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Systemic cyclosporine in high-risk keratoplasty: long-term results
1Department of Ophthalmology, Medical School, University of Cape Town, South Africa.
Insights
Systemic cyclosporine (CSA) significantly reduced corneal graft rejection in high-risk patients. Both short-term and long-term CSA improved graft survival and visual acuity, with sustained benefits after treatment cessation.
Area of Science:
- Ophthalmology
- Immunology
- Transplantation immunology
Background:
- High-risk keratoplasty patients often face graft rejection due to significant vascularization.
- Systemic immunosuppression is a potential strategy to improve graft survival in these challenging cases.
Purpose of the Study:
- To evaluate the efficacy of systemic cyclosporine (CSA) in preventing and managing rejection episodes in high-risk corneal grafts.
- To compare the outcomes of short-term versus long-term CSA treatment against a no-CSA control group.
Main Methods:
- A prospective study involving 43 high-risk keratoplasty patients treated with systemic CSA (short-term or long-term) and 37 controls receiving no CSA.
- Monitoring of graft rejection episodes, reversal rates, overall graft survival, and visual acuity (20/40 or better).
Main Results:
- Systemic CSA significantly reduced the incidence of graft rejection episodes (48.8% vs. 73%, p=0.025).
- CSA treatment markedly improved rejection reversal rates (50% short-term, 87.5% long-term) compared to no CSA (23.3%).
- Both short-term and long-term CSA groups showed significantly better overall graft survival and visual acuity compared to the no CSA group.
Conclusions:
- Systemic cyclosporine is effective in reducing rejection and improving outcomes for high-risk corneal transplants.
- Treatment benefits, including improved graft survival and visual acuity, persist even after CSA cessation, suggesting re-established immunological privilege.
- Both short and long-term systemic CSA regimens offer significant advantages over no immunosuppression in high-risk keratoplasty.
Abstract:
Systemic cyclosporine (CSA) was given to 43 high-risk keratoplasty patients (vascularisation in three or four quadrants and > 16 stromal vessels): 14 received CSA for 12 months (long CSA group) and 29 for a 4-6 month period (short CSA group). A group of 37 similar high-risk keratoplasty patients received no CSA (no CSA group). In the no CSA group 27 (73%) grafts had rejection episodes compared with 21 (48.8%) in the combined CSA group (p = 0.025). Rejection was reversed in only 23.3% of the no CSA group, compared with 50% and 87.5% in the short (p = 0.06) and long (p = 0.002) CSA groups respectively. Compared with the no CSA group, overall graft survival was better in both the short (p = 0.019) and long (p = 0.0056) CSA groups. This improvement resulted from both a reduction in the incidence, and an increase in the reversal rate, of rejection episodes. The improvement continued after stopping CSA, suggesting that some immunological privilege had been re-established. Acuities of 20/40 or better were achieved by 44.8% and 50% of eyes in the short and long CSA groups respectively, compared with 13.5% of eyes in the no CSA group.