Systemic cyclosporin treatment for high-risk corneal transplantation

The success rate for uncomplicated penetrating keratoplasty is very high. However, in high risk patients there is a significantly increased risk for immunologic graft failure and the success rate is relatively poor. Oral cyclosporin A treatment has dramatically decreased the rejection rate in solid organ transplantation. Its oral use in ophthalmology has so far been relatively limited and topical use restricted by poor penetration of the drug into ocular tissues. The favorable results of oral cyclosporin treatment to prevent corneal graft failure in high-risk patients is demonstrated in this study. High-risk corneal transplant patients were selected from the general population scheduled to undergo corneal transplantation. Twenty-two of 277 patients who were operated during a four-year period were regarded as high-risk keratoplasty patients. Systemic cyclosporin A treatment (5mg/kg/day) was given prophylactically to 14 of these patients who were considered to be at high-risk for keratoplasty rejection (CsA group). In addition the patients received a low dose of corticosteroids. Eight similar patients receiving high dose corticosteroids served as a control group (control group). In the CsA group graft survival was 78.6% compared with 37.5% in the control group at 1.5 years. The grafts of patients receiving CsA had a significantly better survival rate (p.o5) than those in control at one and 1.5 years. On the follow-up to four years graft survival in patients treated with CsA was, however, decreasing to 35.7%. The low graft survival in both high-risk groups is in great contrast to graft survival in all patients operated during the same period (93.1%). Systemic cyclosporin treatment when received at the time of the operation is effective in reducing failure from irreversible rejection in high-risk keratoplasty, but for maximal effect, a six-month period of treatment is too short. Subjective side effects were frequent but still acceptable. Blood tests did not reveal any pathological hepatic or renal laboratory values caused by system CsA administration. Careful and frequent follow-ups of the patients are however needed.