Question

What is the effectiveness of topical cyclosporin (CsA) in patients with atopic keratoconjunctivitis (AKC)?

Relevance to nursing care

AKC is a chronic ocular surface non-infectious inflammatory condition that can be severe and is not self resolving. It poses a higher risk of corneal injuries and severe sequelae. Topical CsA is considered as one management option for people with AKC; however, its effectiveness is unknown. Therefore, it is vital for nurses to be updated with evidence related to the use of topical CsA and a systematic review was undertaken.

Study characteristics

This is a summary based on a Cochrane Systematic Review1 containing three randomised controlled trials (RCTs) with 58 participants. Participants were of any age with a clinical diagnosis of AKC of any duration. Trials could include any concentration of topical CsA, alone or combined with other treatments and were compared to no treatment, placebo or other medication. Primary outcomes measured were patient reported symptoms such as itching, tearing, discomfort, mucous discharge, photophobia, foreign body sensation or pain. The secondary outcomes measured were topical steroid use after 3 months of treatment, clinical signs, adverse effects, recurrence of the disease and quality of life.

All trials were considered at a low risk of bias for random sequence generation and blinding of participants, personnel and outcome assessors. One trial showed a low risk of bias in allocation concealment and incomplete outcome data while another showed unclear risk of bias in allocation concealment and incomplete outcome data. The third trial demonstrated a low risk of bias for incomplete outcome data while it was unclear for allocation concealment. No meta-analysis was performed due to variability in interventions, methodology and outcomes across trials. Thus, the findings were presented in narrative form as follows:

* One trial showed a non-significant beneficial effect of topical CsA in controlling signs and symptoms of AKC compared to placebo.

* The second trial reported a statistically significant benefit in controlling signs but not symptoms of AKC compared to placebo.

* The final trial did not show evidence of any improvement in either signs or symptoms.

* Two trials measured topical steroid use with one showing a significant reduction with CsA compared to placebo and the other showing no evidence of improvement compared to placebo.

* No serious adverse events were reported in any trials.

Implications for nursing care

Results from a systematic review suggest that topical CsA may provide clinical and symptomatic relief in patients with steroid-dependent or steroid-resistant AKC; however, this should be interpreted with caution due to the limited number of studies located and included in the review, their methodological quality, the lack of data on adverse effects and the inability to pool results.

Implications for research

More RCTs are required and future trials should prolong the duration of follow-up to one year and use the standardised scales designed by the International Ocular Inflammation Society for outcome assessment. Samples should be large enough to provide sufficient statistical power to assess the safety of CsA.

Reference