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Surico PL, Luo ZK. Understanding Ocular Graft-Versus-Host Disease to Facilitate an Integrated Multidisciplinary Approach. Transplant Cell Ther 2024:S2666-6367(24)00493-7. [PMID: 38986740 DOI: 10.1016/j.jtct.2024.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/10/2024] [Accepted: 06/30/2024] [Indexed: 07/12/2024]
Abstract
Ocular Graft-versus-Host Disease (oGVHD) remains a challenging and potentially devastating complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT). It significantly impacts the quality of life of affected survivors, however, is often underrecognized particularly during the early stages. Targeting all providers in the HSCT community who see patients regularly and frequently for their post-allo-HSCT care, this review and opinion piece introduces the basic concepts of ocular surface pathophysiology, dissects the different stages of clinical presentation of oGVHD, explains why the current diagnostic criteria tend to capture the late disease stages, highlights the warning signs of early disease development, in hope to facilitate prompt referral of oGVHD suspects for ocular specialist care. In addition to introducing a comprehensive list of treatment options, this review emphasizes basic therapeutic strategy and options that are safe and effective to be initiated by any care provider. We believe in empowering the patients as well as the care providers beyond disciplinary boundaries, in order to provide the most cohesive and integrated care to our patients in a multidisciplinary approach.
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Affiliation(s)
- Pier Luigi Surico
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA; Campus Bio-Medico University, Department of Ophthalmology, Rome, Italy
| | - Zhonghui K Luo
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA.
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2
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Lazreg S, Hosny M, Ahad MA, Sinjab MM, Messaoud R, Awwad ST, Rousseau A. Dry Eye Disease in the Middle East and Northern Africa: A Position Paper on the Current State and Unmet Needs. Clin Ophthalmol 2024; 18:679-698. [PMID: 38464499 PMCID: PMC10924846 DOI: 10.2147/opth.s436027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/24/2024] [Indexed: 03/12/2024] Open
Abstract
In the Middle East and Northern Africa (MENA), dry eye disease (DED) is often misdiagnosed or overlooked. This review summarizes a series of conversations with ophthalmologists in the region around a variety of climatic, lifestyle, and iatrogenic factors that contribute to specific features of DED in the MENA region. These considerations are further classified by patient lifestyle and surgical choices. All statements are based on discussions and formal voting to achieve consensus over three meetings. Overall, a deeper understanding of the disease characteristics of DED specific to MENA can better guide local eyecare practitioners on appropriate management and follow-up care. Additionally, population-based studies and patient and physician education on ocular surface diseases, together with the use of culturally appropriate and language-specific questionnaires can help ease the public health burden of DED in this region.
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Affiliation(s)
| | - Mohamed Hosny
- Refractive and Cornea Service, Cairo University Hospitals, Cairo, Egypt
| | - Muhammad A Ahad
- Department of Ophthalmology, Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Mazen M Sinjab
- Dr Sulaiman Al Habib Hospital, DHCC, Dubai, United Arab Emirates
| | - Riadh Messaoud
- Department of Ophthalmology, Tahar SFAR University Hospital, Mahdia, Tunisia
| | - Shady T Awwad
- Department of Ophthalmology, American University of Beirut - Medical Center, Beirut, Lebanon
| | - Antoine Rousseau
- Department of Ophthalmology, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
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3
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Kantor NB, Tovar A, Wang T, Galor A. How does ocular graft-versus-host disease fit under the dry eye umbrella? A review. Clin Exp Ophthalmol 2024; 52:167-185. [PMID: 38204146 PMCID: PMC10939887 DOI: 10.1111/ceo.14347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/28/2023] [Accepted: 12/11/2023] [Indexed: 01/12/2024]
Abstract
Graft-versus-host disease (GVHD) is a systemic disease that can affect multiple organs as a consequence of an allogeneic haematopoietic stem cell transplant. One organ system that is often affected in GVHD is the eyes. Ocular GVHD (oGVHD) may involve various structures within the eye including the lacrimal glands, eyelids, conjunctiva, cornea, and nasolacrimal ducts, and is a source of morbidity in patients with GVHD. Common presenting features of GVHD overlap with dry eye disease (DED), including decreased tear production, epithelial disruption, and Meibomian gland dysfunction (MGD). In this review, we aim to compare oGVHD and DED to better understand the similarities and differences between the conditions, with a focus on pathophysiology, risk factors, clinical features, and treatments.
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Affiliation(s)
- Nicole B. Kantor
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
- Surgical Services, Miami Veterans Affairs Medical Center, Miami, FL, USA
| | | | - Trent Wang
- Division of Transplantation and Cellular Therapy, Sylvester Comprehensive Cancer Center, Adult Stem Cell Transplant Program, University of Miami Hospital and Clinics, Miami, FL, USA
| | - Anat Galor
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
- Surgical Services, Miami Veterans Affairs Medical Center, Miami, FL, USA
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4
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Brockmann T, Simon A, Brockmann C, Fuchsluger TA, Pleyer U, Walckling M. [Corneal wound healing-Pharmacological treatment]. DIE OPHTHALMOLOGIE 2024; 121:245-258. [PMID: 38411733 DOI: 10.1007/s00347-024-02021-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 02/28/2024]
Abstract
Physiological wound healing of the cornea is a complex process and involves numerous multifactorial tissue processes. A proper wound healing, especially without the formation of light-scattering scars, is essential to preserve the integrity and function of the cornea. Misdirected wound healing is of vast clinical relevance as it can lead to corneal fibrosis and the loss of optical transparency with subsequent reduction of visual acuity, up to blindness. In addition to the understanding of the pathophysiological mechanisms, the knowledge of therapeutic concepts and options for treating corneal wound healing disorders and fibrosis is essential to counteract a permanent damage of the cornea as early as possible. Nowadays, various pharmacological and surgical options are available for treatment. The decision, appropriate selection and indication for the optimal treatment depend primarily on the genesis and clinical appearance of the corneal wound, fibrosis or scar. The treatment of wound healing disorders ranges from the use of topical therapy and supportive measures up to tissue replacement procedures. As long as the mechanical stability of the cornea is intact and wound healing processes are still ongoing, a pharmacological modulation is reasonable, which is discussed in this article.
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Affiliation(s)
- Tobias Brockmann
- Klinik und Poliklinik für Augenheilkunde, Universitätsmedizin Rostock, Doberaner Str. 140, 18057, Rostock, Deutschland.
- Fachbereich SciTec, Ernst-Abbe-Hochschule Jena, Carl-Zeiss-Promenade 2, 07745, Jena, Deutschland.
| | - Alexander Simon
- Fachbereich SciTec, Ernst-Abbe-Hochschule Jena, Carl-Zeiss-Promenade 2, 07745, Jena, Deutschland
| | - Claudia Brockmann
- Klinik und Poliklinik für Augenheilkunde, Universitätsmedizin Rostock, Doberaner Str. 140, 18057, Rostock, Deutschland
| | - Thomas A Fuchsluger
- Klinik und Poliklinik für Augenheilkunde, Universitätsmedizin Rostock, Doberaner Str. 140, 18057, Rostock, Deutschland
| | - Uwe Pleyer
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - Marcus Walckling
- Klinik und Poliklinik für Augenheilkunde, Universitätsmedizin Rostock, Doberaner Str. 140, 18057, Rostock, Deutschland
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5
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Song X, Chen Z, Li J, Wu S, Liang L. Therapeutic Efficacy and Safety of Intense Pulsed Light for Meibomian Gland Dysfunction in Patients with Chronic Ocular Graft-Versus-Host Disease. Ocul Immunol Inflamm 2023:1-10. [PMID: 37862586 DOI: 10.1080/09273948.2023.2266763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/29/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE To evaluate the efficacy and safety of intense pulsed light combined with meibomian gland expression (IPL-MGX) for treating meibomian gland dysfunction (MGD) associated with chronic ocular graft-versus-host disease (oGVHD). METHODS This retrospective study included 18 patients (18 eyes) with Fitzpatrick skin type ≤ IV, who underwent 3 to 8 sessions of IPL-MGX. Dry eye symptomology, ocular surface parameters, and adverse events were evaluated. RESULTS Of 18 eyes, 83.3% and 66.7% showed severe oGVHD and severe MGD, respectively. At 4 weeks after the final session, significant improvements in the OSDI (P < 0.001), SPEED (P = 0.001), meibum expressibility (P < 0.001), and meibum quality (P = 0.016) were observed. At 12 weeks after, the OSDI (P = 0.009), SPEED (P = 0.002), and meibum expressibility (P = 0.008) significantly improved. No adverse events owing to IPL were reported. CONCLUSION IPL-MGX may improve the ocular symptoms, ameliorate meibomian gland secretion, and is considered as a safe treatment for MGD in oGVHD patients.
