Can cyclosporine solutions be used to treat allergic conjunctivitis?

Every year allergy season brings a large number of patients with red, itchy, and watery eyes to the practice of eye care providers. After performing a slit lamp exam and getting answers to a few important questions, a physician diagnoses allergic conjunctivitis.

The go-to therapies for this condition vary from cold compresses, over-the-counter drops like ketotifen (Zaditor; Alcon) and olopatadine (Pataday; Alcon), and prescription antihistamines or mast cell stabilizers. If the patient’s symptoms are systemic (beyond ocular discomfort), over-the-counter oral medication like loratadine (Claritin; Bayer) and cetirizine (Zyrtec; Johnson and Johnson) may also be suggested.

If these remedies are not enough and the patient’s symptoms appear to be more severe than average, topical corticosteroids are used as a second-line treatment. They have been effectively applied to allergic signs and symptoms, but not without the risk of adverse side effects. Studies have shown that long-term use of corticosteroids could lead to increased intraocular pressure, cataracts, decreased wound healing, and an increased risk of microbial infections.^1,2

This begs the questions: Should corticosteroids be used as second-line treatment for patients with severe allergic conjunctivitis? Is there a better option to combat inflammation in atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC), and other diseases?

Cyclosporine solutions

Cyclosporine A (CsA) solutions are popular FDA-approved topicals for dry eye disease (DED). They serve as immunomodulators that inhibit CD4 T lymphocyte proliferation by inhibiting interleukin-2 receptor expression.³ CsA concentrations in these solutions may range from 0.05% to 2%, with Restasis (Allergan, an AbbVie company) and Cequa (Sun Ophthalmics) being the most widely used. The CsA concentration in Restasis is 0.05% and in Cequa 0.09%.⁴

CsA has also been shown to inhibit the activation of mast cells and eosinophils, which is vital in treating the inflammation caused by allergies.³ This off-label usage of CsA is effective because it targets the mediators responsible for ocular allergic reactions like tearing, itchiness, and photophobia.³

Owing to its outstanding safety profile, CsA is well-tolerated in the management of allergic conjunctivitis.⁵ Long-term CsA use is not associated with the side effects of long-term steroid use.

Additionally, patients treated with 0.05% CsA had significant improvement in conjunctival hyperemia, lid margin thickening, conjunctival papillae, and tear-film deficiency. Patients reported a decrease in such symptoms as itching, tearing, photophobia, and overall discomfort.⁶

Of the different types of allergic conjunctivitis, AKC is one of the most debilitating and difficult to manage because of chronicity.³ Topical 0.05% CsA has been used to successfully treat signs and symptoms of AKC without adverse side effects.³

For patients who need steroids because of severe allergic conjunctivitis symptoms, CsA is an effective option that has been shown to decrease steroid dependency in a multitude of studies.⁵ About 30% of patients on topical corticosteroids discontinued usage within just 1 month of 0.1% CsA treatment, suggesting that steroids could be tapered if the patient tolerates CsA.⁷

Conclusion

The next time a patient walks in with symptoms of allergic conjunctivitis, consider CsA solutions like Restasis and Cequa as second-line therapy. This would allow you to limit prescribing topical corticosteroids for allergy symptoms.

Patients could be better prepared for allergy season without risking the negative effects that come with prolonged use of topical corticosteroids. Although mast cell stabilizers and antihistamines remain the first-line therapy, the addition of CsA solutions provides a steroid-sparing effect that can yield safer symptom management.

References

1. Gaballa SA, Kompella UB, Elgarhy O, et al. Corticosteroids in ophthalmology: drug delivery innovations, pharmacology, clinical applications, and future perspectives. Drug Deliv Transl Res. 2021 Jun; 11(3):866-893. doi: 10.1007/s13346-020-00843-z

2. Carnahan MC, Goldstein DA. Ocular complications of topical, peri-ocular, and systemic corticosteroids. Curr Opin Ophthalmol. 2000;11(6):478-483. doi: 10.1097/00055735-200012000-00016

3. Akpek EK, Dart JK, Watson S, et al. A randomized trial of topical cyclosporin 0.05% in topical steroid-resistant atopic keratoconjunctivitis. Ophthalmology. 2004;111(3):476-482. doi: 10.1016/j.ophtha.2003.05.035

4. de Oliviera RC, Wilson SE. Practical guidance for the use of cyclosporine ophthalmic solutions in the management of dry eye disease. Clin Ophthalmol. 2019; 13:1115-1122. doi: 10.2147/OPH.S184412

5. Wan KHN, Chen LJ, Rong SS, Pang CP, Young AL. Topical cyclosporine in the treatment of allergic conjunctivitis: a meta-analysis. Ophthalmology. 2013;120(11):2197-2203. doi: 10.1016/j.ophtha.2013.03.044

6. Ozcan AA, Ersoz TR, Dulger E. Management of severe allergic conjunctivitis with topical cyclosporin a 0.05% eyedrops. Cornea. 2007;26(9):1035-1038. doi: 10.1097/ICO.0b013e31812dfab3

7. Ebihara N, Ohashi Y, Uchio E, et al. A large prospective observational study of novel cyclosporine 0.1% aqueous ophthalmic solution in the treatment of severe allergic conjunctivitis. J Ocul Pharmacol Ther. 2009;25(4):365-372. doi: 10.1089/jop.2008.0103