Therapeutic effects of 0.1% tacrolimus eye drops for refractory allergic ocular diseases with proliferative lesion or corneal involvement

Topical Tacrolimus in Anterior Segment Disorders in Ophthalmology: A Review

The purpose of this study is to emphasize topical tacrolimus's role in treating anterior segment diseases in ophthalmology. The present study analyzed research papers and publications from international databases, including Pubmed, MedLine, Google Scholar, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), and Scopus to highlight the significance and advantages of topical application of tacrolimus and its efficacy in treating allergic eye disorders, immune-mediated diseases, and other ocular surface disorders. Tacrolimus and cyclosporine are the two most commonly used topical immunosuppressants in ophthalmology. Tacrolimus is a selective calcineurin inhibitor administered for the prevention and treatment of allograft rejection in solid organ transplant recipients and has a similar mechanism of action to cyclosporine. Management of immune-mediated inflammatory anterior segment requires intense immunosuppression and studies have shown that tacrolimus is ten to hundred times more effective than cyclosporine. Abbreviations: IL-2 = interleukin-2, FDA = Food and Drug Administration Agency, GvHD = graft versus host disease, (Ig)E = immunoglobulin E, SAC = seasonal conjunctivitis, PAC = perennial allergic conjunctivitis, VKC = vernal keratoconjunctivitis, AKC = allergic keratoconjunctivitis, GPC = giant papillary conjunctivitis, PKC = phyctenular keratoconjunctivitis, DED = dry eye disease, TBUT = tear break up time.

Long-Term Clinical Outcome of Tacrolimus Skin Ointment (0.03%) for the Treatment of Vernal Keratoconjunctivitis: A Quasi-Experimental Study

Background Vernal keratoconjunctivitis (VKC) is an allergic conjunctival inflammation with severe ocular complications if left untreated. The current management regimen is plagued with adverse effects, long-term problems, and clinical relapses. Tacrolimus offers an alternative treatment option, and long-term studies are needed to determine its efficacy. Methods A two-year follow-up based study was conducted on moderate to severe VKC patients, who were prescribed tacrolimus skin ointment. The 5-5-5 exacerbation scale was used for the monitoring and grading severity of the disease. Analysis of variance (ANOVA) and intergroup comparisons were conducted on exacerbation scale scores among follow-ups. Results A significant reduction was observed in the total score of severity from baseline (203.17±102.05) to three months' follow-up (69.94±70.54), and it kept reducing for 18 months post therapy. Similar results with statistically significant reduction were observed for all grades of the scale. The relapse rate was 5.71% within a month after therapy cessation, and none of the other patients showed relapse afterward. No significant ocular and systemic complications were observed during the study. Conclusion Tacrolimus is effective in the long-term management of VKC without the complications of conventional steroid-based therapy.

Tacrolimus-Loaded Cationic Nanoemulsion In-Situ Gel System: In-Vitro Characterization and Performance in a Dry-Eye Rabbit Model

Dry eye disease (DED) is a highly prevalent ocular surface disease that affects life quality and reduces productivity at work. The purpose of this study is to improve the efficacy of tacrolimus (FK506) in the treatment of DED using the special eye surface retention properties of cationic nanoemulsion (CNE) modified by thermosensitive in-situ gel (ISG) (CNE-ISG). The precorneal retention of CNE-ISG containing 0.05% FK506 (50 min) was longer than that of CNE containing 0.05% FK506 (25 min) and commercial suspension containing 0.1% FK506 (Talymus®) (10 min). Successfully modeled dry-eye rabbits were treated with 0.05% CNE-ISG (twice/day), 0.05% CNE and 0.1% suspension (Talymus®) (thrice/day). Schirmer's tear secretion test showed no significant difference between the CNE-ISG group and the healthy group after 5 days of treatment (p > 0.05). The results of a tear ferning test (TFT) showed that the tear-fern-like crystal branches in the CNE-ISG group returned to normal after 5 days of treatment. Histological analysis showed that the number of goblet cells in the CNE-ISG group significantly increased. HET-CAM stimulation test showed that the CNE-ISG group had no ocular irritation. The above results indicated that CNE-ISG might be a promising delivery system and as an effective dosage form was employed for FK506 in the treatment of DED.

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.

Investigating the Impact of COVID-19 Infection on Dry Eye Parameters

PURPOSE

This study aims to compare dry eye parameters before and after COVID-19 infection in dry eye patients.

METHODS

We included 44 dry eye patients (88 eyes) from our existing dry eye cohort, with 22 belonging to the post-COVID-19 group due to a prior COVID-19 infection and the other 22 forming the non-COVID-19 group as they had no history of COVID-19. We examined and compared the dry eye parameters of the post-COVID-19 group, including the ocular surface disease index (OSDI), Schirmer's test results (ST), non-invasive Keratography tear break-up time (NIKBUT), lipid layer thickness (LLT), Meibomian gland dysfunction (MGD), and the grading of papillae and follicles, both before and after the COVID-19 infection. We also compared the dry eye parameters difference of the post-COVID-19 group with the non-COVID-19 group.

RESULTS

The post-COVID-19 group was comprised of individuals with an average age of 38.36 ± 14.99 years, of which 82% were female. The time interval between the two tests was 16.92 ± 5.40 months, which did not differ significantly from the non-COVID-19 group. Compared to the pre-COVID-19 eyes, the post-COVID-19 eyes showed a significant decrease in the average LLT (52.86 ± 18.00 nm vs. 63.00 ± 22.40 nm, p < 0.001), as well as the maximum LLT (67.89 ± 20.81 nm vs. 78.48 ± 20.55 nm, p < 0.001). The MGD in both the upper (1.75 ± 0.84) and lower eyelids (1.43 ± 0.73) worsened after a COVID-19 infection. Additionally, the grading of papillae was worse following a COVID-19 infection (0.61 ± 0.69 vs. 0.16 ± 0.37, p < 0.001). The multivariate linear regression model revealed a negative association between COVID-19 infection and NIKBUT-average (β = -2.98, 95%CI: (-5.82, -0.15), p = 0.039), LLT-average (β = -14.12, 95%CI: (-22.66, -5.59), p = 0.001), and LLT max (β = -15.65, 95%CI: (-23.09, -8.20), p < 0.001).

CONCLUSION

From preliminary results, we concluded that dry eye patients who have been infected with COVID-19 appear to have a more severe dry eye condition, as evidenced by lower LLT, worse papillae and MGD, and shorter NIKBUT. It is important to raise awareness of this potential long-term symptom of COVID-19, especially among existing dry eye patients.

