Immunomodulatory (Calcineurin Inhibitor) — Dry Eye Disease Pregnancy: Use with caution — negligible systemic absorption expected; no reproductive toxicity data for topical use; consult specialist

Ciclosporin 0.1% Eye Emulsion

Brand names: Ikervis, Verkazia

Adult dose

Dose: 1 drop (0.1% ciclosporin) to the affected eye(s)

Route: Topical ophthalmic (oil-in-water emulsion)

Frequency: Once daily at bedtime

Max: 1 drop once daily

Ikervis licensed for adults with dry eye disease with severe keratitis unresponsive to artificial tears; Verkazia licensed for vernal keratoconjunctivitis in children ≥4 years; shake well before use; remove contact lenses before instillation; systemic absorption negligible

Paediatric dose

Route: Topical

Frequency: Once daily or as directed by specialist

Max: 1 drop per dose

Verkazia (0.1% ciclosporin) licensed for vernal keratoconjunctivitis (VKC) in children ≥4 years — specialist paediatric ophthalmology; typically given four times daily for VKC vs once daily for dry eye

Dose adjustments

Renal

No adjustment required (negligible systemic absorption from topical use)

Hepatic

No adjustment required

Clinical pearls

Mechanism of action: inhibits calcineurin → prevents T-lymphocyte activation and proinflammatory cytokine production (IL-2, IFN-γ) in ocular surface; dry eye disease is fundamentally an immune-mediated inflammatory disease, not merely a lubrication deficiency — ciclosporin addresses the underlying pathophysiology
NICE TA369 (2015): Ikervis recommended for severe dry eye disease with keratitis when artificial tears insufficient; prescribing requires confirmation of keratitis severity (Oxford grading ≥3 or OSDI score ≥23); funded via NHS with specific indication criteria
Onset of action: 3–6 months for full benefit — onset is slow due to immunomodulatory mechanism; patients must be counselled to continue treatment even without early improvement; bridging with topical steroids (e.g. loteprednol or prednisolone) for first 4 weeks helps manage symptoms during initiation
Emulsion formulation (Ikervis): unlike Restasis (0.05% in the US), Ikervis is 0.1% in a preservative-free oil-in-water emulsion — the formulation improves corneal penetration; single-dose units reduce preservative exposure in an already compromised ocular surface
VKC in children (Verkazia): vernal keratoconjunctivitis is a severe allergic inflammatory condition causing corneal shield ulcers; ciclosporin 0.1% QID reduces shield ulcer recurrence and steroid dependence; MHRA-approved paediatric indication

Contraindications

Active ocular or periocular infection (bacterial, viral, fungal)
Hypersensitivity to ciclosporin
Concurrent systemic ciclosporin therapy (additive immunosuppression risk — theoretical)

Side effects

Burning and stinging on instillation (most common, ~25%)
Eye pain
Visual blurring (transient)
Blepharitis
Discharge
Pruritus

Interactions

Systemic ciclosporin — additive immunosuppression (monitor if concurrent)
Topical steroids — often co-prescribed as bridge therapy; reduce steroid over time as ciclosporin takes effect

Monitoring

Corneal fluorescein staining (Oxford grade) at 4–6 weeks and 3 months
OSDI score (Ocular Surface Disease Index)
Signs of infection before starting
Compliance (slow onset may lead to early discontinuation)

Reference: BNFc; BNF 90; NICE TA369 (Ikervis for Dry Eye Disease, 2015); SPC Ikervis; SPC Verkazia; TFOS DEWS II Report (Ocul Surf 2017). Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways