Topical cyclosporine A therapy for dry eye disease.

rationaleOcular surface inflammation is a key component of dry eye disease (DED). Topical cyclosporine A (CsA) is commonly used to treat DED. However, uncertainty remains regarding its benefits and harms, despite extensive clinical evaluation. This updates a Cochrane review published in 2019.

objectivesTo assess the benefits and harms of topical CsA in the treatment of dry eye disease. SEARCH

methodsWe used CENTRAL, MEDLINE, Embase, two other databases, and two trial registers, together with reference checking, to identify studies included in the review. The latest search date was 17 March 2026. ELIGIBILITY CRITERIA: We included randomized controlled trials (RCTs) in participants with DED, regardless of age, sex, disease severity, or etiology, that compared topical CsA with its vehicle (the formulation without the active ingredient), artificial tears, or alternative CsA formulations or concentrations, with or without artificial tears. OUTCOMES: We assessed: DED symptoms, ocular surface staining, tear production, tear film stability, artificial tear use, conjunctival goblet cell density, and discontinuation rates due to adverse events at 3 months. RISK OF BIAS: We used RoB 1 (Cochrane's original risk of bias assessment tool) to assess bias in the RCTs. SYNTHESIS

methodsWe synthesized results for each outcome using meta-analysis where possible, calculating mean differences (MDs), standardized mean differences (SMDs), or risk ratios (RRs) with 95% confidence intervals (CIs), using fixed-effect or random-effects models as appropriate. Where meta-analysis was not possible, we summarized results descriptively. We assessed the certainty of evidence using GRADE. INCLUDED STUDIES: We included 58 RCTs involving 10,225 participants with DED. Three countries - South Korea, the USA, and China - contributed 35 of the 58 included studies (60%). The follow-up period was typically three months (range: three days to 12 months), and the median participant age was 53 years. The proportion of women ranged from 46% to 100% (median 80%). Most studies compared topical CsA 0.05% or 0.1% with vehicle or artificial tears, while 14 studies compared different formulations or concentrations. SYNTHESIS OF

resultsWe grouped studies into six comparisons. Overall, the certainty of evidence was very low to moderate, downgraded for imprecision, risk of bias, or heterogeneity. CsA 0.05% versus vehicle, artificial tears, or both. CsA 0.05% may improve DED symptoms at three months compared with vehicle, artificial tears, or both (SMD -0.33, 95% CI -0.65 to -0.01; I² = 86%; 13 studies, 1396 participants; low-certainty evidence). CsA 0.05% may also improve corneal staining (SMD -0.20, 95% CI -0.31 to -0.09; I² = 0%; 7 studies, 1355 participants; low-certainty evidence), while the effect estimate was imprecise for conjunctival staining (SMD -0.21, 95% CI -0.52 to 0.09; I² = 65%; 3 studies, 582 participants; low-certainty evidence). Participants treated with CsA 0.05% were probably more likely to discontinue treatment due to adverse events (RR 1.99, 95% CI 1.02 to 3.87; I² = 23%; 9 studies, 2109 participants; moderate-certainty evidence). For other outcomes, low- or very low-certainty evidence favored CsA 0.05% over vehicle or artificial tears. Other CsA formulations or concentrations versus CsA 0.05%. Fourteen studies compared different CsA formulations (e.g. nanoemulsion or cationic emulsion) or concentrations (e.g. 0.1%) with CsA 0.05%. Effect estimates were imprecise for all outcomes, except tear production, which favored other CsA formulations in the pooled analysis (MD 0.30, 95% CI 0.17 to 0.43; I² = 0%; 5 studies, 572 participants), and CsA 0.08% nanoemulsion in the formulation subgroup analysis (MD 0.30, 95% CI 0.17 to 0.43; 1 study, 155 participants), both with low-certainty evidence. CsA 0.05% likely had a lower rate of discontinuation due to adverse events than other CsA formulations (RR 1.72, 95% CI 1.07 to 2.78; I² = 0%; 6 studies, 1421 participants; moderate-certainty evidence). CsA 0.1% versus vehicle, artificial tears, or both. The evidence was mixed for DED symptoms and imprecise for tear stability (MD 0.15, 95% CI -0.11 to 0.42; I² = 0%; 3 studies, 979 participants; low-certainty evidence). CsA 0.1% probably improves corneal staining (SMD -0.16, 95% CI -0.24 to -0.08; I² = 15%; 7 studies, 2940 participants) and conjunctival staining (SMD -0.20, 95% CI -0.28 to -0.12; I² = 0%; 5 studies, 2303 participants), both with moderate-certainty evidence, and may improve tear production (MD 0.66, 95% CI 0.09 to 1.24; I² = 30%; 3 studies, 735 participants; low-certainty evidence). Participants treated with CsA 0.1% were probably more likely to discontinue due to adverse events (RR 1.58, 95% CI 1.04 to 2.41; I² = 0%; 7 studies, 3051 participants; moderate-certainty evidence). CsA 0.1% versus CsA 0.1% plus artificial tears. One study evaluating 0.1% CsA, with or without artificial tears, in moderate-to-severe DED found very low-certainty evidence of no significant difference in the assessed outcomes. CsA 1% versus vehicle. One study (60 participants) indicated that CsA 1% may improve DED symptoms (MD -2.34, 95% CI -3.70 to -0.98), corneal staining (MD -0.33, 95% CI -0.56 to -0.10), tear production (MD 2.01, 95% CI 1.11 to 2.91), and tear stability (MD 2.77, 95% CI 2.14 to 3.40), but the evidence is very uncertain. No participants discontinued due to adverse events. CsA 2% versus vehicle. Two studies compared these treatments. CsA 2% may improve DED symptoms and ocular staining (MD -1.82, 95% CI -2.19 to -1.45; 1 study, 30 participants), and may have little to no effect on tear production (MD 0.35, 95% CI -0.24 to 0.94; 1 study, 30 participants) or tear film stability (MD 2.82, 95% CI 2.17 to 3.47; 1 study, 30 participants), but the evidence is very uncertain. Discontinuation rates were minimal. AUTHORS'

conclusionsLow-certainty evidence suggests that topical CsA may improve DED symptoms and certain clinical signs compared with vehicle or artificial tears. However, results for DED symptoms and tear parameters were inconsistent and highly heterogeneous. Higher CsA concentrations were associated with increased treatment discontinuation. Future studies should stratify DED by subtype and severity, compare formulations, and assess long-term benefit and harm.

fundingThe Cochrane Eyes and Vision US Project is supported by grant UG1EY020522, National Eye Institute, National Institutes of Health. REGISTRATION: Original review (2019) DOI: 10.1002/14651858.CD010051.pub2.