Biologics for allergy: therapeutic potential for ocular allergic diseases and adverse effects on the eye

Biologics applying antibodies against IgE, IL-5, IL-5 receptor α, IL-4 receptor α, and IL-13 have dramatically improved recent treatment outcomes in allergic diseases including asthma, rhinitis, and atopic dermatitis. However, these drugs have not been approved for ocular allergic diseases such as allergic conjunctivitis, vernal keratoconjunctivitis, and atopic keratoconjunctivitis. Although the putative mechanisms suggest that these drugs should have beneficial effects in patients with ocular allergies and some studies have reported such beneficial effects, various adverse ocular symptoms have also been observed in clinical trials and off-label use studies. Since ocular allergic diseases have distinct pathogeneses, each biologic drug must be examined regarding specific effects on each ocular allergy. For example, IgE-mediated type 1 hypersensitivity plays a critical role in allergic conjunctivitis. By contrast, T cells and eosinophilic and non-IgE-mediated type 2 inflammation play important roles in vernal keratoconjunctivitis. Allergists must fully understand the effects of each drug on the eye. This review outlines both potential therapeutic and adverse effects of various biologics on allergic diseases of the eye.

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.

Safety and efficacy of topical tacrolimus 0.03% in the management of vernal keratoconjunctivitis: a non-randomized controlled clinical trial

Background

Vernal keratoconjunctivitis (VKC) is a bilateral, recurrent, chronic conjunctival inflammatory disease with seasonal exacerbations. This study aimed to assess the efficacy and safety of tacrolimus 0.03% eye ointment in the management of chronic VKC.

Methods

This was an open-label, prospective, non-randomized, comparative interventional study that enrolled 50 patients with chronic VKC, who were allocated to one of two groups. The first group was treated with tacrolimus 0.03% eye ointment twice daily for 2 months then once daily for 2 months, followed by once every other day for another 2 months. The control group was treated with standard anti-allergic drugs, topical fluorometholone 0.1% eye drops three times daily for 2 weeks and gradually tapered for another 2 weeks, with topical olopatadine 0.1% administered twice daily during the follow-up period. Disease severity was assessed using a four-point scale for symptoms and signs. Treatment efficacy was assessed by analyzing changes in symptoms and signs, and by clinical photography.

Results

Fifty patients with bilateral chronic VKC completed the follow-up. The mean (standard deviation) ages of the tacrolimus and control groups were comparable (16.20 [5.10] years versus 16.48 [4.19] years, P > 0.05). The most commonly reported symptom was itching, and the most common signs were papillary hypertrophy and conjunctival hyperemia. All symptoms and signs were significantly reduced after treatment in both groups. The tacrolimus group showed a more significant improvement at 3 and 6 months in the mean composite symptom score (both P < 0.05) and in the mean composite sign score (both P < 0.05). Regarding complications, one case of increased intraocular pressure occurred in the control group (4%) after 2 weeks of steroid treatment, while there were no complications in the tacrolimus group, except for some reports of stinging sensation, which was well tolerated.

Conclusions

Treatment of chronic bilateral VKC with tacrolimus 0.03% eye ointment is effective and safe. It could be considered an alternative treatment to reduce steroid-associated complications in patients with chronic VKC. Future double-blinded clinical trials with a longer follow-up period are necessary to confirm our findings and to determine the long-term safety of topical tacrolimus 0.03% ointment in VKC.

Diagnosis, Management, and Treatment of Vernal Keratoconjunctivitis in Asia: Recommendations From the Management of Vernal Keratoconjunctivitis in Asia Expert Working Group

Vernal keratoconjunctivitis (VKC) is an underdiagnosed and underrecognized ocular surface disease with limited epidemiological data in Asia. It is more prevalent in warm, dry, and windy climates, and often has a substantial impact on a patient’s quality of life. In rare cases, VKC can be associated with vision loss, either through corticosteroid overuse or inadequate treatment of persistent inflammation. As a potentially severe and complex disease, there is variability with how VKC is managed across Asia and among the various allergic eye diseases. Diagnosis and treatment of patients with VKC is a challenge for many ophthalmologists, since no precise diagnostic criteria have been established, the pathogenesis of the disease is unclear, and anti-allergic treatments are often ineffective in patients with moderate or severe disease. In addition, the choice of treatment and management strategies used for patients varies greatly from country to country and physician to physician. This may be because of a lack of well-defined, standardized guidelines. In response, the Management of Vernal Keratoconjunctivitis in Asia (MOVIA) Expert Working Group (13 experts) completed a consensus program to evaluate, review, and develop best-practice recommendations for the assessment, diagnosis, and management of VKC in Asia. The expert-led recommendations are summarized in this article and based on the currently available evidence alongside the clinical expertise of ophthalmologists from across Asia with specialism and interest in the ocular surface, VKC, and pediatric ophthalmology.

Ocular surface disturbance in patients after acute COVID-19

Background

We investigated the ocular surface disturbances in COVID‐19 patients discharged from the hospital.

Methods

One hundred and seventy‐nine eyes of 109 healthy participants and 456 eyes of 228 post‐COVID‐19 patients received comprehensive eye examinations; the latter were interviewed with questionnaires on ocular symptoms before and after COVID‐19 diagnosis. Associations of ocular surface manifestations with virological and ophthalmic parameters were evaluated by multivariable mixed linear or logistic regression models.

Results

Mean interval between COVID‐19 diagnosis and ophthalmic evaluation was 52.23 ± 16.12 days. The severity of meibomian gland dysfunction (MGD) based on clinical staging was higher in post‐COVID‐19 than healthy eyes (1.14 ± 0.67 vs. 0.92 ± 0.68, p = 0.002) and so was ocular surface staining score (0.60 ± 0.69 vs. 0.49 ± 0.68, p = 0.044). Patients requiring supplementary oxygen during hospitalisation had shorter tear break‐up time (β −1.63, 95% CI ‐2.61 to −0.65). Cycle threshold (Ct) value from upper respiratory samples (inversely correlated with viral load) at diagnosis had an OR = 0.91 (95% CI 0.84–0.98) with new ocular surface symptoms 4 weeks after diagnosis. The presence of ocular surface symptoms 1 week prior to COVID‐19 diagnosis showed an OR of 20.89 (95% CI 6.35–68.66) of persistent or new ocular symptoms 4 weeks afterward.

Conclusions

MGD and ocular surface staining are more common and severe in post‐COVID‐19 patients. Patients with higher viral loads have greater risks of ocular surface symptoms. Patients requiring supplementary oxygen are more likely to show tear film instability. Ocular surface evaluation should be considered 1–3 months following hospital discharge for any COVID‐19 patient.

