Ointment Tacrolimus In The Treatment Of Corneal Vascularization With Lipid Keratopathy

We report a case of lipid keratopathy secondary to repeated corneal infection due to underlying herpetic disciform keratitis. It was successfully treated with needle cautery in combination with G. fluoromethalone (FML) (AbbVie, Ireland), ointment acyclovir 3% (FDC Limited, India) and ointment tacrolimus 0.03% (Ajanta, India). 

Lipid keratopathy is a common complication in a vascularized cornea due to recurrent cornea infection or trauma. An upregulation of angiogenic factors causes corneal neovascularization with lipid leakages. The period of follow up at Topvision clinic was 22 months. By using fine needlle cautery af the feeder vessels, the vascularization resolved quickly. The cornea regained clarity with the continuous application of G. FML, ointment acyclovir and tacrolimus. No complications were observed. 

Mr H. presented with the complaint of progressive blurring of vision associated with whitish appearance of his left eye. He had earlier recurrent left eye infection but did not seek any eye treatment. Examination revealed visual acuity left eye 6/24 pH 6/18, right eye 6/6 uncorrected. There were multiple engorged feeder cornea vessels from 11 to 1 o’clock position forming a deep stromal circumferential neovascularization with cream-coloured deposits along the mid periphery cornea, encircling the pupil.

He was treated with G. FML LE BD, Ointment Acyclovir LE OM, Ointment Tacrolimus LE ON and 3 weeks later, left eye needle cautery at 6mW were done at the multiple feeder corneal vessels from 11 to 1 o’clock. 1 week post needle cautery showed resolution of feeder corneal vessels from 11 to 1 o’clock with partial resolution of deep corneal neovascularization.

We maintained G. FML LE OM, Ointment Acyclovir LE OM and Ointment Tacrolimus LE ON over the next 22 months which continue to show improvement and partial improvement of corneal clarity. The deep corneal stromal vessels remain absent with some residual faint corneal superficial vessels at 11 to 1 o’clock position. Patient’s vision improved from 6/24 at initial presentation to 6/9-2 at 22 months post treatment. No cataract or intraocular pressure spike was observed throughout the treatment period.

Ointment tacrolimus can be safely used as the initial preferred treatment choice in the presence of severe corneal neovascularization with lipid keratopathy, even in herpetic eye disease. It is important to identify the root cause of the cornea neovascularization and treat the underlying pathology accordingly. Needle cautery is an effective adjunct to reduce cornea vascularization by coagulating the main feeder vessels. However, if the inflammatory cause is not addressed well, the cornea vascularization will recur easily despite the cautery. With long term immunomodulation with ointment tacrolimus as demonstrated in this case, lipid keratopathy is reversible.