How should I manage a patient post-corneal transplant who presents with signs of graft rejection?

Management of a patient presenting with signs of corneal graft rejection following a transplant requires urgent and aggressive treatment to preserve graft clarity and visual function. First-line management involves prompt initiation of intensive topical corticosteroids, typically hourly prednisolone acetate 1%, to suppress the immune response causing rejection NICE NG81 Panda et al. 2007. Adjunctive systemic corticosteroids may be considered in severe or sight-threatening cases to enhance immunosuppression NICE NG81 Tabbara 2008. Close monitoring is essential, with frequent follow-up to assess response and adjust therapy accordingly NICE NG81.

In addition to corticosteroids, cyclosporine or tacrolimus eye drops can be used as steroid-sparing agents or in refractory cases Tabbara 2008. Early recognition of clinical signs such as endothelial rejection line, corneal edema, and anterior chamber inflammation is critical to initiate treatment promptly Maharana et al. 2023. Patient education on symptoms of rejection and the importance of adherence to immunosuppressive therapy is vital to prevent graft failure NICE NG81.

Long-term management includes maintenance immunosuppression tailored to the individual risk of rejection, with regular ophthalmic review to detect any recurrence early NICE NG81. Recent immunopathogenesis insights highlight the role of T-cell mediated mechanisms, supporting the use of targeted immunomodulatory therapies alongside corticosteroids Maharana et al. 2023.