A Case of Tacrolimus Maculopathy

(1) Background: Tacrolimus is an immunosuppressive agent commonly used in the management of solid organ allogeneic transplants in the prevention of rejection. Serious ophthalmic adverse effects with Tacrolimus have been reported in the literature, which includes cortical blindness and optic neuropathy. (2) Methods: We describe a rare case of maculopathy as a possible complication of Tacrolimus therapy. A 56-year-old man receiving Tacrolimus for immunosuppression after liver transplantation developed unilateral visual disturbance with a central scotoma. (3) Results: Ophthalmologic examination revealed unilateral maculopathy; a Tacrolimus macular toxicity was suspected. After drug discontinuation, a complete visual recovery was observed; however, the ultrastructural macular damage was irreversible. (4) Conclusions: Reports regarding maculopathy associated with Tacrolimus are limited. This case report adds to the current literature regarding the possible macular toxicity of this immunosuppressive agent, especially if it exceeds therapeutic serum levels. Further data are needed to confirm this possible association. A careful ophthalmologic examination should be promptly performed in patients manifesting visual disturbance while taking Tacrolimus to prevent irreversible, permanent vision loss due to possible drug toxicity.

Incremental Concentrations of Tacrolimus Eye Drops as a Strategy for the Management of Severe Vernal Keratoconjunctivitis

Purpose: To assess the effect of different concentrations of tacrolimus eye suspension on the epithelium and stromal keratocytes of human corneas and investigate whether it can be safely used for severe cases of vernal keratoconjunctivitis (VKC).

Methods: Tacrolimus eye suspension was prepared in a range of concentrations of 0.005%, 0.01%, 0.05%, 0.1%, and 0.2%. Molecular analysis was performed ex vivo on human corneas (n = 18), obtained from the eye bank. Transparency and thickness of each cornea were measured while live/dead staining was performed using a triple labeling assay. An incremental concentration approach was then tested on three severe cases of VKC.

Results: All tested tacrolimus concentrations showed no significant changes in corneal thickness or transparency. In corneas treated with 0.1%, rare scattered dead cells were observed, while the folds of corneal surfaces were mostly viable, unlike concentrations higher than 0.1% and lower than 0.05%. Stromal cell densities were highest in the 0.1% tacrolimus treatment condition. Incremental concentrations of tacrolimus suspension were shown to significantly improve VKC cases, where the concentration used for each case depended on the severity of the case.

Conclusions: Topical administration of tacrolimus was not toxic to human corneal cells at all tested concentrations, and the 0.1% concentration has shown the best viability of the corneal tissue. Tacrolimus eye suspension was shown to be safe and effective for use in severe VKC and is proposed as a topical ocular immunosuppressant drug enabling clinicians to incrementally increase the drug concentration according to the clinical severity of the disease to achieve the optimal therapeutic response.

Topical treatment of dupilumab-associated refractory conjunctivitis and keratitis

Purpose

To report 3 cases of severe dupilumab-related conjunctivitis and keratitis topical treatment.

Observation

Description, management, and outcomes of dupilumab-related refractory conjunctivitis associated with punctate keratitis.

Three patients with atopic dermatitis (AD) experiencing severe ophthalmic complications following dupilumab treatment were referred to us when conventional management methods failed. We treated them topical and external pimecrolimus 10 mg/g cream to the eyelids. The patients showed substantial clinical remission within 10 days.

Conclusions and importance

Those cases are remarkable as a drug applied externally to the eyelid skin successfully treated underlying conjunctivitis and punctate keratitis. The complete clinical remission suggests that pimecrolimus applied topically to the eyelid skin is a safe and effective delivery route. The resolution of the keratitis and conjunctivitis presumably represents either a contiguous effect of the improvement of the cutaneous inflammation, or the effect of transcutaneous pimecrolimus penetration through the eyelid.

Further studies are needed to support the use of this drug for dupilumab-associated conjunctivitis.

Treating refractory corneal hydrops in a male patient with vernal keratoconjunctivitis and mental retardation: a case report

Background

Keratoconus is the most common noninflammatory bilateral corneal ectasia. Vernal keratoconjunctivitis (VKC) and eye rubbing may be associated with keratoconus in children and young adults. Timely management of advanced keratoconus is important to improve visual quality. In addition, it is challenging to carry out VKC treatment with an intent to avoid the occurrence of punctate epithelial keratitis, ulceration, or corneal neovascularization on corneal grafts.

Case presentation

We report the case of an 18-year-old male patient with a long-term history of mental retardation due to megalencephaly presenting with acute onset of corneal hydrops with prominent bulging and refractory steroid-induced glaucoma of the right eye. The topography of the right eye was unavailable due to advanced ectasia, and that of the left eye revealed central steepening with inferior-superior dioptric asymmetry. According to the clinical findings, the patient was diagnosed with keratoconus. Because of progressive corneal opacity and neovascularization, the patient underwent penetrating keratoplasty (PK) with combination of interrupted and intrastromal running suturing after receiving a preoperative subconjunctival injection of bevacizumab in his right eye, followed by lower eyelid correction. After surgery, the patient was treated with 0.1% tacrolimus dermatological ointment, 0.1% cyclosporine eye drops, artificial tears, and 0.5% loteprednol for keratoplasty and VKC. Repeated education on avoiding eye rubbing was offered to the patient. Two years after PK treatment, his best-corrected visual acuity of the right eye successfully improved from hand motion at 10 cm preoperatively to 6/20 postoperatively.

Conclusions

Large-diameter PK with intrastromal suturing technique for advanced keratoconus could achieve better visual outcomes and avoid suture-related complications. In addition, tacrolimus dermatological ointment rather than tacrolimus topical eye drops or ointment showed satisfactory efficacy when combined with topical cyclosporine and steroid that no significant VKC reactivation were noted after PK.

When to start tacrolimus ointment for vernal keratoconjunctivitis? A proposed treatment protocol

PURPOSE

The aim of this study was to compare treatment regimens of tacrolimus and of topical steroids for VKC and suggest a treatment protocol according to our clinical experience.

METHODS

This retrospective, nonrandomized case series enrolled 85 patients with VKC. Patients were classified clinically according to severity (mild, moderate, severe) and were treated according to a suggested protocol. Analysis was made according to treatment received: tacrolimus ointment as first line treatment (tacrolimus 1st line), tacrolimus ointment after topical steroid drops treatment (tacrolimus 2nd line) and topical steroid drops or artificial tears alone (topical steroid and tears group).

