title: Systemic Immunosuppression in High-Risk Penetrating Keratoplasty: A Systematic Review.
abstract: Cornea transplantation has a high success rate and typically only requires topical immunomodulation. However, in high-risk cases, systemic immunosuppression can be used. We conducted a systematic review on the efficacy and side effects of systemic immunosuppression for high-risk cornea transplantation. The study population was 18 years old or older with a high-risk transplant (two or more clock hours of cornea vascularization or a previous failed graft or a graft needed because of herpes simplex keratitis). A comprehensive search strategy was performed with the help of an information specialist and content experts from ophthalmology. All study designs were accepted for assessment. Level 1 and level 2 screening was performed by two reviewers followed by data abstraction. Forest plots were created whenever possible to synthesize treatment effects. Quality assessment was done with a Downs and Blacks score. From 1,150 articles, 29 were ultimately used for data abstraction. The odds ratios (ORs) for clear graft survival in cyclosporine and controls were 2.43 (95% CI: 1.00 - 5.88) and 3.64 (95% CI: 1.48 - 8.91) for rejection free episodes. Mycophenolate mofetil (MMF) significantly improved the rejection free graft survival rates at 1 year (OR: 4.05, 95% CI: 1.83 - 8.96). The overall results suggested that both systemic cyclosporine and MMF improved 1-year rejection free graft survival in high-risk keratoplasty. Cyclosporine also significantly improved clear graft survival rates at 1 year; however, there were insufficient data to analyze the same in the MMF group. Higher quality studies are needed to understand this issue better.
authors.affiliation: Department of Ophthalmology, Western University, London, Ont. N6A 4V2, Canada.
authors.forename: Shveta
authors.initials: S
authors.lastname: Bali
authors.affiliation: Department of Ophthalmology, Western University, London, Ont. N6A 4V2, Canada; Department of Pathology, Western University, London, Ont. N6A 4V2, Canada.
authors.forename: Richard
authors.initials: R
authors.lastname: Filek
authors.affiliation: Department of Ophthalmology, Western University, London, Ont. N6A 4V2, Canada.
authors.forename: Francie
authors.initials: F
authors.lastname: Si
authors.affiliation: Department of Ophthalmology, Western University, London, Ont. N6A 4V2, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ont. N6A 4V2, Canada.
authors.forename: William
authors.initials: W
authors.lastname: Hodge
keywords: Cyclosporine; High risk; Immunosuppression; Keratoplasty; Mycophenolate mofetil; Systematic review