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Affiliation(s)
- Xi Song
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
| | - Ziyan Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
| | - Jing Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
| | - Shaowen Wu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
| | - Lingyi Liang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-sen University, Guangzhou, China
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6
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Soleimani M, Mahdavi Sharif P, Cheraqpour K, Koganti R, Masoumi A, Baharnoori SM, Salabati M, Djalilian AR. Ocular graft-versus-host disease (oGVHD): From A to Z. Surv Ophthalmol 2023; 68:697-712. [PMID: 36870423 PMCID: PMC10293080 DOI: 10.1016/j.survophthal.2023.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation is a definitive therapy for a variety of disorders. One of the complications is acute graft-versus-host disease (aGVHD), which has a high mortality rate. Patients can also develop chronic graft-versus-host disease (cGVHD), a more indolent yet afflicting condition that affects up to 70% of patients. Ocular involvement (oGVHD) is one of the most prevalent presentations of cGVHD and can manifest as dry eye disease, meibomian gland dysfunction, keratitis, and conjunctivitis. Early recognition of ocular involvement using regular clinical assessments as well as robust biomarkers can aid in better management and prevention. Currently, the therapeutic strategies for the management of cGVHD, and oGVHD in particular, have mainly focused on the control of symptoms. There is an unmet need for translating the preclinical and molecular understandings of oGVHD into clinical practice. Herein, we have comprehensively reviewed the pathophysiology, pathologic features, and clinical characteristics of oGVHD and summarized the therapeutic landscape available to combat it. We also discuss the direction of future research regarding a more directed delineation of pathophysiologic underpinnings of oGVHD and the development of preventive interventions.
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Affiliation(s)
- Mohammad Soleimani
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Pouya Mahdavi Sharif
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kasra Cheraqpour
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Raghuram Koganti
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Ahmad Masoumi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mahbod Baharnoori
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Mirataollah Salabati
- Department of Ophthalmology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Ali R Djalilian
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA.
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7
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Chiang TL, Sun YC, Wu JH, Hsieh YT, Huang WL, Chen WL. The ocular graft-versus-host disease: the path from current knowledge to future managements. Eye (Lond) 2023; 37:1982-1992. [PMID: 36333534 PMCID: PMC10333261 DOI: 10.1038/s41433-022-02288-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/26/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is one of the major complications of allogenic haematopoietic stem cell transplantation (HSCT). The manifestation of ocular GVHD (oGVHD) is variable and may involve cornea, lacrimal gland, conjunctiva, eyelid, and/or nasolacrimal duct. We reviewed and summarized the current managements of oGVHD with specific focus on the emerging therapeutic advances. METHODS PubMed, Web of Science, and Google Scholar were searched for relevant literatures published within 20 years. Keywords used included "Graft-Versus-Host Disease", "GVHD", "ocular", "ocular surface", "ocular GVHD", "oGVHD", "dry eye", "keratitis", etc. RESULTS: Current managements of oGVHD can be classified into topical immunosuppressants, local tear-preservatory treatments, local non-pharmacological/surgical interventions, and systemic treatments. Additionally, some innovative therapies with promising treatment effects have been proposed, including topical target therapies, epitheliotrophic and neurotrophic treatments, recombinant DNase eye drops, mesenchymal stromal cell injection, and more. CONCLUSIONS Clinical managements of oGVHD are administered in a symptom-based, stepwise manner. The advances in innovative therapies may help improve clinical outcomes, and it is essential that physicians stay updated with these novel treatment options.
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Affiliation(s)
- Tung-Lin Chiang
- School of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Chen Sun
- Department of Ophthalmology, Taipei Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan
- College of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jo-Hsuan Wu
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California, San Diego, La Jolla, CA, USA
| | - Ying-Tung Hsieh
- School of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Lun Huang
- Department of Ophthalmology, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Li Chen
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan.
- Advanced Ocular Surface and Corneal Nerve Regeneration Centre, National Taiwan University Hospital, Taipei, Taiwan.
- Department of Ophthalmology, College of Medicine, National Taiwan University, Taipei, Taiwan.
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8
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Nilles JP, Roberts D, Salmon JH, Song L, O’Dea C, Marjoram LT, Bower JJ, Hirsch ML, Gilger BC. AAV-mediated expression of HLA-G for the prevention of experimental ocular graft vs. host disease. Mol Ther Methods Clin Dev 2023; 29:227-235. [PMID: 37090476 PMCID: PMC10119803 DOI: 10.1016/j.omtm.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 03/21/2023] [Indexed: 04/08/2023]
Abstract
Ocular graft versus host disease (OGvHD) develops after allogeneic hematopoietic stem cell transplantation (HSCT) and manifests as ocular surface inflammatory disease. This study evaluated the efficacy of adeno-associated virus (AAV) gene therapy encoding human leukocyte antigen G (HLA-G) to inhibit OGvHD. A major histocompatibility mismatch chronic OGvHD murine model was evaluated. 7 days after HSCT, mice were dosed subconjunctivally with scAAV8-HLA-G1/5 (1 x 109 vg/eye), topical cyclosporine (twice daily), or left untreated. Body weights and tear production (red thread test) were recorded, and eyelid, corneal opacity, and corneal fluorescein retention were scored through day 44 after HSCT. Tissues were collected for vector biodistribution, ocular histology, and immunofluorescence. Compared with untreated HSCT eyes, those dosed with scAAV8-HLA-G1/5 had significantly reduced clinical inflammatory signs of OGvHD. On histology, eyes that received scAAV8-HLA-G1/5 or cyclosporine had a significantly lower mean limbal mononuclear cell count when compared with non-treated HSCT eyes. HLA-G immunofluorescence was detected in the subconjunctiva and peripheral cornea in HSCT animals treated with scAAV8-HLA-G1/5. Vector genomes were detected in the lacrimal gland, but not in the other tested organs. These results provide evidence that subconjunctival AAV targets ocular surface and corneal disease and support that HLA-G-based gene therapy may be an effective treatment for OGvHD.
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Affiliation(s)
- Jacob P. Nilles
- Clinical Sciences, North Carolina State University, Raleigh, NC, USA
| | - Darby Roberts
- Clinical Sciences, North Carolina State University, Raleigh, NC, USA
| | - Jacklyn H. Salmon
- Clinical Sciences, North Carolina State University, Raleigh, NC, USA
| | - Liujiang Song
- Ophthalmology, University of North Carolina, Chapel Hill, NC, USA
| | - Carly O’Dea
- Powered Research, Research Triangle Park, NC, USA
| | | | | | - Matthew L. Hirsch
- Ophthalmology, University of North Carolina, Chapel Hill, NC, USA
- Gene Therapy Center, University of North Carolina, Chapel Hill, NC, USA
| | - Brian C. Gilger
- Clinical Sciences, North Carolina State University, Raleigh, NC, USA
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Perez VL, Mah FS, Willcox M, Pflugfelder S. Anti-Inflammatories in the Treatment of Dry Eye Disease: A Review. J Ocul Pharmacol Ther 2023; 39:89-101. [PMID: 36796014 DOI: 10.1089/jop.2022.0133] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023] Open
Abstract
Inflammation is an important driver of dry eye disease (DED) pathogenesis. An initial insult that results in the loss of tear film homeostasis can initiate a nonspecific innate immune response that leads to a chronic and self-sustaining inflammation of the ocular surface, which results in classic symptoms of dry eye. This initial response is followed by a more prolonged adaptive immune response, which can perpetuate and aggravate inflammation and result in a vicious cycle of chronic inflammatory DED. Effective anti-inflammatory therapies can help patients exit this cycle, and effective diagnosis of inflammatory DED and selection of the most appropriate treatment are therefore key to successful DED management and treatment. This review explores the cellular and molecular mechanisms of the immune and inflammatory components of DED, and examines the evidence base for the use of currently available topical treatment options. These agents include topical steroid therapy, calcineurin inhibitors, T cell integrin antagonists, antibiotics, autologous serum/plasma therapy, and omega-3 fatty acid dietary supplements.