RESULTS

Significant improvements in clinical signs and symptoms were achieved under tacrolimus treatment 14 months in the moderate group and 5 months in the severe group. The longest duration of treatment was for tacrolimus 2nd line group (p = 0.031) and the mean number of visits in the clinic was the highest. The mean number of topical treatments per day was higher in the topical steroid and tears group (2.6 times) than in the two tacrolimus groups (1.3 times for both). The mean time needed to achieve disease remission or relief did not differ between the tacrolimus 1st line and 2nd line groups.

CONCLUSION

Tacrolimus treatment is effective and safe for VKC. Tacrolimus as 1st line treatment may be preferred for severe cases, for faster disease remission compared to tacrolimus as 2nd line treatment; and with fewer topical treatments per day compared to topical steroids.

Evaluation of Clinical Efficacy and Safety of Prolonged Treatment of Vernal and Atopic Keratoconjunctivitis Using Topical Tacrolimus

PURPOSE

To evaluate the clinical improvement and safety of prolonged treatment of vernal (VKC) and atopic keratoconjunctivitis (AKC) using topical tacrolimus.

METHODS

We included 36 eyes of 36 patients who had VKC and AKC and were treated with topical tacrolimus ophthalmic suspension (0.1%) for 24 months. The demographic data of the enrolled patients were collected from their medical files. Clinical scores, remission rates, number of relapses, concomitant use of steroids, and refractory indices were assessed. Clinical outcomes were determined using papillae-limbus-cornea (PLC) scores and 5-5-5 exacerbation grading scale scores. Clinical characteristics associated with the need for concomitant steroid eye drops administration were determined using logistic regression analysis. All patients were classified into 3 subgroups using cluster analysis.

RESULTS

PLC scores recorded in the sixth month were significantly improved compared with those recorded at baseline. PLC scores recorded in the 18th, 21st, and 24th months were significantly improved compared with those recorded in the sixth month. The remission rates increased diachronically and significantly, reaching 92% in the 24th month. Logistic regression analysis showed that, for every 10-year increase in patient age, the risk for requiring concomitant administration of steroid eye drops was reduced by half (odds ratio, 0.53; 95% confidence interval, 0.29-0.96). Using cluster analysis, the patients were divided into 3 clusters: adolescent type, pediatric type, and adult type.

CONCLUSIONS

Two years of treatment with topical tacrolimus ophthalmic suspension is an effective method for inducing and maintaining the stable stages of VKC and AKC.

Development of Cytomegalovirus Corneal Endotheliitis During Long-Term Topical Tacrolimus and Steroid Treatment for Chronic Ocular Surface Inflammatory Diseases

PURPOSE

We report 3 cases of patients with chronic ocular surface inflammatory disease who developed cytomegalovirus (CMV) corneal endotheliitis during immunosuppressant and steroid treatment.

PATIENTS AND METHODS

This is a retrospective observational study analyzing the clinical characteristics and outcomes of 3 patients with ocular surface inflammatory diseases (2 with Mooren ulcer and 1 with idiopathic scleritis) who developed CMV corneal endotheliitis. All patients developed CMV corneal endotheliitis between 8 and 14 months of starting steroid and immunosuppressant treatment, including topical 0.1% tacrolimus. Decimal visual acuity, endothelial counts, and intraocular pressure were analyzed.

RESULTS

All patients received topical 0.5% ganciclovir after the diagnosis of CMV corneal endotheliitis, which improved endothelial inflammation. However, all patients developed irreversible mydriasis and required additional surgeries, including endothelial keratoplasty, cataract surgery, and glaucoma surgery. At the final follow-up (14-46 months post-CMV corneal endotheliitis onset), fair outcomes were achieved, as demonstrated by a mean decimal best-corrected visual acuity of 0.3 and a well-controlled intraocular pressure.

CONCLUSIONS

Topical steroids and immunosuppressants can induce fulminant CMV corneal endotheliitis with cataract progression and irreversible mydriasis. In these cases, early diagnosis and treatment, including topical 0.5% ganciclovir, glaucoma surgery, cataract surgery, and endothelial keratoplasty, are necessary for preserving the patient's vision.

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.

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.

Formulation development, optimization, and in vitro assessment of thermoresponsive ophthalmic pluronic F127-chitosan in situ tacrolimus gel

To overcome problems associated with topical delivery of tacrolimus (TCS), a thermoresponsive in situ gel system containing pluronic F127 (PL), and chitosan (CS) was developed, to enhance the precorneal retention, and to sustain the release of the drug. The PL-CS in situ gel was optimized using a 2-factor-3-level central composite experimental design by selecting the concentration of PL and CS as independent variables while gelation time, gelation temperature, and spreadability as dependent variables. The optimized formulation was developed using 22.5 g PL and 0.3 g CS, gels at 33.6 °C, in 22.93 s, and showed the spreadability of 6.2 cm. In vitro studies conducted for the optimized gel revealed the sustained release of TCS (81.73% in 4 h) and improved corneal permeation (74.13% in 4 h), compared with TCS solution. The mechanism of release of TCS followed the Higuchi model with Fickian diffusion transport. Further, histopathology and HET-CAM studies revealed that the developed gel was non-irritating and safe for ocular administration.

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.

Vernal keratoconjunctivitis: An update

Vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) are potentially severe and complex disease in its management among the various allergic eye diseases. In this regard, studies clarified the etiopathogenetic mechanisms. The workup should be multidisciplinary. The treatment includes topical and systemic medications with anti-inflammatory and immunosuppressant activity. However, a definition of nationally- and internationally-shared diagnostic protocols would also be needed and validated access to therapeutic options of proven safety and efficacy to avoid the use of galenic preparations, up to now still essential in the management of moderate-severe VKC. Finally, recognizing VKC and AKC, among rare diseases, at a national and international level would be an essential step to allow the management of VKC with adequate timings and settings within the National Health System.

Sequelae of microsporidial keratoconjunctivitis and its management

Purpose:

To characterize the sequelae of microsporidia keratoconjunctivitis (MKC) and outline its management.

Methods:

Retrospective analysis of microbiologically proven MKC returned with persistent disease between January 2015 and December 2019 was done. Demographics, clinical features, management, and outcome were analyzed.

