• Pearls for Ocular Graft-vs.-Host Disease

    Ocular graft-vs.-host disease (GVHD) is one of the most common, rapidly progressive organ manifestations of chronic GVHD, occurring in 30% to 70% of patients after bone marrow transplants. Sandeep Jain, MD, offered his top tips for managing this condition during the “Ocular Surface Inflammation: Keeping It Cool” session (Cor03V) at Cornea Subspecialty Day.

    It’s not dry eye disease. Generally diagnosed five to 18 months after bone marrow transplant, patients usually describe symptoms of ocular surface inflammation (e.g., discomfort, dryness, and sensitivity to light) and present with signs such as meibomian gland disease, tear fluid deficiency, and conjunctival and corneal epitheliopathy. However, ocular GVHD is not another form of dry eye disease, said Dr. Jain, and generic dry eye therapies do not always work to prevent GVHD progression. Although there are no signs confirmed to be specific for ocular GVHD, certain combinations of findings tend to occur more commonly in GVHD than in dry eye disease.

    Ophthalmology exams. “Without early diagnosis and appropriate treatment, ocular surface inflammation progresses relentlessly, resulting in reduced vision quality and substantial loss of quality of life,” noted Dr. Jain.

    He recommends ophthalmic examinations before bone marrow transplantation and then every three months postop. Because patients may have meibomian gland atrophy, tear fluid deficiency, or other conditions before transplantation, documenting baseline ocular surface disease will help discern changes in disease severity due to ocular GVHD.

    In 2013, the International Chronic Ocular GVHD Consensus Group proposed a disease severity scale for chronic ocular GVHD based on Schirmer testing, corneal fluorescein staining, and Ocular Surface Disease Index scores.

    Step-down treatment. According to Dr. Jain, “Treatment initiation should not wait for the diagnosis of definite [ocular] GVHD to be made on the classification system.” Once a patient who has a history of bone marrow transplant presents with the clinical signs and symptoms of ocular GVHD, there is a small window of opportunity — as short as two to three months — to prevent ocular surface inflammation from destroying lacrimal and meibomian gland function. An aggressive step-down treatment strategy should be quickly implemented, with simultaneous use of anti-inflammatory, immunomodulatory, tear-fluid-replenishing and lubricating eyedrops. All topical treatments should be preservative free, if possible.  Kanaga Rajan, PhD

    Watch Cornea Subspecialty Day. If you are registered for AAO 2020 Virtual, you have access to the archived presentations on the virtual meeting platform until Feb. 15, 2021. . Log in to the virtual meeting platform: Next, from the Lobby screen, select “Sessions” from the top navigation; click “Agenda” from the drop-down menu; and click on the “Friday” tab.  

    Financial disclosures. Dr. Jain: Advaite: O,E; Ocugen: C.

    Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.

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