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Affiliation(s)
- Victor L Perez
- Department of Ophthalmology, Foster Center for Ocular Immunology at Duke Eye Center, Duke University School of Medicine, Durham, North Carolina. USA
| | - Francis S Mah
- Scripps Clinic Torrey Pines, La Jolla, California, USA
| | - Mark Willcox
- School of Optometry and Vision Science, UNSW Sydney, Sydney, New South Wales, Australia
| | - Stephen Pflugfelder
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA
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10
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Perez VL, Mousa HM, Soifer M, Beatty C, Sarantopoulos S, Saban DR, Levy RB. Meibomian Gland Dysfunction: A Route of Ocular Graft-Versus-Host Disease Progression That Drives a Vicious Cycle of Ocular Surface Inflammatory Damage. Am J Ophthalmol 2023; 247:42-60. [PMID: 36162534 PMCID: PMC10270654 DOI: 10.1016/j.ajo.2022.09.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To investigate the role of aggressive meibomian gland dysfunction (MGD) in the immune pathogenesis of ocular graft-vs-host disease (GVHD). METHODS In mice, an allogeneic GVHD model was established by transferring bone marrow (BM) and purified splenic T cells from C57BL/6J mice into irradiated C3-SW.H2b mice (BM+T). Control groups received BM only. Mice were scored clinically across the post-transplantation period. MGD severity was categorized using the degree of atrophy on harvested lids. Immune disease was analyzed using flow cytometry of tissues along with fluorescent tracking of BM cells onto the ocular surface. In humans, parameters from 57 patients with ocular GVHD presenting to the Duke Eye Center were retrospectively reviewed. MGD was categorized using the degree of atrophy on meibographs. Immune analysis was done using high-parameter flow cytometry on tear samples. RESULTS Compared with BM only, BM+T mice had higher systemic disease scores that correlated with tear fluid loss and eyelid edema. BM+T had higher immune cell infiltration in the ocular tissues and higher CD4+-cell cytokine expression in draining lymph nodes. BM+T mice with worse MGD scores had significantly worse corneal staining. In patients with ocular GVHD, 96% had other organs affected. Patients with ocular GVHD had abnormal parameters on dry eye testing, high matrix metalloproteinase-9 positivity (92%), and abundance of immune cells in tear samples. Ocular surface disease signs were worse in patients with higher MGD severity scores. CONCLUSIONS Ocular GVHD is driven by a systemic, T-cell-dependent process that causes meibomian gland damage and induces a robust form of ocular surface disease that correlates with MGD severity. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
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Affiliation(s)
- Victor L Perez
- Foster Center for Ocular Immunology, Department of Ophthalmology (V.L.P., H.M.M., M.S.); Duke Eye Center, Duke University School of Medicine; Department of Immunology, Duke University Medical Center (C.B., D.R.S.).
| | - Hazem M Mousa
- Foster Center for Ocular Immunology, Department of Ophthalmology (V.L.P., H.M.M., M.S.); Duke Eye Center, Duke University School of Medicine; Department of Immunology, Duke University Medical Center (C.B., D.R.S.)
| | - Matias Soifer
- Foster Center for Ocular Immunology, Department of Ophthalmology (V.L.P., H.M.M., M.S.); Duke Eye Center, Duke University School of Medicine; Department of Immunology, Duke University Medical Center (C.B., D.R.S.)
| | - Cole Beatty
- Duke Eye Center, Duke University School of Medicine; Department of Immunology, Duke University Medical Center (C.B., D.R.S.)
| | - Stefanie Sarantopoulos
- Division of Hematological Malignancies and Cellular Therapy, Duke University Department of Medicine, Duke Cancer Institute (S.S.) Durham, North Carolina
| | - Daniel R Saban
- Duke Eye Center, Duke University School of Medicine; Department of Immunology, Duke University Medical Center (C.B., D.R.S.)
| | - Robert B Levy
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida (R.B.L.), USA
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11
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Tappeiner C, Heiligenhaus A, Halter JP, Miserocchi E, Bandello F, Goldblum D. Challenges and concepts in the diagnosis and management of ocular graft-versus-host disease. Front Med (Lausanne) 2023; 10:1133381. [PMID: 36891189 PMCID: PMC9987249 DOI: 10.3389/fmed.2023.1133381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 01/18/2023] [Indexed: 02/19/2023] Open
Abstract
Graft-versus-host disease (GVHD) is characterized by tissue inflammation in the host following an allogeneic hematopoietic cell transplantation (HCT). The pathophysiology is complex and only incompletely understood yet. Donor lymphocyte interaction with the histocompatibility antigens of the host plays a crucial role in the pathogenesis of the disease. Inflammation may affect multiple organs and tissues, e.g., the gastrointestinal tract, liver, lung, fasciae, vaginal mucosa, and the eye. Subsequently, alloreactive donor-derived T and B lymphocytes may lead to severe inflammation of the ocular surface (i.e., cornea and conjunctiva) and the eyelids. Furthermore, fibrosis of the lacrimal gland may lead to severe dry eye. This review focuses on ocular GVHD (oGVHD) and provides an overview of current challenges and concepts in the diagnosis and management of oGVHD. Ophthalmic manifestations, diagnostic procedures, grading of severity and recommendations for ophthalmic examination intervals are provided. Management of ocular surface disease with lubricants, autologous serum eye drops, topical anti-inflammatory agents and systemic treatment options are described based on the current evidence. Ocular surface scarring and corneal perforation are severe complications of oGVHD. Therefore, ophthalmic screening and interdisciplinary treatment approaches are highly relevant to improve the quality of life of patients and to prevent potentially irreversible visual loss.
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Affiliation(s)
- Christoph Tappeiner
- Department of Ophthalmology, Pallas Klinik, Olten, Switzerland.,Department of Ophthalmology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Department of Ophthalmology, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy.,Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Arnd Heiligenhaus
- Department of Ophthalmology at St. Franziskus Hospital, Muenster, Germany
| | - Joerg P Halter
- Department of Hematology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Elisabetta Miserocchi
- Department of Ophthalmology, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - Francesco Bandello
- Department of Ophthalmology, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
| | - David Goldblum
- Department of Ophthalmology, Pallas Klinik, Olten, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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12
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[Ocular Graft-Versus-Host Disease : Guidelines of the German Society of Ophthalmology (DOG) and the German Professional Association of Ophthalmologists (BVA)]. DIE OPHTHALMOLOGIE 2023; 120:50-58. [PMID: 36525047 DOI: 10.1007/s00347-022-01781-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
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13
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Cheng X, Huang R, Huang S, Fan W, Yuan R, Wang X, Zhang X. Recent advances in ocular graft-versus-host disease. Front Immunol 2023; 14:1092108. [PMID: 36761771 PMCID: PMC9905686 DOI: 10.3389/fimmu.2023.1092108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/10/2023] [Indexed: 01/26/2023] Open
Abstract
Ocular graft-versus-host-disease (GVHD) remains a significant clinical complication after allogeneic hematopoietic stem cell transplantation. Impaired visual function, pain, and other symptoms severely affect affected individuals' quality of life. However, the diagnosis of and therapy for ocular GVHD involve a multidisciplinary approach and remain challenging for both hematologists and ophthalmologists, as there are no unified international criteria. Through an exploration of the complex pathogenesis of ocular GVHD, this review comprehensively summarizes the pathogenic mechanism, related tear biomarkers, and clinical characteristics of this disease. Novel therapies based on the mechanisms are also discussed to provide insights into the ocular GVHD treatment.