Results:

Sixteen patients (21 eyes) of 332 treated for MKC returned with the persisting disease. The mean age of 11 males (68.7%), and 5 females was 35.1 ± 12.2 years. Three-quarter of them did not have a known predisposing risk factor and one-quarter of them were referred for chronic conjunctivitis. Past medications included topical antivirals (n = 8) and topical corticosteroid (n = 6). Three predominant presentations were persistent (>3 weeks) superficial punctate keratitis (SPKs, n = 7), sub-epithelial infiltrates (SEIs, n = 13), and uveitis (n = 2). The lesions recurred in eight eyes (SPK and SEI 4 each) after a disease-free interval of 60.4 ± 40.6 days; there were 13 episodes of recurrence. Topical low potent corticosteroids (loteprednol/fluorometholone), and tacrolimus ointment 0.03% were used in 17 (80.9%) and 8 (38%) eyes, respectively, for a mean duration of 44.8 ± 31.6 and 226.8 ± 180.5 days, respectively. At follow-up, 172.3 ± 183.6 days, visual recovery was statistically significant in persistent eyes (BCVA 0.07 ± 0.07 logMAR; P < 0.00001) but, not in recurrent eyes (BCVA 0.16 ± 0.08 logMAR; P = 0.07). Five of 21 eyes were left with residual significant scar.

Conclusion:

The sequelae of microsporidial keratoconjunctivitis are not uncommon. Topical 0.03% tacrolimus ointment appeared to be an effective corticosteroid-sparing agent for the treatment of SEIs and prevention of recurrence.

Experience With 0.1% Tacrolimus Eye Drop for Noninfectious, Non-necrotizing Anterior Scleritis

OBJECTIVES

To report experience with 0.1% tacrolimus eye drops in the treatment of noninfectious, non-necrotizing anterior scleritis.

METHODS

This prospective, single-arm study included nine patients (4 men and 5 women; mean age=59.4 years, SD=10.5) with anterior scleritis. All patients were first treated with steroids for 1 month and then switched to tacrolimus eye drops alone. We defined baseline as the initiation of tacrolimus eye drops. Hyperemia and pain were scored before each treatment, at 1 and 2 weeks, and at 1 month after initiation of each treatment using 5 grades (0=none; 1+=mild; 2+=moderate; 3+=severe; 4+=extremely severe). Intraocular pressure (IOP) was also measured during treatment with each drug. Safety was assessed based on the severity and the incidence of adverse events.

RESULTS

The scores of hyperemia and pain had significantly decreased from baseline by 1 week after initiating tacrolimus eye drops (both P<0.05). No significant reduction was observed with steroid treatment throughout the 1-month period in both scores. Tacrolimus eye drops elicited statistically significant differences in mean IOP over the course of treatment (P=0.02). No additional medications were required to provide relief in any of the patients receiving tacrolimus treatment. No patient demonstrated infectious adverse events after initiation of tacrolimus treatment.

CONCLUSIONS

Topical tacrolimus may effectively and immediately reduce clinical signs and symptoms of noninfectious, non-necrotizing anterior scleritis in cases unresponsive to a course of topical steroid.

Efficacy of 2% Rebamipide Suspension for Vernal Keratoconjunctivitis: A Clinical Comparison with Topical Immune Modulators Cyclosporine and Tacrolimus

Purpose: To compare the efficacy of 2% rebamipide suspension with topical cyclosporine and tacrolimus for managing vernal keratoconjunctivitis (VKC)Methods: In this prospective, interventional study, 38 patients with moderate to severe VKC were allocated to receive either 2% rebamipide in one eye and 0.03% tacrolimus ointment in the contralateral eye (n = 19) or 2% rebamipide in one eye and 0.05% cyclosporine in the contralateral eye (n = 19) for 12 weeks. Ten ocular signs and 7 symptoms were graded on a scale of 0-3 each for each eye at every visit.Results: Total sign and symptom scores reduced significantly in all 4 subgroups (all p's <0.05) at 12 weeks. Reduction of mean sign scores between rebamipide and tacrolimus (- 4.67 ± 4.63 and - 2.80 ± 3.18 respectively) and between rebamipide and cyclosporine (-6.00 ± 3.74 and -5.42 ± 3.68 respectively) was comparable. Reduction in symptom scores was also comparable between subgroups.Conclusion: Our findings suggest that efficacy of topical rebamipide is comparable to topical cyclosporine and tacrolimus for managing moderate to severe VKC and it merits further evaluation as a novel steroid sparing alternative for this disorder.

Clinical Observation of Allergic Conjunctival Diseases with Portable and Recordable Slit-Lamp Device

BACKGROUND

The incidence of allergic conjunctival diseases (ACDs) is gradually increasing worldwide. Both ophthalmologists and non-ophthalmologists prescribe eye drops to treat ACDs; however, there are many cases which are treated without sufficient examination and diagnosis of the eyes. We have invented a portable, recordable, and smartphone-attachable slit-lamp device-Smart Eye Camera (SEC). The purpose of this study was to compare the diagnostic abilities of ACDs between the SEC and the conventional, non-portable slit-lamp microscope.

METHODS

This prospective observational study included 32 eyes of 17 Japanese patients (mean age: 21.5 ± 14.8 years; range: 11-51 years; female: 5). The severity of 10 objective signs in the palpebral conjunctiva, bulbar conjunctiva, limbus, and cornea were scored on a grading scale of 0 to 4 (0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe), respectively. First, the conventional slit-lamp microscope was used to examine the grade of the ACDs. Second, another ophthalmologist filmed the eyes using the SEC and two other ophthalmologists evaluated the grades on another day. The correlation and inter-rater reproducibility in total scores among the two devices were determined.

RESULTS

Total scores of clinical signs, evaluated by the two approaches, correlated significantly (both eyes: r = 0.918 (95% CI: 0.839 to 0.959; p < 0.001)), with substantial inter-rater agreement (weighted κ value = 0.631 (95% CI: 0.601 to 0.661; p < 0.001)).

CONCLUSIONS

The SEC is as reliable as the conventional non-portable slit-lamp microscope for assessing ACDs.

Long-term outcomes of 0.1% tacrolimus eye drops in eyes with severe allergic conjunctival diseases

Background

Because atopic dermatitis does not heal completely, associated severe atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) often require long-term treatment. This study aims to evaluate the long-term outcomes of using 0.1% tacrolimus eye drops to treat these severe allergic conjunctival diseases.

Methods

Two-hundred-and-seventy eyes of 135 patients diagnosed with AKC or VKC from April 2004 to April 2014 were screened retrospectively. Patient demographics and objective signs were extracted from the electronic medical records. The severity of 10 objective signs, related to the palpebral and bulbar conjunctiva, limbus, and cornea, and intraocular pressure (IOP) were observed at baseline, at 2 weeks, 1, 2, 3, 6, and 12 months after starting treatment, and every 1 year thereafter (average use period: 8.4 ± 2.9 years). Safety was evaluated based on the incidence and severity of adverse events.

