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P. Nguyen, F. Barte, S. Kang, S. Shinada, J. C. Song, S. C. Yiu; A Novel Pharmaceutical Protocol for Management of Immunogenic Rejection Following Repeat Penetrating Keratoplasty. Invest. Ophthalmol. Vis. Sci. 2008;49(13):5757. doi: https://doi.org/.
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To investigate the effectiveness of a systemic triple immunosuppressive regimen to prevent and manage corneal graft immunogenic rejection following repeat penetrating keratoplasty (rPK). We exploit the synergistic actions of corticosteroid, cyclosporine A, and azathioprine to maximize the immunosuppressive efficacy while minimizing the dosage and the side effect profile.
Six patients with previous failed penetrating keratoplasty (PK) were included in this retrospective chart review study, at the Doheny Eye Institute. The study was approved by the Institutional Review Board at the University of Southern California / Keck School of Medicine. All patients were informed on the risks and benefits of the management plan. Informed consents were collected upon voluntary participation. The rPK procedure was performed by the primary surgeon, S.C. Yiu. Rheumatology was consulted to maintain the standardized protocol with reduced dosage (prednisone 1 mg/kg/day, cyclosporine 2-3 mg/kg/day, azathioprine 1.5 mg/kg/day) and to monitor any adverse side effects. After the induction phase, the maintenance phase was maintained for 9-12 months, depending on graft status, with gradual tapering to completion. Visual acuity and graft viability were recorded regularly.
All patients performed well under the systemic triple immunosuppressive regimen. One patient developed alopecia and voluntarily withdrew from the study. Her alopecia resolved after cessation of the triple therapy. Typical adverse side effects include mild hyperglycemia and mild anemia. The average visual acuity remains in the 20/30 to 20/300 range, uncorrected visual acuity, with clear cornea, over an observation period of one to three years.
We report successful management of immunogenic corneal allograft rejection following rPK using the systemic triple immunosuppression therapy. Our clinical success rate compared to the literature demonstrates the effectiveness of the synergistic actions of these multiple agents. And the lower dosage optimizes the adverse effect profile. We encourage clinicians to develop similar strategies to capitalize on the synergistic pharmacology. However, given the exceptional and realistic adverse side effects, an interdisciplinary approach to patient care is highly encouraged.
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