Topical cyclosporin stimulates neovascularization in resolving sterile rheumatoid central corneal ulcers. Gottsch JD, Akpek EK. Tr Am Ophth Soc 2000;98:81–90.

Abstract

The authors reported the successful use of topical cyclosporin for treatment of central sterile corneal ulcers associated with rheumatoid disease in this retrospective and noncomparative case series. Five patients (7 eyes) with collagen vascular disorders presented with central, sterile corneal ulcers. An extensive medical evaluation did not reveal active underlying rheumatoid disease in any patient. Inadequate clinical response with use of topical steroids and lubricants led to corneal perforations requiring multiple tectonic procedures. Systemic immunosuppressive therapy either could not be initiated owing to a systemic contraindication or was discontinued owing to intolerance and side effects. The patients were ultimately treated with topical cyclosporin. Six of the seven eyes responded favorably. An intense limbal vascularization began within 48 hours of treatment. The neovascularization progressed centrally with the simultaneous arresting of epithelial and stromal ulceration. Over a two-week period, re-epithelialization occurred with vascularization proceeding throughout the cornea. After several months, the corneal vessels attenuated, and all signs of inflammation subsided. Intrastromal bleeding with corneal blood staining occurred in one patient; this resolved over several months. No recurrences of corneal ulceration occurred in a mean follow-up period of 28 months (range, 7–60 months). None of the five patients had a reactivation of their rheumatoid disease in the follow-up period. The clinical response in these patients contrasts with previous animal studies demonstrating an anti-angiogenic property of cyclosporin. The authors feel that an immediate intense neovascularization is the first sign of a favorable clinical response and that treatment with topical cyclosporin alone may be considered in patients with sterile corneal ulcers associated with rheumatoid disease in the absence of systemic activation.—Thomas J. Liesegang