Results

12 patients (AKC; 7 cases, VKC; 5 cases) who were treated with 0.1% tacrolimus eye drops were enrolled in this study. The total score of clinical signs significantly decreased after 2 weeks and remained effective thereafter. Tacrolimus eye drops elicited a statistically significant difference in the mean total clinical scores and IOP over the course of treatment (P < 0.001). Elevated IOP was observed in 2 cases and corneal infection in 1 case; these effects were completely controlled with medication.

Conclusions

Topical tacrolimus may provide effective and long-term improvement in clinical signs of severe AKC and VKC cases that refractory to standard conventional treatment.

Trial registration: University Hospital Medical Information Network (UMIN) 000034460.

Long term keratits treatment with topical cyclosporin a in autoimmune polyglandular syndrome type 1

Purpose

To report long term results of two cases treated with topical cyclosporin A 1% for keratitis associated with autoimmune polyglandular syndrome (APS1).

Observations

A 25-year-old male and a 17-year-old female were referred from endocrinology as APS1-related autoimmune keratitis. Extended-duration treatment with topical cyclosporin A (CsA) 1% was used for 24 and 18 months, respectively. The first patient had improved best-corrected visual acuity (BCVA) from 20/200 and 20/300 in right and left eye to 20/60 in both eyes with markedly improved corneal opacification, while the second patient had improved BCVA from 20/400 and 20/300 in right and left eye to 20/160 in both eyes with persistent central stromal scarring in the right eye and discrete areas of stromal scarring in the left eye.

Conclusions and Importance

Long-term topical CsA 1% offers a valuable option for treatment of APS1-related autoimmune keratitis.

Development and Characterization of a Tacrolimus/Hydroxypropyl-β-Cyclodextrin Eye Drop

Uveitis is a vision inflammatory disorder with a high prevalence in developing countries. Currently, marketed treatments remain limited and reformulation is usually performed to obtain a tacrolimus eye drop as a therapeutic alternative in corticosteroid-refractory eye disease. The aim of this work was to develop a mucoadhesive, non-toxic and stable topical ophthalmic formulation that can be safely prepared in hospital pharmacy departments. Four different ophthalmic formulations were prepared based on the tacrolimus/hydroxypropyl-β-cyclodextrin (HPβCD) inclusion complexes’ formation. Phase solubility diagrams, Nuclear Magnetic Resonance (NMR) and molecular modeling studies showed the formation of 1:1 and 1:2 tacrolimus/HPβCD inclusion complexes, being possible to obtain a 0.02% (w/v) tacrolimus concentration by using 40% (w/v) HPβCD aqueous solutions. Formulations also showed good ophthalmic properties in terms of pH, osmolality and safety. Stability studies proved these formulations to be stable for at least 3 months in refrigeration. Ex vivo bioadhesion and in vivo ocular permanence showed good mucoadhesive properties with higher ocular permanence compared to the reference pharmacy compounding used in clinical settings (t_1/2 of 86.2 min for the eyedrop elaborated with 40% (w/v) HPβCD and Liquifilm^® versus 46.3 min for the reference formulation). Thus, these novel eye drops present high potential as a safe alternative for uveitis treatment, as well as a versatile composition to include new drugs intended for topical ophthalmic administration.

Reduced steroid-induced intraocular pressure elevation in tacrolimus-treated refractory allergic ocular diseases

PURPOSE

To determine whether topical tacrolimus can lessen steroid-induced intraocular pressure (IOP) elevation.

STUDY DESIGN

Open cohort post hoc analysis study.

METHODS

Five hundred eleven patients with vernal keratoconjunctivitis or atopic keratoconjunctivitis (mean age 17.0 ± 9.2 years) were studied. All 511 patients were treated with topical tacrolimus with or without topical steroids, and the changes in IOP were measured monthly for 3 months. The elevation in IOP induced by use of topical steroids was calculated using mixed linear regression analyses. The relationship between the elevation in IOP within 4 weeks and the use or nonuse of tacrolimus reported in published data was analyzed using metaregression analysis to estimate the effects of tacrolimus on the IOP in eyes treated with topical steroids.

RESULTS

The mean topical steroid-induced IOP elevation in tacrolimus-treated eyes was lower, by 5.2 mmHg (P = 0.04), than that in earlier published data without tacrolimus as the control. In the tacrolimus-treated eyes, the mean betamethasone-induced IOP elevation was 1.3 mmHg without discontinuation of the steroid. Metaregression analysis indicated that glaucoma history and younger age had significant effects on topical steroid-induced IOP elevation, by 4.0 mmHg (P = 0.002) and 3.9 mmHg (P = 0.01), respectively. In tacrolimus-treated eyes, the most significant effect on the IOP was associated with glaucoma history or medication; however, its effect on the IOP was limited to 1.7 mmHg elevation (P = 0.006).

CONCLUSIONS

Topical tacrolimus may lessen the steroid-induced elevation in IOP in younger individuals and may be a good adjunctive therapy to avoid IOP elevation in refractory cases.

Corneal fibroblasts: Function and markers

Corneal stromal keratocytes contribute to the maintenance of corneal transparency and shape by synthesizing and degrading extracellular matrix. They are quiescent in the healthy cornea, but they become activated in response to insults from the external environment that breach the corneal epithelium, with such activation being associated with phenotypic transformation into fibroblasts. Corneal fibroblasts (activated keratocytes) act as sentinel cells to sense various external stimuli-including damage-associated molecular patterns derived from injured cells, pathogen-associated molecular patterns of infectious microorganisms, and inflammatory mediators such as cytokines-under pathological conditions such as trauma, infection, and allergy. The expression of various chemokines and adhesion molecules by corneal fibroblasts determines the selective recruitment and activation of inflammatory cells in a manner dependent on the type of insult. In infectious keratitis, the interaction of corneal fibroblasts with various components of microbes and with cytokines derived from infiltrated inflammatory cells results in excessive degradation of stromal collagen and consequent corneal ulceration. Corneal fibroblasts distinguish between type 1 and type 2 inflammation through recognition of corresponding cytokines, with their activation by type 2 cytokines contributing to the pathogenesis of corneal lesions in severe ocular allergic diseases. Pharmacological targeting of corneal fibroblast function is thus a potential novel therapeutic approach to prevention of excessive corneal stromal inflammation, damage, and scarring.