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Affiliation(s)
- Xianjing Cheng
- Medical Center of Hematology, Xinqiao Hospital, State Key Laboratory of Trauma, Burns and Combined Injury, Army Medical University, Chongqing, China.,School of Medicine, Chongqing University, Chongqing, China
| | - Ruihao Huang
- Medical Center of Hematology, Xinqiao Hospital, State Key Laboratory of Trauma, Burns and Combined Injury, Army Medical University, Chongqing, China
| | - Shiqin Huang
- Medical Center of Hematology, Xinqiao Hospital, State Key Laboratory of Trauma, Burns and Combined Injury, Army Medical University, Chongqing, China
| | - Wei Fan
- Department of Ophthalmology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Rongdi Yuan
- Department of Ophthalmology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xiaoqi Wang
- Medical Center of Hematology, Xinqiao Hospital, State Key Laboratory of Trauma, Burns and Combined Injury, Army Medical University, Chongqing, China
| | - Xi Zhang
- Medical Center of Hematology, Xinqiao Hospital, State Key Laboratory of Trauma, Burns and Combined Injury, Army Medical University, Chongqing, China.,School of Medicine, Chongqing University, Chongqing, China.,Jinfeng Laboratory, Chongqing, China
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14
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Altan-Yaycıoğlu R, Aydın Akova Y, Dönmez O. Age-Related Differences in the Clinical Patterns of Ocular Graft-Versus-Host Disease. Turk J Ophthalmol 2022; 52:366-373. [PMID: 36578178 PMCID: PMC9811231 DOI: 10.4274/tjo.galenos.2022.50945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives To evaluate age-related differences in clinical patterns of ocular graft-versus-host disease (GVHD). Materials and Methods In this cross-sectional study, patients diagnosed with ocular GVHD were evaluated in two groups: Group I included those aged 18 years or younger and Group II included those over 18 years of age. Demographic and clinical information were recorded and compared between the groups. Results Forty eyes of 20 patients were included (11 patients were in Group I and 9 patients were in Group II). Follow-up was at least 6 months. All patients had burning, dryness, and foreign body sensation. Conjunctival hyperemia, cicatricial conjunctivitis, and limbal stem cell disease (LSCD) was observed more frequently in Group II. In addition to non-preserved artificial tears, cyclosporine A 0.05% (65%) and autologous/allogeneic serum eye drops (80%) were given and silicone plugs were inserted (28%). In Group I, an improvement in GVHD scoring and best corrected visual acuity was observed after 6 months of treatment (p<0.0005). Conclusion In ocular GVHD, conjunctival cicatrization and limbal stem cell deficiency might be observed more often in adults. Topical cyclosporine, autologous/allogenic serum drops, and punctal plugs are helpful in moderate or more severe cases. With early diagnosis and treatment, an improvement in clinical signs and visual acuity might be observed, particularly in younger patients.
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Affiliation(s)
| | - Yonca Aydın Akova
- Bayındır Kavaklıdere Hospital, Clinic of Ophthalmology, Ankara, Turkey,* Address for Correspondence: Bayındır Kavaklıdere Hospital, Clinic of Ophthalmology, Ankara, Turkey E-mail:
| | - Oya Dönmez
- İzmir Tınaztepe University Faculty of Medicine, Department of Ophthalmology, İzmir, Turkey
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15
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Recent advances in novel formulation approaches for tacrolimus delivery in treatment of various ocular diseases. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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16
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Liu SH, Saldanha IJ, Abraham AG, Rittiphairoj T, Hauswirth S, Gregory D, Ifantides C, Li T. Topical corticosteroids for dry eye. Cochrane Database Syst Rev 2022; 10:CD015070. [PMID: 36269562 PMCID: PMC9586197 DOI: 10.1002/14651858.cd015070.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Dry eye disease (DED), arising from various etiologic factors, leads to tear film instability, ocular surface damage, and neurosensory changes. DED causes symptoms such as ocular dryness, burning, itching, pain, and visual impairment. Given their well-established anti-inflammatory effects, topical steroid preparations have been widely used as a short-term treatment option for DED. Because of potential risks of ocular hypertension, cataracts, and infections associated with the long-term use of topical steroids, published trials comparing the efficacy and safety of topical steroids (versus placebo) have mostly been of short duration (three to eight weeks). OBJECTIVES To evaluate the effectiveness and safety of topical corticosteroids compared with no treatment, placebo, other steroidal or non-steroidal therapies, or a combination of therapies for DED. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 8); Ovid MEDLINE; Ovid Embase; Latin American and Caribbean Health Sciences database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), without restriction on language or year of publication. The date of the last search was 20 August 2021. SELECTION CRITERIA We included randomized controlled trials (RCTs) in which topical corticosteroids, alone or in combination with tobramycin, were compared with no treatment, artificial tears (AT), vehicles, AT plus tobramycin, or cyclosporine A (CsA). DATA COLLECTION AND ANALYSIS We applied standard Cochrane methodology. MAIN RESULTS We identified 22 RCTs conducted in the USA, Italy, Spain, China, South Korea, and India. These RCTs reported outcome data from a total of 4169 participants with DED. Study characteristics and risk of bias All trials recruited adults aged 18 years or older, except one trial that enrolled children and adolescents aged between 3 and 14 years. Half of these trials involved predominantly female participants (median 79%, interquartile range [IQR] 76% to 80%). On average, each trial enrolled 86 participants (IQR 40 to 158). The treatment duration of topical steroids ranged between one week and three months; trial duration lasted between one week and six months. Eight trials were sponsored exclusively by industry, and four trials were co-sponsored by industry and institutional or governmental funds. We assessed the risk of bias of both subjective and objective outcomes using RoB 2, finding nearly half of the trials to be at high risk of bias associated with selective outcome reporting. Findings Of the 22 trials, 16 evaluated effects of topical steroids, alone or in combination with tobramycin, as compared with lubricants (AT, vehicle), AT plus tobramycin, or no treatment. Corticosteroids probably have a small to moderate effect on improving patient-reported symptoms by 0.29 standardized mean difference (SMD) (95% confidence interval [CI] 0.16 to 0.42) as compared with lubricants (moderate certainty evidence). Topical steroids also likely have a small to moderate effect on lowering corneal staining scores by 0.4 SMDs (95% CI 0.18 to 0.62) (moderate certainty evidence). However, steroids may increase tear film break-up time (TBUT) slightly (mean difference [MD] 0.70 s, 95% CI 0.06 to 1.34; low certainty evidence) but not tear osmolarity (MD 1.60 mOsm/kg, 95% CI -10.47 to 13.67; very low certainty evidence). Six trials examined topical steroids, either alone or in combination with CsA, against CsA alone. Low certainty evidence indicates that steroid-based interventions may have a small to moderate effect on improving participants' symptoms (SMD -0.33, 95% CI -0.51 to -0.15), but little to no effect on corneal staining scores (SMD 0.05, 95% CI -0.25 to 0.35) as compared with CsA. The effect of topical steroids compared to CsA alone on TBUT (MD 0.37 s, 95% CI -0.13 to 0.87) or tear osmolarity (MD 5.80 mOsm/kg, 95% CI -0.94 to 12.54; loteprednol etabonate alone) is uncertain because the certainty of the evidence is low or very low. None of the included trials reported on quality of life scores. Adverse effects The evidence for adverse ocular effects of topical corticosteroids is very uncertain. Topical corticosteroids may increase participants' risk of intraocular pressure (IOP) elevation (risk ratio [RR] 5.96, 95% CI 1.30 to 27.38) as compared with lubricants. However, when compared with CsA, steroids alone or combined with CsA may decrease or increase IOP elevation (RR 1.45, 95% CI 0.25 to 8.33). It is also uncertain whether topical steroids may increase risk of cataract formation when compared with lubricants (RR 0.34, 95% CI 0.01 to 8.22), given the short-term use and study duration (four weeks or less) to observe longer-term adverse effects. AUTHORS' CONCLUSIONS: Overall, the evidence for the specified review outcomes was of moderate to very low certainty, mostly due to high risk of bias associated with selective results reporting. For dry eye patients whose symptoms require anti-inflammatory control, topical corticosteroids probably provide small to moderate degrees of symptom relief beyond lubricants, and may provide small to moderate degrees of symptom relief beyond CsA. However, the current evidence is less certain about the effects of steroids on improved tear film quality or quantity. The available evidence is also very uncertain regarding the adverse effects of topical corticosteroids on IOP elevation or cataract formation or progression. Future trials should generate high certainty evidence to inform physicians and patients of the optimal treatment strategies with topical corticosteroids in terms of regimen (types, formulations, dosages), duration, and its time-dependent adverse profile.
