Ocular Microbiology and Immunology Group
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2024 OMIG Abstract

Topical Tacrolimus as Adjunctive Therapy in Mycotic Corneal Ulcers
-- A Pilot Study

Kunal Mandlik, Josephine Christy, and Jennifer Rose-Nussbaumer

Department of Cornea & Refractive Surgery, Aravind Eye Hospital, Pondicherry, India

Purpose: To determine if the addition of topical tacrolimus in patients who underwent therapeutic penetrating keratoplasty (TPK) for fungal ulcers is beneficial in terms of graft clarity.

Methods: Patients with smear or culture-positive fungal ulcers requiring TPK were included.

Intervention: On the first post-operative day study participants began topical Natamycin 5% every hour for 2 days followed by 4 times daily for 1 month. They were also treated with topical Moxifloxacin 0.05% 4 times daily for 2 weeks or until epithelial healing, Tacrolimus 0.1% ointment was started 3 times daily for 2 months and then tapered to 2 times daily for 2-3 month. Thereafter the patient was instructed to use the tacrolimus daily at bedtime until 6 months. Prednisolone acetate 1% was started after 1 month if there was no evidence of re-infection. Prednisolone was continued QID for 3 months, TID for 3 months, BID until 6 months and daily until 1 year.

Outcomes: The primary study outcome was graft clarity at 6 months. Secondary outcomes included BSCVA at 3 and 6 months, preservation of the anterior chamber anatomy, and complications including recurrence of infection, development of glaucoma or need for further surgery.

Results: The study included individuals who tested positive for a fungal infection and underwent TPK for the same. The average age was 62 years with 10 male and 3 female. All patients had poor visual acuity at baseline with a mean logMAR visual acuity of 2.2 (SD 0.05) and mean corneal ulcer size was 6.3 mm (SD 1.3). All patients had microbiological evidence of filamentous fungus either on corneal smear (N=11, 85%), corneal culture (N=12, 92%) and/or culture of the corneal button (N=7, 54%). Aspergillus spp (N=5, 38%) and Fusarium spp (N=5, 38%) were the most commonly isolated fungi.

Donor corneal tissue had a mean age of 49 years (SD 20) with death to preservation time of 16.6 hours (SD 6.3). The mean cell count was 2300 cells/mm2 (SD 790). Intraoperatively, the mean donor graft size was 9.2 mm (SD 0.72).

At 6 months clear graft survival was 2/13 (15%), mild corneal edema with good view to anterior chamber (AC) details and normal AC anatomy was noted in 4/13 (31%), moderate corneal edema with hazy view to the AC was noted in 3/13 (23%) and severe opacity with vascularization was noted in 4/13 (31%). Visual acuity was logMAR 2.0 (SD 0.62) at 6 months. Three patients had re-infection and required repeat TPK 3/13 (23%). In these patients’ tacrolimus was stopped. There were no cases of endophthalmitis, and no patients required glaucoma surgery.

Clinical Implications: Topical tacrolimus is efficient in controlling post-operative inflammation after therapeutic transplantation. Unlike topical steroids, the use of tacrolimus did not precipitate any recurrent graft infections.

Conclusions: The use of topical tacrolimus might have a beneficial effect on graft outcomes by improving the graft survival rate and reducing graft re-infections.


Disclosure:

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