Corticosteroids in ophthalmology: drug delivery innovations, pharmacology, clinical applications, and future perspectives

Corticosteroids remain the mainstay of the treatment for various ocular conditions affecting the ocular surface, anterior and posterior segments of the eye due to their anti-inflammatory, anti-oedematous, and anti-neovascularization properties. Prednisolone, prednisolone acetate, dexamethasone, triamcinolone acetonide, fluocinolone acetonide, and loteprednol etabonate are amongst the most widely used ophthalmic corticosteroids. Corticosteroids differ in their activity and potency in the eye due to their inherent pharmacological and pharmaceutical differences. Different routes and regimens are available for ocular administration of corticosteroids. Conventional topical application to the eye is the route of choice when targeting diseases affecting the ocular surface and anterior segment, while periocular, intravitreal, and suprachoroidal injections can be potentially effective for posterior segment diseases. Corticosteroid-induced intraocular pressure elevation and cataract formation remain the most significant local risks following topical as well as systemic corticosteroid administration. Invasive drug administration via intracameral, subconjunctival, and intravitreal injection can enhance ocular bioavailability and minimize dose and dosing frequency of administration, yet may exacerbate ocular side effects of corticosteroids. This review provides a critical appraisal of the ophthalmic uses of corticosteroid, routes of administration, drug delivery fundamentals and novel ocular implantable steroid delivery systems, factors influencing side effects, and future perspectives for ocular corticosteroid therapy.

Pentacam corneal densitometry-guided treatment of adenoviral corneal subepithelial infiltrates: a comparative study between transepithelial phototherapeutic keratectomy and topical tacrolimus

PURPOSE

To compare the changes in the measurement of corneal densitometry and total corneal higher-order aberrations (HOAs) between topical tacrolimus and transepithelial phototherapeutic keratectomy (Te-PTK) in the treatment of adenoviral corneal subepithelial infiltrates (SEIs).

SUBJECT AND METHODS

This is an interventional prospective randomized study, including 63 eyes of 35 patients with symptomatic adenoviral corneal SEIs for at least 6 months. All patients underwent previous topical steroid therapy associated with unsatisfactory response and/or complications. Patients were assigned into three groups: (1) Te-PTK group: Te-PTK with MMC 0.02% was performed by a Technolas; Teneo excimer laser; (2) tacrolimus group: tacrolimus 0.03% ointment was applied once daily for 2-6 months; the endpoint of treatment was based on the improvement in the corneal densitometry, BCVA, and OSDI; and (3) control group: no intervention was done. BCVA, corneal densitometry, and total corneal higher-order aberrations (HOAs) evaluation using Pentacam HR were done at the baseline, 1 week, and then 1, 3, 6, and 12 months of the study.

RESULTS

The study population was similar between all groups. The mean follow-up was 12.75 ± 0.9 months. Bilateral corneal SEI was recorded at 80%. At 12-month follow-ups, the mean BCVA improved in both the Te-PTK and tacrolimus groups without significant changes in the control group. The mean corneal densitometry of the anterior, central, and total cornea decreased significantly in the Te-PTK and tacrolimus groups. HO-RMS and total RMS decreased significantly in the Te-PTK and tacrolimus groups. BCVA, corneal densitometry (anterior, central, and total cornea), and corneal aberrations (total coma, total trefoil, HO-RMS, and total RMS) values were significantly better for the Te-PTK and tacrolimus groups than the control group. There were no statistically significant differences between Te-PTK and tacrolimus groups in terms of BCVA, corneal densitometry, corneal HOA, and the persistence of corneal SEIs. The persistence of corneal SEIs was significantly lower in Te-PTK and tacrolimus groups than the control group.

CONCLUSION

Te-PTK and topical tacrolimus are effective methods for the treatment of adenoviral corneal SEIs improving visual acuity, corneal densitometry, and corneal HOA. The densitometry program of the Pentacam may give an objective guide for the treatment of adenoviral corneal SEIs.

TRIAL REGISTRATION

ClinicalTrials.gov ID is NCT04267991.

Japanese guidelines for allergic conjunctival diseases 2020

The definition, classification, pathogenesis, test methods, clinical findings, criteria for diagnosis, and therapies of allergic conjunctival disease are summarized based on the Guidelines for Clinical Management of Allergic Conjunctival Disease 2019. Allergic conjunctival disease is defined as "a conjunctival inflammatory disease associated with a Type I allergy accompanied by some subjective or objective symptoms." Allergic conjunctival disease is classified into allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis. Representative subjective symptoms include ocular itching, hyperemia, and lacrimation, whereas objective symptoms include conjunctival hyperemia, swelling, folliculosis, and papillae. Patients with vernal keratoconjunctivitis, which is characterized by conjunctival proliferative changes called giant papilla accompanied by varying extents of corneal lesion, such as corneal erosion and shield ulcer, complain of foreign body sensation, ocular pain, and photophobia. In the diagnosis of allergic conjunctival diseases, it is required that type I allergic diathesis is present, along with subjective and objective symptoms accompanying allergic inflammation. The diagnosis is ensured by proving a type I allergic reaction in the conjunctiva. Given that the first-line drug for the treatment of allergic conjunctival disease is an antiallergic eye drop, a steroid eye drop will be selected in accordance with the severity. In the treatment of vernal keratoconjunctivitis, an immunosuppressive eye drop will be concomitantly used with the abovementioned drugs.

Carboxymethyl Cellulose-Coated Tacrolimus Nonspherical Microcrystals for Improved Therapeutic Efficacy of Dry Eye

Dry eye (DE) is a highly prevalent ocular surface disease which affects the quality of life and results in low working efficiency. Frequent instillation is required due to low bioavailability of conventional eye drops. The aim of this study is to develop a novel formulation of tacrolimus (TAC), routinely prescribed for DE, by combination of the microcrystal technology and layer-by-layer assembly. First, nonspherical tacrolimus microcrystals (TAC MCs) are synthesized by antisolvent-induced precipitation. These TAC MCs are modified by alternate deposition of poly(allylamine hydrochloride) (PAH) and carboxymethyl cellulose (CMC) subsequently to obtain CMC-coated TAC MCs (TAC-(PAH/CMC)₃ ). The resultant formulations are evaluated in vivo in a mouse DE model induced by an intelligently controlled environmental system. Compared with commercially available TAC eye drops and the TAC MCs counterpart, TAC-(PAH/CMC)₃ exhibits superior therapeutic performance with reduced drug instillation frequency, which is attributed to the nonspherical geometry of MCs, the lubricant, mucoadhesive effect of CMC, and the anti-inflammatory function of TAC. Therefore, TAC-(PAH/CMC)₃ represents a better option for the management of DE.

