Ophthalmic cyclosporine for the treatment of psoriatic conjunctivitis
Authors: Kaiane A. Habeshian, Jacob Oren Levitt
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: A 54-year-old woman with a history of moderate to severe psoriasis and psoriatic arthritis presented with red scaly plaques on her knees, elbows, and trunk affecting 8% of her total body surface area. She reported contemporaneous onset of her psoriasis and conjunctivitis. Bilateral conjunctival injection was noted with no exudates, photophobia, miosis, or eyelid edema (Fig 1). Physical exam was otherwise normal. Past medical history included hypertension, diabetes, and depression. Medications included metformin, enalapril, and amlodipine. The patient had failed treatment with etanercept and adalimumab in the past. She was started on a regimen of 5- to 10-mg/kg infliximab intravenous (IV) infusion every 4 to 6 weeks. After 5 rounds of treatment, her conjunctival erythema had cleared completely and her psoriasis had improved. The infliximab was discontinued prematurely due to a lapse in her insurance coverage. After 2 months without systemic treatment, the conjunctival injection recurred bilaterally, at which time she was started on cyclosporine ophthalmic emulsion 0.05%, 1 drop in each eye twice daily, and methotrexate 20 mg/week. On follow-up at 11 days, the conjunctivitis had completely resolved (Fig 2).Fig 2Psoriatic conjunctivitis resolved after treatment with ophthalmic cyclosporine.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Ocular involvement occurs in approximately 10% of psoriasis patients and commonly includes conjunctivitis, keratoconjunctivitis sicca, and uveitis.1Erbagci I. Erbagci Z. Gungor K. Berkir N. Ocular anterior segment pathologies and tear film changes in patients with psoriasis vulgaris.Acta Med Okayama. 2003; 57: 299-303PubMed Google Scholar, 2Au S. Yaniv S. Gottlieb A.B. Psoriatic eye manifestations.Psoriasis Forum. 2011; 17: 169-179Google Scholar An ophthalmology referral at initial presentation is suggested to assess the degree of ocular involvement and for ongoing monitoring. The prevalence of conjunctivitis in psoriasis patients has been reported to be as high as 64.5%.1Erbagci I. Erbagci Z. Gungor K. Berkir N. Ocular anterior segment pathologies and tear film changes in patients with psoriasis vulgaris.Acta Med Okayama. 2003; 57: 299-303PubMed Google Scholar Karabulut et al3Karabulut A.A. Yalvac I.S. Vahaboglu H. Nurozler A.B. Duman S. Conjunctival impression cytology and tear-film changes in patients with psoriasis.Cornea. 1999; 18: 544-548Crossref PubMed Scopus (31) Google Scholar found that the conjunctival epithelial cells of psoriasis patients lacking clinical ocular disease demonstrated increased rates of squamous metaplasia compared with controls, with no correlation between the presence of squamous metaplasia and duration of skin disease. They also found increased rates of neutrophil clumping in the conjunctival tissue of these patients, reminiscent of the epidermal microabscesses pathognomonic of psoriasis. Their findings suggest a common underlying disease process, as in our patient, whose conjunctivitis responded independently to both IV infliximab and ophthalmic cyclosporine. Her rapid response to treatment after relapse is most likely attributable to treatment with cyclosporine, which has a faster onset of action than methotrexate. Her comorbid psoriatic arthritis further supports the notion that the conjunctivitis was a manifestation of her underlying disease, in that ocular inflammation is a common feature of overlap among the seronegative arthritides.4Lambert J.R. Wright V. Eye inflammation in psoriatic arthritis.Ann Rheum Dis. 1976; 35: 354-356Crossref PubMed Scopus (115) Google Scholar Ophthalmic cyclosporine has demonstrated an excellent safety profile with minimal intraocular penetration and absorption in the bloodstream and has been successful for the treatment of several inflammatory ocular surface disorders including allergic conjunctivitis, vernal keratoconjunctivitis, posterior blepharitis, and ocular rosacea.5Utine C.A. Stern M. Akpek E.K. Clinical review: topical ophthalmic use of cyclosporine A.Ocular Immunol Inflamm. 2010; 18: 352-361Crossref PubMed Scopus (121) Google Scholar Our case suggests that ophthalmic cyclosporine may also be a treatment option for ocular psoriasis.