Is cyclosporine (an immunosuppressant) effective as a treatment for keratoconus?

Cyclosporine for Keratoconus

Cyclosporine is not effective as a treatment for keratoconus itself, but may be beneficial in managing associated allergic eye conditions that can contribute to keratoconus progression through eye rubbing. 1

Role of Cyclosporine in Keratoconus Management

• Keratoconus is a progressive corneal ectasia that requires specific treatments focused on corneal biomechanical stabilization, not immunomodulation 1
• The primary evidence-based treatment for progressive keratoconus is corneal cross-linking (CXL), which has been shown to halt progression in the majority of patients 1
• Cyclosporine has no direct effect on the corneal structural changes that characterize keratoconus 1, 2

Connection Between Allergic Eye Disease and Keratoconus

• Allergic conjunctivitis and atopic disease are associated with keratoconus development and progression 1
• Eye rubbing due to ocular allergies is a significant risk factor for keratoconus progression 1
• Adequate control of allergic eye conditions is important to decrease progression of corneal ectasia 1

Appropriate Use of Cyclosporine in Patients with Keratoconus

• Topical cyclosporine may be beneficial in keratoconus patients who have comorbid allergic eye conditions such as:
  • Vernal keratoconjunctivitis (VKC) 1, 3
  • Atopic keratoconjunctivitis 1, 4
• Cyclosporine 0.1% is FDA approved for the treatment of vernal keratoconjunctivitis in children and adults 1
• Commercially available 0.05% topical cyclosporine used at least four times daily has shown effectiveness for severe vernal conjunctivitis 1, 5

Clinical Considerations for Management

• Vernal and atopic keratoconjunctivitis should be controlled prior to corneal cross-linking to decrease the risk of developing sterile keratitis 1
• Controlling allergic eye disease with cyclosporine may indirectly benefit keratoconus by:
  • Reducing eye rubbing behavior 1
  • Decreasing inflammation that may contribute to disease progression 1
• Long-term studies have shown topical cyclosporine to be safe and effective for extended treatment of vernal keratoconjunctivitis in children 3

Treatment Algorithm for Keratoconus with Allergic Eye Disease

1. Primary keratoconus treatment: Corneal cross-linking for progressive disease 1, 2
2. For coexisting allergic eye conditions:
   • First-line: Cool compresses, preservative-free artificial tears, antihistamines, mast cell stabilizers 1
   • Second-line: Topical cyclosporine (0.05-0.1%) for moderate to severe allergic eye disease 1, 5
   • Third-line: Short-term topical corticosteroids for acute exacerbations 1

Important Caveats

• Cyclosporine should not be considered a treatment for keratoconus itself, but rather for associated allergic conditions 1, 4
• Patients should be counseled to avoid eye rubbing, which is critical in preventing keratoconus progression 1
• Regular monitoring for keratoconus progression is essential regardless of allergic eye disease management 1
• Corneal cross-linking remains the only treatment proven to halt keratoconus progression 1, 2