In a new study from LVPEI, Drs. Anahita Kate, Sayan Basu, and others explored the indications and outcomes of oral cyclosporine, an immunosuppressive drug, in the treatment of vernal keratoconjunctivitis, a vision-threatening allergic eye disorder.
Vernal keratoconjunctivitis (VKC) is a chronic inflammation of the eye’s surface, primarily triggered by a dry and warm climate. The disease involves T-cells and other immune pathways in the eye. Patients, commonly male and very young, complain of itching, redness, and excessive tears. Despite its prevalence, VKC is often underdiagnosed and undertreated. While it can be self-limiting, it can result in sight-threatening sequelae in a subset of affected patients. These serious consequences include corneal inflammation, scarring, loss of limbal stem cells—cells that maintain the cornea and enable its self-renewal—resulting in blindness. Treatment typically involves use of local immunosuppressants (corticosteroid eye drops) to help reduce inflammation. A subgroup of VKC patients often require repeated courses of topical steroids and such chronic usage can result in other vision-threatening disorders like cataracts and glaucoma. These patients often require steroid sparing topical immunosuppressants. Some patients experience disease progression despite these medications or develop steroid-induced complications that preclude further steroid use. They can also develop steroid dependency, where the inflammation aggravates if steroid intake is reduced or stopped.
This subgroup requires systemic immunosuppressants that can be administered orally, offering stronger inflammation control. Cyclosporine A is a systemic immunosuppressant that targets the T-cell-mediated immune pathway in the eye. Crucially, it is not a corticosteroid, reducing some of the risks associated with that class of medicine. A few case reports have shown the successful use of oral cyclosporine A (oCsA) in treating severe VKC. However, such reports are sparse and insufficient for evaluating the safety and efficacy of oCsA in VKC treatment.
In a new study published in the journal Cornea, Drs. Anahita Kate, Sayan Basu, and others explored the application and outcomes of oCsA in VKC. The study included 27 patients (54 eyes) with VKC (70% male) who presented at LVPEI over an 8-year period. More than half of the eyes were at a severe stage of the disease. Thirty eyes had vision-threatening consequences due to VKC. The most common consequence (46%) was limbal stem cell deficiency (LSCD), where the cornea is unable to self-renew and degenerates. Other VKC-induced sequelae included cataract (19%) and glaucoma (7%).
Treatment with oCsA stopped the progression of sequelae in all 27 patients. Moreover, 42 acute allergic/inflammatory episodes were observed in the patients over the course of 403 person-months (total duration before treatment) before receiving oCsA. After starting oCsA treatment, only 10 such episodes were observed over 250 person-months. In fact, the odds of getting an acute flare-up of VKC were calculated to be 2.6 times higher in patients who did not receive oCsA. Additionally, a milder course of VKC was observed in a subgroup of patients in whom the oral cyclosporine was discontinued. The study cements the viability of ocular cyclosporine A in treating severe VKC and presents an alternative to long-term steroid use.
‘In children with severe vernal keratoconjunctivitis, there is a narrow window of opportunity to address the allergy effectively to mitigate vision loss,’ notes Dr Anahita Kate, the first author, and consultant ophthalmologist at the Kode Venkatadri Chowdary campus, LVPEI. ‘Doing so is crucial since these individuals are young and the resultant vision related morbidity can significantly affect quality of life. Oral cyclosporine is an effective option in such cases to control disease activity and reduce dependency on steroids, thus lowering the risk of serious steroid-related side effects.’
Citation
Kate, A., Tallapelly, H. G., Jain, N., Yukti, K., & Basu, S. (2025). Oral Cyclosporine in Vernal Keratoconjunctivitis: Indications, Outcomes, and Effect on Corticosteroid Use. Cornea, Advance online publication. https://doi.org/10.1097/ICO.0000000000003786
Photo credit: Cyclosporine; Brendan Gates, CC BY 2.0