Ocular Co-Morbidities of Atopic Dermatitis. Part II: Ocular Disease Secondary to Treatments

Treatments used for managing atopic dermatitis (AD) may have adverse ocular effects that permanently affect vision. The objective of this review is to raise awareness among dermatologists regarding the potential ocular adverse effects of various AD therapies, including corticosteroids, calcineurin inhibitors, an interleukin-4 receptor α (IL-4Rα) antagonist, and phototherapy. Pertinent potential short- and long-term risks of these therapies include elevations in intraocular pressure from use of topical corticosteroids and conjunctivitis from use of dupilumab. Since some of these adverse effects may not exhibit symptomatology until permanent vision impairment occurs, it is important for dermatologists to understand these risks and proactively ensure their patients are receiving appropriate measures to prevent them.

Treatment of refractory conjunctivitis associated to dupilumab with topical pimecrolimus applied to the eyelid skin

Patients with atopic dermatitis commonly experience ophthalmic complications, and a higher incidence of conjunctivitis has been observed during treatment with dupilumab. We present the case of a 49-year-old woman with persistent severe atopic dermatitis who complained of refractory conjunctivitis associated with dupilumab. Ocular examination showed features of atopic conjunctivitis for which an external topical application to the eyelids of pimecrolimus 10 mg/g cream was prescribed. The patient showed substantial clinical remission after only 12 days. This case was remarkable as the medication applied externally to the eyelid skin was effective in treating the conjunctival involvement possibly due to penetration of pimecrolimus through the eyelid layers. Further studies are needed to support the use of this drug for dupilumab-related conjunctivitis.

Mini-monoka stenting for patients with perennial allergic conjunctivitis

Purpose: To assess the effectiveness of mini-monoka (MM) stenting in treating patients with perennial allergic conjunctivitis (PAC) and punctal stenosis. Methods: A retrospective case analysis was performed on 20 patients (40 eyes) who suffered from PAC with punctal stenosis who underwent MM (FCI Ophthalmics, Pembroke, MA, USA) stenting. Results: Nineteen patients (95%) were females, with an age range of 19-66 years (average 40.6 ± 25.4 years). All 20 patients (100% of eyes) had signs of PAC and punctal stenosis. All 20 patients (40 eyes) had received previous topical treatment including steroids. Nineteen patients (95% of eyes) had significant improvement in their allergy symptoms (tearing and conjunctival inflammation) following MM stenting. Conclusions: Stenosis of the punctum may play a role in the relapsing symptoms in PAC. MM stenting is a simple, safe, effective, and relatively non-invasive treatment option for the management of PAC in the presence of punctal stenosis.

Conjunctivitis in atopic dermatitis patients with and without dupilumab therapy - international eczema council survey and opinion

Background

Conjunctivitis is common in patients with atopic dermatitis (AD) in general and a commonly reported adverse event in AD clinical trials with dupilumab.

Objective

To survey opinions and experience about conjunctivitis occurring in AD, including those during dupilumab treatment in a group of AD experts from the International Eczema Council (IEC).

Methods

Electronic survey and in‐person discussion of management strategies.

Results

Forty‐six (53.5%) IEC members from 19 countries responded to the survey. Consensus was reached for several statements regarding diagnostic workup, referral and treatment. IEC members suggest that patients with AD should (i) routinely be asked about ocular complaints or symptoms, (ii) obtain information about the potential for conjunctivitis before starting dupilumab therapy and (iii) if indicated, be treated with dupilumab despite previous or current conjunctivitis. In cases of new‐onset conjunctivitis, there was consensus that dupilumab treatment should be continued when possible, with appropriate referral to an ophthalmologist.

Limitations

The study relies on expert opinion from dermatologists. Responses from few dermatologists without dupilumab access were not excluded from the survey.

Conclusion

The IEC recommends that dermatologists address conjunctivitis in patients with AD, especially during treatment with dupilumab.

Monotherapy of topical tacrolimus 0.03% in the treatment of vernal keratoconjunctivitis in the pediatric population

PURPOSE

To report the results of treating children with vernal keratoconjunctivitis (VKC) using a monotherapy of topical tacrolimus 0.03%.

METHODS

This was a prospective, nonrandomized observational study of children newly diagnosed with VKC. The severity of the disease was graded on a 4-point scale of symptoms and signs. Patients were treated with tacrolimus 0.03% ointment and were followed for 8 months according to a schedule based on the severity of the disease. The primary measure of treatment efficacy was the change in the score of objective signs. The incidence and severity of adverse events, if any, were recorded.

RESULTS

A total of 45 children aged 5-15 years were enrolled. The mean composite symptom score was 6.84 ± 2.26 at baseline and 0.71 ± 1.62 at 8 months, a statistically significant reduction (P < 0.001). The mean composite sign score was 9.6 ± 3.14 at baseline and 1.16 ± 1.28 at 8 months, also a statistically significant reduction (P < 0.001). Four patients had to be started on steroids within the first month of treatment and were considered treatment failures. Thus, 89% of patients showed significant improvement. No participant experienced adverse effects, although some reported a transient stinging sensation.

CONCLUSIONS

In our study cohort topical tacrolimus ointment 0.03% as a monotherapy for VKC was successful in the majority of subjects, and there was no adverse effect.

The efficacy of 0.1% tacrolimus ophthalmic suspension in the treatment of severe atopic keratoconjunctivitis

BACKGROUND

Severe atopic keratoconjunctivitis (AKC) is a relatively rare disease, and some cases are refractory to conventional steroid treatment.

OBJECTIVE

To examine the efficacy of 0.1% tacrolimus ophthalmic suspension in treating severe AKC during a 1-year follow-up.

METHODS

This was a single-center, retrospective clinical study. Sixty eyes from 30 patients with severe AKC who were treated with 0.1% tacrolimus ophthalmic suspension 4 times per day, were included. The mean age of the patients was 21.5 ± 13.7 years. The severity of objective signs was observed at baseline (before treatment), at 2 weeks, and at 1, 2, 3, 6, and 12 months after treatment initiation. Ten objective signs of palpebral conjunctiva, bulbar conjunctiva, limbus, and cornea were assessed using 4 grades (0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe). Safety was assessed based on the incidence and the severity of adverse events.

RESULTS

The total score of the 10 clinical signs significantly decreased from baseline 2 weeks after initiating tacrolimus eye drop treatment, except at 2 months. The mean total score of clinical signs was 13.6 ± 6.6 at the beginning of treatment, and decreased to 5.4 ± 4.8 12 months after initiation. Treatment was gradually tapered, with increasing intervals between applications. Additional medications were required to provide relief in 18 patients during follow-up. No patient discontinued treatment due to adverse drug effects. Herpes keratitis was observed in 3 cases during follow-up. However, these cases were completely controlled.

CONCLUSION

The 0.1% tacrolimus ophthalmic suspension is effective for the treatment of severe AKC refractory to standard conventional treatments throughout a full year.