The Role of Topical Cyclosporine A in Ocular Surface Inflammatory Disorders

Various ocular surface inflammatory disorders (OSID) such as allergic eye disease, Sjogren's syndrome, cicatrizing conjunctivitis, and ocular graft versus host disease have a chronic course, leading to visual morbidity and significantly impacting quality of life. They have chronic ocular surface inflammation which needs topical anti-inflammatory therapy to break the vicious cycle of inflammation and prevent worsening of the ocular surface disease. Topical cyclosporine A (CsA) acts by inhibiting T-cell activation and inflammatory cytokine production, thereby reducing inflammation and maintain the health of the tear film and the surface epithelial cells. The aim of this review is to provide an overview of mechanism of action, indications, formulations, concentration and efficacy of topical cyclosporine available for the treatment of ocular surface diseases. After carrying out a literature search on "Cyclosporine A", "Ocular surface disease", "Dry eye", "Vernal keratoconjunctivitis", "Graft versus host disease", "Restasis", "Cequa", "Vevye", "Ikervis", a total of 101 articles were included for this review. CsA has been found useful in cases of dry eye disease, vernal keratoconjunctivitis, graft versus host disease, SJS and high-risk corneal transplantation. Multiple clinical trials have demonstrated significant improvement in corneal fluorescein staining, Schirmer's test scores, and tear break-up time with CsA use in patients with dry eye. Topical CsA formulations such as Restasis (0.05%), Cequa (0.09%), and Vevye (0.1%) have been FDA-approved, showing long-term efficacy and safety. Advancements in drug delivery, including cationic emulsions (Ikervis), nanomicellar solutions (Cequa), and water-free technology (Vevye), have enhanced its bioavailability and patient compliance. However, challenges such as delayed onset of action, transient irritation, and high discontinuation rates remain. Topical CsA remains a cornerstone therapy in the management of OSID, providing long-term inflammation control, improved ocular surface integrity, and symptomatic relief. Continued research into optimized formulations, combination therapies, and alternative delivery systems may further refine its clinical utility and enhance patient adherence.