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Affiliation(s)
- Su-Hsun Liu
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Ian J Saldanha
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Alison G Abraham
- Department of Epidemiology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Thanitsara Rittiphairoj
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Scott Hauswirth
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Darren Gregory
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Cristos Ifantides
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Tianjing Li
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
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17
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[Treatment of chronic ocular graft versus host disease]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:877-880. [PMID: 36709206 PMCID: PMC9669625 DOI: 10.3760/cma.j.issn.0253-2727.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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18
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Aldebasi T, Bashir R, Gangadharan S, Shaheen NA, Alhussain B, Almudhaiyan T, Alahmari B. Incidence of ocular manifestations in patients with graft versus host disease after allogeneic stem cell transplant in Riyadh, Saudi Arabia. Int J Ophthalmol 2022; 15:1149-1156. [PMID: 35919329 DOI: 10.18240/ijo.2022.07.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 04/28/2022] [Indexed: 11/23/2022] Open
Abstract
AIM To evaluate the incidence and severity of ocular graft versus host disease (oGVHD) in patients who underwent allogeneic stem cell transplant (SCT) in King Abdul-Aziz Medical City, Saudi Arabia. METHODS This is a retrospective cohort study conducted in King Abdul Aziz Medical City on patients who underwent allogeneic hematopoietic cell transplant (allo-HCT) from 2010 to 2017. The ocular examination findings including visual acuity, meibomian gland dysfunction, corneal and conjunctival staining with severity, corneal scarring, tear film meniscus and breakup time, anterior and posterior segment examination findings, intraocular pressure, treatment given, punctual plugs used or not, and follow up response were collected. RESULTS The five years cumulative incidence of oGVHD among post-transplant patients was 56.98% (95%CI 38.6%-71.7%). The potential risk factors assessed for developing ocular manifestation were age, gender, donor's age, donor gender mismatch CD3 and CD34 infusion, while none of the correlates were identified as statistically significant risk factors of developing ocular manifestation. However, the incidence was statistically significantly different between patients diagnosed with acute myelocytic leukemia and acute lymphocytic leukemia (P=0.038). The mean latent period to develop ocular symptoms was 20.5mo. All patients had variable degree of dry eyes. None of the patients developed any posterior segment complication. CONCLUSION The incidence of oGVHD is low in King Abdul-Aziz Medical City. This can be attributed to the preconditioning and immunosuppressive regime.
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Affiliation(s)
- Tariq Aldebasi
- Department of Ophthalmology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh 11426, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), Riyadh 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | - Rabia Bashir
- Department of Ophthalmology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh 11426, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), Riyadh 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | - Shiji Gangadharan
- Department of Ophthalmology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh 11426, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), Riyadh 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | - Naila A Shaheen
- King Abdullah International Medical Research Center (KAIMRC), Riyadh 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | - Basil Alhussain
- Department of Ophthalmology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh 11426, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), Riyadh 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | - Tariq Almudhaiyan
- Department of Ophthalmology, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh 11426, Saudi Arabia.,King Abdullah International Medical Research Center (KAIMRC), Riyadh 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | - Bader Alahmari
- King Abdullah International Medical Research Center (KAIMRC), Riyadh 11426, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia.,Divisions of Adult Hematology and SCT, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh 11426, Saudi Arabia
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19
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Albarry MA, Parekh M, Ferrari S, Eltahir HM, Shehata AM, Shaker MA, Elbadawy HM. Incremental Concentrations of Tacrolimus Eye Drops as a Strategy for the Management of Severe Vernal Keratoconjunctivitis. Front Pharmacol 2022; 13:798998. [PMID: 35401178 PMCID: PMC8990096 DOI: 10.3389/fphar.2022.798998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose: To assess the effect of different concentrations of tacrolimus eye suspension on the epithelium and stromal keratocytes of human corneas and investigate whether it can be safely used for severe cases of vernal keratoconjunctivitis (VKC). Methods: Tacrolimus eye suspension was prepared in a range of concentrations of 0.005%, 0.01%, 0.05%, 0.1%, and 0.2%. Molecular analysis was performed ex vivo on human corneas (n = 18), obtained from the eye bank. Transparency and thickness of each cornea were measured while live/dead staining was performed using a triple labeling assay. An incremental concentration approach was then tested on three severe cases of VKC. Results: All tested tacrolimus concentrations showed no significant changes in corneal thickness or transparency. In corneas treated with 0.1%, rare scattered dead cells were observed, while the folds of corneal surfaces were mostly viable, unlike concentrations higher than 0.1% and lower than 0.05%. Stromal cell densities were highest in the 0.1% tacrolimus treatment condition. Incremental concentrations of tacrolimus suspension were shown to significantly improve VKC cases, where the concentration used for each case depended on the severity of the case. Conclusions: Topical administration of tacrolimus was not toxic to human corneal cells at all tested concentrations, and the 0.1% concentration has shown the best viability of the corneal tissue. Tacrolimus eye suspension was shown to be safe and effective for use in severe VKC and is proposed as a topical ocular immunosuppressant drug enabling clinicians to incrementally increase the drug concentration according to the clinical severity of the disease to achieve the optimal therapeutic response.
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Affiliation(s)
- Maan Abdullah Albarry
- Department of Ophthalmology, College of Medicine, Taibah University, Madinah, Saudi Arabia
| | - Mohit Parekh
- Institute of Ophthalmology, University College London, London, United Kingdom
- International Center for Ocular Physiopathology, Veneto Eye Bank Foundation, Venice, Italy
| | - Stefano Ferrari
- International Center for Ocular Physiopathology, Veneto Eye Bank Foundation, Venice, Italy
| | - Heba Mahmoud Eltahir
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Madinah, Saudi Arabia
| | - Ahmed M Shehata
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Madinah, Saudi Arabia
- Department of Pharmacology, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed A Shaker
- Pharmaceutics and Pharmaceutical Technology Department, College of Pharmacy, Taibah University, Madinah, Saudi Arabia
- Pharmaceutics Department, Faculty of Pharmacy, Helwan University, Cairo, Egypt
| | - Hossein Mostafa Elbadawy
- Department of Pharmacology and Toxicology, College of Pharmacy, Taibah University, Madinah, Saudi Arabia
- *Correspondence: Hossein Mostafa Elbadawy,
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20
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Therapeutic Applications of Adeno-Associated Virus (AAV) Gene Transfer of HLA-G in the Eye. Int J Mol Sci 2022; 23:ijms23073465. [PMID: 35408825 PMCID: PMC8998501 DOI: 10.3390/ijms23073465] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 01/09/2023] Open
Abstract
The purpose of this paper is to review human leukocyte antigen G (HLA-G) in the eye, its role in immune tolerance, and the potential therapeutic use of AAV gene transfer and expression of HLA-G in various ocular tissues. Several studies are reviewed that demonstrate efficacy in animal models of disease, including intracorneal delivery of AAV-HLA-G to treat corneal inflammation and prevent corneal graft rejection, subconjunctival injection of AAV-HLA-G for ocular graft vs. host disease and potentially dry eye disease, and intravitreal injection of AAV-HLA-G to inhibit uveitis. Furthermore, due to the anti-vascular function of HLA-G, AAV-HLA-G may be an effective therapy for posterior ocular diseases, such as neovascular age-related macular degeneration, diabetic retinopathy, and choroidal neovascularization. Therefore, AAV-mediated gene transfer of HLA-G may be an effective treatment for common immune-mediated, inflammatory, and neovascular diseases of the eye.
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21
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Bernales A, Berger O, Hamada S. Topical tacrolimus for the treatment of external eye inflammation in children. EXPERT REVIEW OF OPHTHALMOLOGY 2022. [DOI: 10.1080/17469899.2022.2039628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Osvaldo Berger
- Corneoplastic department. Queen Victoria Hospital. East Grinstead. United Kingdom
| | - Samer Hamada
- Corneoplastic department. Queen Victoria Hospital. East Grinstead. United Kingdom
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22
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Zhou T, He C, Lai P, Yang Z, Liu Y, Xu H, Lin X, Ni B, Ju R, Yi W, Liang L, Pei D, Egwuagu CE, Liu X. miR-204-containing exosomes ameliorate GVHD-associated dry eye disease. SCIENCE ADVANCES 2022; 8:eabj9617. [PMID: 35020440 PMCID: PMC8754411 DOI: 10.1126/sciadv.abj9617] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Graft-versus-host disease (GVHD)–associated dry eye disease is characterized by extensive inflammatory destruction in the ocular surface and causes unbearable pain and visual impairment. Current treatments provide limited benefits. Here, we report that exosomes from mesenchymal stromal cells (MSC-exo) administered as eye drops notably alleviate GVHD-associated dry eye disease by suppressing inflammation and improving epithelial recovery in mice and humans. In a prospective clinical trial, 28 eyes with refractory GVHD–dry eye disease exhibited substantial relief after MSC-exo treatment, showing reduced fluorescein scores, longer tear-film breakup time, increased tear secretion, and lower OSDI scores. Mechanistically, MSC-exo reprogramed proinflammatory M1 macrophages toward the immunosuppressive M2 via miR-204–mediated targeting of the IL-6/IL-6R/Stat3 pathway. Blockade of miR-204 abolished the effects of MSC-exo, while overloading L929-exo with miR-204 markedly attenuated dry eye. Thus, this study suggests that MSC-exo are efficacious in treating GVHD-associated dry eye disease and highlights miR-204 as a potential therapeutic agent.
