50 ± 11 years) who were followed up for an average of 22 weeks. The mean BCVA (logarithm of the minimum angle of resolution [logMAR]) before and after treatment was 0.34 ± 0.09 and 0.08 ± 0.04 respectively (p = 0.042). All the patients evidenced significant objective clinical improvement, and none had a severe degree of SEI at the end of the treatment. The patients reported considerable reduction in the severity of their symptoms (foreign body sensation, glare, etc.). Three patients were excluded due to side-effects (one had severe dizziness and discomfort), and their data were excluded from the study.

CONCLUSION

Topical tacrolimus 0.03% is a safe and effective alternative treatment in patients with SEIs who do not respond to other treatment modalities or have untoward side-effects from topical steroids.

Phlyctenular keratoconjunctivitis - an atypically severe case treated with systemic biologic immunosuppressive therapy

PURPOSE

To report an atypically severe and refractory phlyctenular keratoconjunctivitis case treated successfully with systemic biologic immunosuppressive therapy.

METHODS

A 10-year-old female was followed in the ophthalmology clinic for three years for a severe form of bilateral PKC. The patient was treated for blepharitis and intestinal parasitosis, and underwent topical corticosteroid therapy, followed by subconjunctival injections and systemic corticosteroids with no clinical improvement. An association of topical cyclosporine A and oral methotrexate had no clinical response either. Phlyctenae of the cornea remained evident with neovascularization, progressive peripheral corneal thinning and occasional anterior chamber reaction.

RESULTS

The patient was treated with a combination of infliximab and methotrexate and corticosteroid therapy was tapered, with a fast and sustained resolution of the symptoms and corneal signs. Eleven months past initiation of the treatment, the patient remains asymptomatic and without any recurrence of the disease.

CONCLUSION

Phlyctenular keratoconjunctivitis may present with a broad spectrum of symptoms and signs, and its severity varies significantly. In cases of severe PKC, which are refractory to conventional therapy, systemic biologic immunosuppressive therapy may be a valuable alternative.

Application for tacrolimus ointment in treating refractory inflammatory ocular surface diseases

PURPOSE

To evaluate the therapeutic effects of topical tacrolimus ointment on refractory inflammatory ocular surface diseases.

DESIGN

Retrospective interventional consecutive case series.

METHODS

In Severance Hospital, Seoul, South Korea, 0.02% tacrolimus ointment was topically applied 1 to 3 times per day, depending on disease severity, for up to 31 months in eyes of 12 consecutive patients with refractory inflammatory ocular surface diseases who had previously been treated with steroid therapy. Seven patients had chronic cicatrizing conjunctivitis (6 cases caused by Stevens-Johnson syndrome and 1 attributable to ocular cicatricial pemphigoid); 4 had scleritis (3 necrotizing scleritis, 1 recurrent nodular scleritis); and 1 patient had Mooren ulcer with corneal perforation. The therapeutic outcomes after tacrolimus treatment were evaluated according to the following criteria: change in clinical findings (eg, decrease of hyperemia, ocular pain, epithelial defect, and pseudomembrane), intraocular pressure (IOP), and need for steroid therapy.

RESULTS

In all 3 groups, tacrolimus showed an immunosuppressive effect, especially on scleritis and Mooren ulcer. These effects included suppression of corneoscleral melting and reduction of hyperemia. In chronic cicatrizing conjunctivitis, simultaneous topical tacrolimus while tapering steroid therapy suppressed inflammatory relapse. The elevated IOP in steroid responders recovered to normal range after successful tapering of steroid. No adverse side effects were noted after 1.5 to 31 months of continuous tacrolimus treatment.

CONCLUSION

The use of topical tacrolimus ointment is effective in controlling refractory inflammatory ocular surface disease, and can reduce the need for steroid use while reducing inflammation recurrence.