The Ocular Graft-Versus-Host Disease
The Ocular Graft-Versus-Host Disease The ocular manifestation of graft-versus-host disease (GVHD) represents a significant and often challenging complication following allogeneic hematopoietic stem cell transplantation. GVHD occurs when donor immune cells recognize the recipient’s tissues as foreign and initiate an immune response, primarily affecting organs such as the skin, liver, and gastrointestinal tract. However, the eyes, particularly the ocular surface and adnexa, are also vulnerable, leading to a condition known as ocular GVHD.
Ocular GVHD typically presents months after transplantation, although early onset is possible. Patients often report symptoms such as dryness, irritation, redness, burning, foreign body sensation, and fluctuating vision. These symptoms are primarily due to damage and inflammation of the lacrimal glands, conjunctiva, and corneal epithelium. The immune-mediated attack causes sicca syndrome, leading to decreased tear production, increased tear film instability, and ocular surface inflammation. Over time, chronic inflammation can lead to conjunctival scarring, symblepharon (adhesion between the eyelid and eyeball), keratopathy, and even vision loss if left untreated.
Diagnosis of ocular GVHD involves a thorough clinical evaluation, including slit-lamp examination, tear film assessment, and conjunctival and corneal evaluation. The presence of conjunctival scarring, keratopathy, and meibomian gland dysfunction supports the diagnosis. Laboratory tests and biopsies are rarely necessary but can help rule out other causes of dry eye or ocular surface disease. Importantly, ocular GVHD often coexists with systemic GVHD, and interdisciplinary collaboration between ophthalmologists and hematologists is crucial for optimal management.
Management of ocular GVHD focuses on symptom relief, preservation of vision, and control of inflammation. Artificial tears and lubricating ointments are the mainstays for managing dryness, providing symptomatic relief and protecting the ocular surface. Advancing to corticosteroid eye drops, immunosuppressive agents such as cyclosporine or lifitegrast, and topical antibiotics may be necessary to control inflammation and prevent secondary infections. In severe cases, more invasive procedures like punctal plugs, scleral lenses, or even surgical interventions such as conjunctival grafts or amniotic membrane transplantation might be considered to restore ocular surface integrity.
Preventive strategies are vital, including regular ocular surface monitoring post-transplantation and early intervention at the first signs of dryness or inflammation. Patients are advised to maintain eyelid hygiene, avoid environmental triggers, and adhere to prescribed therapies diligently. Systemic control of GVHD plays a crucial role in reducing ocular involvement, emphasizing the importance of comprehensive care.
Overall, ocular GVHD is a complex condition that requires a multidisciplinary approach for effective management. Early recognition and intervention can significantly improve patients’ quality of life by alleviating symptoms and preventing irreversible ocular damage. Continued research into targeted therapies promises better outcomes and a deeper understanding of this challenging complication.