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Affiliation(s)
- Tian Zhou
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Chang He
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
- Corresponding author. (X.L.); (C.H.)
| | - Peilong Lai
- Guangzhou Institutes of Biomedicine and Health, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Guangzhou 510530, P. R. China
- Department of Hematology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, P. R. China
| | - Ziqi Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Yan Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Huiyi Xu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Xiaojing Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Biyan Ni
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Rong Ju
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Wei Yi
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Lingyi Liang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
| | - Duanqing Pei
- Guangzhou Institutes of Biomedicine and Health, University of Chinese Academy of Sciences, Chinese Academy of Sciences, Guangzhou 510530, P. R. China
| | - Charles E. Egwuagu
- Molecular Immunology Section, Laboratory of Immunology, National Eye Institute (NEI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Xialin Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou 510060, P. R. China
- Corresponding author. (X.L.); (C.H.)
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23
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Holtzman NG, Pavletic SZ. The clinical landscape of chronic graft-versus-host disease management in 2021. Br J Haematol 2021; 196:830-848. [PMID: 34599519 DOI: 10.1111/bjh.17835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/27/2021] [Accepted: 09/02/2021] [Indexed: 12/16/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) is an important systemic complication of allogeneic haematopoietic stem cell transplantation with heterogeneous, multi-organ involvement that can lead to increased morbidity and mortality. Despite significant advances in understanding the complex pathophysiology driving the disease, curative treatment options remain suboptimal. The past decade, however, has seen much growth in collaborative research efforts and standardization of criteria for clinical trials that have led to discovery of several new second-line therapies in cGVHD. The key to successful cGVHD control and management includes a comprehensive and sustained multidisciplinary effort with emphasis on ancillary and supportive care for these patients. The focus of this review is to summarize the new developments in systemic, organ-specific, and topical treatments in the management of cGVHD that emerged since the 2014 NIH consensus conference.
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Affiliation(s)
- Noa G Holtzman
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven Z Pavletic
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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24
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Carreno-Galeano JT, Dohlman TH, Kim S, Yin J, Dana R. A Review of Ocular Graft-versus-Host Disease: Pathophysiology, Clinical Presentation and Management. Ocul Immunol Inflamm 2021; 29:1190-1199. [PMID: 34228599 DOI: 10.1080/09273948.2021.1939390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Graft-versus-host disease is a common complication following allogeneic hematopoetic stem cell transplantation that can affect multiple organ systems, including the eyes. Ocular GVHD (oGVHD) is characterized by a T cell-mediated immune response that leads to immune cell infiltration and inflammation of ocular structures, including the lacrimal glands, eyelids, cornea and conjunctiva. oGVHD has a significant negative impact on visual function and quality of life and successful management requires a multi-disciplinary approach with frequent monitoring. Here, we review the pathophysiology and clinical presentation of oGVHD, along with current therapeutic strategies based on our clinical experience and the reported literature.
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Affiliation(s)
| | - Thomas H Dohlman
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Stella Kim
- Department of Ophthalmology, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Jia Yin
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Reza Dana
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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25
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Ogawa Y, Kawakami Y, Tsubota K. Cascade of Inflammatory, Fibrotic Processes, and Stress-Induced Senescence in Chronic GVHD-Related Dry Eye Disease. Int J Mol Sci 2021; 22:ijms22116114. [PMID: 34204098 PMCID: PMC8201206 DOI: 10.3390/ijms22116114] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/30/2021] [Accepted: 05/31/2021] [Indexed: 01/12/2023] Open
Abstract
Ocular graft-versus-host disease (GVHD) is a major complication after allogeneic hematopoietic stem cell transplantation. Ocular GVHD affects recipients' visual function and quality of life. Recent advanced research in this area has gradually attracted attention from a wide range of physicians and ophthalmologists. This review highlights the mechanism of immune processes and the molecular mechanism, including several inflammation cascades, pathogenic fibrosis, and stress-induced senescence related to ocular GVHD, in basic spectrum topics in this area. How the disease develops and what kinds of cells participate in ocular GVHD are discussed. Although the classical immune process is a main pathological pathway in this disease, senescence-associated changes in immune cells and stem cells may also drive this disease. The DNA damage response, p16/p21, and the expression of markers associated with the senescence-associated secretory phenotype (SASP) are seen in ocular tissue in GVHD. Macrophages, T cells, and mesenchymal cells from donors or recipients that increasingly infiltrate the ocular surface serve as the source of increased secretion of IL-6, which is a major SASP driver. Agents capable of reversing the changes, including senolytic reagents or those that can suppress the SASP seen in GVHD, provide new potential targets for the treatment of GVHD. Creating innovative therapies for ocular GVHD is necessary to treat this intractable ocular disease.
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Affiliation(s)
- Yoko Ogawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo 160-8582, Japan;
- Correspondence: ; Tel.: +81-3-3353-1211
| | - Yutaka Kawakami
- Division of Cellular Signaling, Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo 160-8582, Japan;
- Department of Immunology, School of Medicine, International University of Health and Welfare, Chiba 286-8686, Japan
| | - Kazuo Tsubota
- Department of Ophthalmology, Keio University School of Medicine, Tokyo 160-8582, Japan;
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Abstract
ABSTRACT Sjögren syndrome (SS) is a chronic inflammatory autoimmune disease of the lacrimal and salivary glands. Salivary gland biopsy is still one of the most valuable and acceptable diagnostic tests for SS, which however, is an invasive test. Therefore, noninvasive diagnostic biomarkers with high specificity and sensitivity are required for the diagnosis and assessment of SS. Because ophthalmological testing constitutes to an important part for the diagnosis of SS. Tears harbor biomarkers with a high potential to be used for differential diagnosis and assessment of treatment in many systemic disorders, including SS. This review aims to summarize recent advances in the identification of tear biomarkers of SS, trying to identify reliable, sensitive, and specific biomarkers that can be used to guide treatment decisions.
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Affiliation(s)
- Cem Simsek
- Department of Ophthalmology (C.S.), Mugla Sitki Kocman University School of Medicine, Mugla, Turkey ; and Department of Ophthalmology (M.D.), Keio University School of Medicine, Tokyo, Japan
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Bruscolini A, Gharbiya M, Sacchetti M, Plateroti R, Ralli M, Moramarco A, Greco A, Lambiase A. Involvement of ocular surface in graft-versus-host disease: An update from immunopathogenesis to treatment. J Cell Physiol 2021; 236:6190-6199. [PMID: 33507561 DOI: 10.1002/jcp.30304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/13/2021] [Accepted: 01/19/2021] [Indexed: 01/14/2023]
Abstract
Graft-versus-host disease is a common complication of hematopoietic stem cell transplantation and the ocular surface is a main target of inflammatory reaction.
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Affiliation(s)
- Alice Bruscolini
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Magda Gharbiya
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Marta Sacchetti
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Rocco Plateroti
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Massimo Ralli
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | | | - Antonio Greco
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
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Tahmaz V, Wiesen MHJ, Gehlsen U, Sauerbier L, Stern ME, Holtick U, Gathof B, Scheid C, Müller C, Steven P. Detection of systemic immunosuppressants in autologous serum eye drops (ASED) in patients with severe chronic ocular graft versus host disease. Graefes Arch Clin Exp Ophthalmol 2021; 259:121-128. [PMID: 32812133 PMCID: PMC7790777 DOI: 10.1007/s00417-020-04865-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Chronic graft versus host disease is a major consequence after allogeneic stem cell transplantation (allo-SCT) and has great impact on patients' morbidity and mortality. Besides the skin, liver, and intestines, the eyes are most commonly affected, manifesting as severe ocular surface disease. Treatment protocols include topical steroids, cyclosporine, tacrolimus, and ASED. Since these patients often receive systemic immunosuppressant therapy from their oncologists, a topical re-administration of these drugs via ASED with potentially beneficial or harmful effects is possible. The purpose of the study was to determine whether and to which extent systemic immunosuppressants are detectable in ASED. METHODS A total of 34 samples of ASED from 16 patients with hemato-oncological malignancies after allo-SCT were collected during the manufacturing process and screened for levels of cyclosporine, mycophenolic acid, everolimus, and tacrolimus via liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). The study followed the tenets of the Declaration of Helsinki and informed consent was obtained from the subjects after explanation of the nature and possible consequences of the study. RESULTS Cyclosporine was found in 18 ASED samples in concentrations ranging from 6.5-105.0 ng/ml (32.0 ± 22.8 ng/ml, mean ± SD). The concentration range of mycophenolic acid in 19 samples was 0.04-25.0 mg/l (4.0 ± 5.4 mg/l, mean ± SD). Everolimus and tacrolimus concentrations were well below the respective limits of quantification (< 0.6 and < 0.5 ng/ml) of the established LC-MS/MS method in all samples. CONCLUSIONS Our study suggests that orally administered cyclosporine and mycophenolic acid for the treatment of systemic GvHD, but not everolimus and tacrolimus, are distinctly detectable in ASED in relevant concentrations. It is highly likely that these agents affect topical therapy of ocular GvHD. However, the extent of this effect needs to be evaluated in further studies.
