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J. C. Lew, J. A. Smith, B. Rubin, R. Bishop, M. R. Robinson, S. Z. Pavletic; Ocular Surface Changes After Hematopoietic Stem Cell Transplant (HSCT): The Shifting Clinical Spectrum of Ocular Graft Versus Host Disease (oGVHD). Invest. Ophthalmol. Vis. Sci. 2007;48(13):357.
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To describe the spectrum of ocular surface disease and lacrimal gland dysfunction in a large population of patients (pts) receiving HSCT in an era of improved conditioning regimens and immunosuppressive therapy.
A retrospective chart review of 301 consecutive pts who underwent HSCT from 2004 to 2006 was conducted. Patients underwent standardized ocular surface exam at the NEI, regardless of systemic GVHD or ocular complaints. Outcome measures were: Schirmer (Sch) with anesthesia, punctate keratopathy defined as fluorescein staining of the cornea, and conjunctival involvement based on the Robinson GVHD grading system: Grades 1 (hyperemia), 2 (fibrovascular change of < 25% of palpebral conj), 3 (25-75%), and 4 (> 75%).
301 pts (127, 42.2% F, 174, 57.8% M) received HSCT for a total of 35 different indications. Clinical diagnosis of oGVHD was established for 124 (41.2%) pts based on conjunctival disease alone (25/124, 20.2%), punctate keratopathy alone (26/124, 21%), or the presence of both (73/124, 58.9%). Punctate keratopathy was found 95 pts, ranging in severity from mild (46/95, 48.4%), moderate (43/95, 45.2%), to severe (6/95, 6.3%). Conjunctival GVHD was found in 91 patients: Grades 1 (5/91, 5.5%), 2 (19/91, 20.9%), 3 (17/91, 18.7%), and 4 (10/91, 11%). 252 (83.7%) pts had a Sch of ≤ 10 in at least one eye. 167 (55.5%) pts had a Sch of ≤ 5 in at least one eye. For pts carrying the clinical diagnosis of oGVHD, the mean Sch was 3.15 in the worse eye, compared to a mean of 11.24 in the remaining patients (p < 0.0001). There was a statistically significant negative correlation between conjunctival Grade and Sch with a correlation coefficient of -0.36 (p<0.0001). Other GVHD ocular surface complications included filamentary keratitis (4), corneal ulcer (2) and perforated corneal ulcer (1). Visual acuity was reduced to less than 20/40 in at least one eye of only one patient.
While conjunctival disease remains a common feature of oGVHD, decreased tear production and corneal epithelial compromise are found in over half of affected pts, and are important aspects of this disease. Close follow-up of pts status post HSCT may permit early diagnosis and anti-inflammatory treatment of oGVHD, before surface changes have occurred. Further investigation evaluating quality of life implications of oGVHD would be helpful in assessing the impact of this disease.
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