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Affiliation(s)
- Volkan Tahmaz
- Division for Dry-eye disease and ocular GvHD, Department of Ophthalmology, University of Cologne Medical Faculty and University Hospital of Cologne, Cologne, Germany
- Cluster of Excellence: Cellular Stress Responses in Aging-associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Martin H J Wiesen
- Center of Pharmacology, Department of Therapeutic Drug Monitoring, University Hospital of Cologne, Cologne, Germany
| | - Uta Gehlsen
- Division for Dry-eye disease and ocular GvHD, Department of Ophthalmology, University of Cologne Medical Faculty and University Hospital of Cologne, Cologne, Germany
- Cluster of Excellence: Cellular Stress Responses in Aging-associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - Laura Sauerbier
- Division for Dry-eye disease and ocular GvHD, Department of Ophthalmology, University of Cologne Medical Faculty and University Hospital of Cologne, Cologne, Germany
| | - Michael E Stern
- Division for Dry-eye disease and ocular GvHD, Department of Ophthalmology, University of Cologne Medical Faculty and University Hospital of Cologne, Cologne, Germany
- ImmunEyez LLC., Irvine, CA, USA
| | - Udo Holtick
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Birgit Gathof
- Institute of Transfusion Medicine, University of Cologne, Cologne, Germany
| | - Christof Scheid
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Carsten Müller
- Center of Pharmacology, Department of Therapeutic Drug Monitoring, University Hospital of Cologne, Cologne, Germany
| | - Philipp Steven
- Division for Dry-eye disease and ocular GvHD, Department of Ophthalmology, University of Cologne Medical Faculty and University Hospital of Cologne, Cologne, Germany.
- Cluster of Excellence: Cellular Stress Responses in Aging-associated Diseases (CECAD), University of Cologne, Cologne, Germany.
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Prevalence and Risk Factors Associated With Corneal Perforation in Chronic Ocular Graft-Versus-Host-Disease. Cornea 2020; 40:877-882. [PMID: 32947414 DOI: 10.1097/ico.0000000000002526] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the prevalence and risk factors associated with corneal perforation in patients with chronic ocular graft-versus-host disease (oGVHD). METHODS We reviewed the case records of 405 patients diagnosed with chronic oGVHD over 8 years at a single academic center and assessed the prevalence of corneal perforation in the cohort. We reviewed patient demographics, indication for and type of hematopoietic stem cell transplantation (HSCT), time elapsed between HSCT and perforation, and clinical characteristics including oGVHD severity scores, ocular comorbidities, and topical medications at the time of perforation. Data were analyzed to determine the characteristics of patients with corneal perforation and establish the risk factors. RESULTS Of the 405 patients with chronic oGVHD, 15 (3.7%) developed a corneal perforation. The mean age of patients at the time of perforation was 64 ± 11 years and 10 (67%) were men. The median time to corneal perforation was 3.3 years post-HSCT. Although perforation occurred unilaterally in all cases, 44% had epithelial defects and 38% had stromal abnormalities in the contralateral eye. Of the patients with corneal perforation, 9 (60%) had a National Institute of Health oGVHD severity score of 2 and 6 (40%) had a score of 3. Patients with chronic oGVHD on antiglaucoma drops had a significantly higher risk of corneal perforation (P < 0.001). CONCLUSIONS Corneal perforation is a rare but vision-threatening complication of chronic oGVHD. Our study emphasizes the need for frequent and long-term follow-up of patients with oGVHD regardless of the severity of disease. In particular, patients with chronic oGVHD on topical antiglaucoma medications should be monitored closely due to a higher risk for corneal perforation.
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Hu B, Qiu Y, Hong J. Tear cytokine levels in the diagnosis and severity assessment of ocular chronic graft-versus-host disease(GVHD). Ocul Surf 2020; 18:298-304. [DOI: 10.1016/j.jtos.2019.12.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/26/2019] [Accepted: 12/12/2019] [Indexed: 12/20/2022]
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Greenan E, Vandenberghe E, Murphy CC. Refractory recurrent ocular graft versus host disease. BMJ Case Rep 2019; 12:12/12/e232579. [PMID: 31843781 DOI: 10.1136/bcr-2019-232579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Ocular graft-versus-host disease (GVHD) is one of the most frequent and long-term complications affecting patients after haematopoietic stem cell transplantation. It is associated with significant morbidity and a marked reduction in quality of life. Although common, currently there are no widely accepted guidelines available for its management, and no suggested regime of treatment that is completely satisfactory. So far, prophylactic treatment strategies for ocular GVHD have yet to be developed and treatment is normally initiated based on symptoms often after permanent ocular tissue changes and surface damage has occurred. Here we describe a case of recurrent ocular GVHD and its associated complications that was highly refractory to treatment.
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Affiliation(s)
- Emily Greenan
- Ophthalmology, Royal College of Surgeons in Ireland, Dublin, Ireland.,Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin, Ireland
| | | | - Conor C Murphy
- Ophthalmology, Royal College of Surgeons in Ireland, Dublin, Ireland .,Ophthalmology, Royal Victoria Eye and Ear Hospital, Dublin, Ireland
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Roy NS, Wei Y, Yu Y, Ying GS, Kuklinski E, Barry B, Maguire MG, Dana R, Brightwell-Arnold M, Asbell PA. Conjunctival HLA-DR Expression and Its Association With Symptoms and Signs in the DREAM Study. Transl Vis Sci Technol 2019; 8:31. [PMID: 31489258 PMCID: PMC6707226 DOI: 10.1167/tvst.8.4.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/20/2019] [Indexed: 12/29/2022] Open
Abstract
Purpose Evaluation of dry eye disease (DED) relies on subjective symptoms and signs. We examined HLA-DR expression (HLA-DR%) in conjunctival cells, a minimally invasive biomarker with objective metrics, as an alternative method. Methods Dry Eye Assessment and Management (DREAM) study participants completed the Ocular Surface Disease Index questionnaire. Clinicians evaluated tear volume, tear breakup time, and corneal and conjunctival staining. Conjunctival impression cytology samples (n = 1049) were assessed for HLA-DR% in total cells (TCs), epithelial cells (ECs), and white blood cells (WBCs). Associations (categorized into <5%, 5%–15%, >15%–25%, and >25%) with symptoms and signs were evaluated. Results The HLA-DR% varied markedly across samples. Over 40% had <5 HLA-DR% positive cells in TCs and ECs and under 23% in WBCs. Higher HLA-DR% was associated with higher conjunctival staining for ECs (mean score 2.77 for <5% and 3.28 for >25%, linear trend P = 0.009) and TCs (mean score 2.82 for <5% and 3.29 for >25%, linear trend P = 0.04) and in TCs was associated with higher corneal staining (mean score 3.59 for <5% and 4.46 for >25%, linear trend P = 0.03). HLA-DR% in WBCs did not correlated with signs (all P ≥ 0.58), and in TCs, ECs or WBCs were not associated with symptoms (P> 0.06). Conclusions The distribution of HLA-DR% in conjunctival cells reflects the heterogeneity of disease in DREAM participants. High percentages of samples with <5% positive cells indicate that HLA-DR% may not be a sensitive marker for DED in all patients. Translational Relevance High HLA-DR% in ECs in association with high conjunctival staining may identify a subgroup of DED patients prone to epithelial disease and possibly need a different approach from current standards of treatment.
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Affiliation(s)
- Neeta S Roy
- Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center, 930 Madison Avenue, Memphis, TN, USA
| | - Yi Wei
- Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center, 930 Madison Avenue, Memphis, TN, USA
| | - Yinxi Yu
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 700, Philadelphia, PA, USA
| | - Gui-Shuang Ying
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 700, Philadelphia, PA, USA
| | - Eric Kuklinski
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Brendan Barry
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Maureen G Maguire
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 700, Philadelphia, PA, USA
| | - Reza Dana
- Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Mary Brightwell-Arnold
- Department of Ophthalmology, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Suite 700, Philadelphia, PA, USA
| | - Penny A Asbell
- Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Science Center, 930 Madison Avenue, Memphis, TN, USA
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Eberwein P, Krösser S, Steven P. Semifluorinated Alkane Eye Drops in Chronic Ocular Graft-versus-Host Disease: A Prospective, Multicenter, Noninterventional Study. Ophthalmic Res 2019; 63:50-58. [DOI: 10.1159/000499158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 02/27/2019] [Indexed: 11/19/2022]
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Ogawa Y. Sjögren's Syndrome, Non-Sjögren's Syndrome, and Graft-Versus-Host Disease Related Dry Eye. Invest Ophthalmol Vis Sci 2019; 59:DES71-DES79. [PMID: 30481809 DOI: 10.1167/iovs.17-23750] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
I have reviewed available literature on dry eye related to Sjögren's syndrome (SS), non-Sjögren's syndrome (non-SS), and graft-versus-host disease (GVHD) to examine aqueous tear deficient dry eye as a subtype of dry eye. This section will focus on clinical studies regarding those subtypes of dry eye. I searched the PubMed database from 1990-2017 for discussion of clinical features, diagnostic criteria, and risk factors of SS, non-SS, and GVHD-related dry eye. In addition, therapeutic options for each subtype of dry eye are described. Although the clinical presentations of SS and chronic graft-versus-host disease (cGVHD) are similar, ocular surface fibrotic changes are characteristic of ocular GVHD but not SS- or non-SS-related dry eye. Recently, diagnostic criteria for each disease have been proposed and include the American College of Rheumatology/European League Against Rheumatism (ACR-EULAR) for SS and the International Chronic Ocular GVHD consensus criteria. Although there has been gradual progress, there are currently no specific therapies and few approved treatment options for these intractable diseases, including SS and GVHD. As judged by the findings, these subtypes of dry eye are different clinical entities from simple dry eye. Therefore, novel therapies, specific to these subtypes of dry eye, may be required in the future.
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Affiliation(s)
- Yoko Ogawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
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Ocular surface system alterations in ocular graft-versus-host disease: all the pieces of the complex puzzle. Graefes Arch Clin Exp Ophthalmol 2019; 257:1341-1351. [PMID: 30944986 DOI: 10.1007/s00417-019-04301-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/11/2019] [Accepted: 03/20/2019] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cells transplantation, occurring in about half of transplanted patients. This condition seems to be the result of a progressive immune-mediated damage that can involve various tissues, including the eyes. The ocular surface system is the ocular structure most frequently impaired, and dry eye disease is considered the hallmark of ocular GVHD. Given the increasing prevalence and the frequent severe involvement of the ocular surface with vision-threatening complications, ocular GVHD represents a current diagnostic and therapeutic challenge. The purpose of this literature review is to describe all the clinical manifestations occurring in the setting of ocular GVHD, and to further report the outcomes of conventional and novel therapies. METHODS A literature search about ocular GVHD was performed in PubMed, Scopus, Medline databases, and ClinicalTrials.gov as well as through the reference lists of identified publications until January 2019. We have included RCTs, prospective observational studies, prospective and retrospective cohort studies, pilot studies, and review articles. RESULTS Overall, 107 articles, 3 book chapters, and 6 ongoing registered clinical trials were collected and analyzed. Ocular GVHD can affect all the structures of the entire ocular surface system, including lacrimal and meibomian glands, cornea, conjunctiva, eyelids, nasolacrimal duct, and tears. Current medical treatment is mainly focused on lubrication and control of drainage, tear evaporation, and ocular surface inflammation. Surgical treatment may be necessary in severe, recalcitrant, or complicated cases. Amniotic membrane and tectonic keratoplasty can be valid options to restore the integrity of the cornea. Recently, conjunctival and limbal transplantation from the same living-related bone marrow donor has been proposed to manage both dry eye and limbal stem cell deficiency, without any risk of immunologic rejection. CONCLUSION This review provides an up-to-date analysis on clinical findings and current and future management of ocular GVHD. A correct and prompt diagnosis along with an appropriate and aggressive treatment are fundamental for avoiding the occurrence of vision-threatening complications.
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Non-GVHD ocular complications after hematopoietic cell transplantation: expert review from the Late Effects and Quality of Life Working Committee of the CIBMTR and Transplant Complications Working Party of the EBMT. Bone Marrow Transplant 2019; 54:648-661. [PMID: 30531955 PMCID: PMC6497536 DOI: 10.1038/s41409-018-0339-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 08/22/2018] [Indexed: 02/02/2023]
Abstract
Non-graft-versus-host disease (non-GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT), but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplant physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We have summarized incidence, risk factors, screening, prevention and treatment of individual complications and generated evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical symptoms, signs and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplant physicians and ophthalmologists should be knowledgeable of non-GVHD ocular complications and provide comprehensive collaborative team care.
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How I treat refractory chronic graft-versus-host disease. Blood 2019; 133:1191-1200. [PMID: 30674472 PMCID: PMC6418480 DOI: 10.1182/blood-2018-04-785899] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 01/20/2019] [Indexed: 02/07/2023] Open
Abstract
Approximately 35% to 50% of patients otherwise cured of hematologic malignancies after allogeneic hematopoietic stem cell transplantation will develop the pleomorphic autoimmune-like syndrome known as chronic graft-versus-host disease (cGVHD). Since in 2005, National Institutes of Health (NIH) consensus panels have proposed definitions and classifications of disease to standardize treatment trials. Recently, the first agent was approved by the US Food and Drug Administration for steroid-refractory cGVHD. Despite these advances, most individuals do not achieve durable resolution of disease activity with initial treatment. Moreover, standardized recommendations on how to best implement existing and novel immunomodulatory agents and taper salvage agents are often lacking. Given the potential life-threatening nature of cGVHD, we employ in our practice patient assessment templates at each clinic visit to elucidate known prognostic indicators and red flags. We find NIH scoring templates practical for ongoing assessments of these complex patient cases and determination of when changes in immunosuppressive therapy are warranted. Patients not eligible or suitable for clinical trials have systemic and organ-directed adjunctive treatments crafted in a multidisciplinary clinic. Herein, we review these treatment options and offer a management and monitoring scaffold for representative patients with cGVHD not responding to initial therapy.
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Review of Biomarkers in Ocular Matrices: Challenges and Opportunities. Pharm Res 2019; 36:40. [PMID: 30673862 PMCID: PMC6344398 DOI: 10.1007/s11095-019-2569-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/07/2019] [Indexed: 02/05/2023]
Abstract
Biomarkers provide a powerful and dynamic approach to improve our understanding of the mechanisms underlying ocular diseases with applications in diagnosis, disease modulation or for predicting and monitoring of clinical response to treatment. Defined as measurable indicator of normal or pathological processes, biomarker evaluation has been used extensively in drug development within clinical settings to better comprehend effectiveness of treatment in ocular diseases. Biomarkers in the eye have the advantage of access to multiple ocular matrices via minimally invasive methods. Repeat sampling for biomarker assessment has enabled reproducible objective measures of disease process or biological responses to a drug treatment. This review describes the usage of biomarkers with respect to four commonly sampled ocular matrices in clinic: tears, conjunctiva, aqueous humor and vitreous. Issues that affect the evaluation of biomarkers are discussed along with opportunities to leverage biomarkers such that ultimately, they can be used for customized targeted therapy.
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The Immunosuppressant Macrolide Tacrolimus Activates Cold-Sensing TRPM8 Channels. J Neurosci 2018; 39:949-969. [PMID: 30545944 DOI: 10.1523/jneurosci.1726-18.2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 11/02/2018] [Accepted: 11/18/2018] [Indexed: 12/30/2022] Open
Abstract
TRPM8 is a polymodal, nonselective cation channel activated by cold temperature and cooling agents that plays a critical role in the detection of environmental cold. We found that TRPM8 is a pharmacological target of tacrolimus (FK506), a macrolide immunosuppressant with several clinical uses, including the treatment of organ rejection following transplants, treatment of atopic dermatitis, and dry eye disease. Tacrolimus is an inhibitor of the phosphatase calcineurin, an action shared with cyclosporine. Tacrolimus activates TRPM8 channels in different species, including humans, and sensitizes their response to cold temperature by inducing a leftward shift in the voltage-dependent activation curve. The effects of tacrolimus on purified TRPM8 in lipid bilayers demonstrates conclusively that it has a direct gating effect. Moreover, the lack of effect of cyclosporine rules out the canonical signaling pathway involving the phosphatase calcineurin. Menthol (TRPM8-Y745H)- and icilin (TRPM8-N799A)-insensitive mutants were also activated by tacrolimus, suggesting a different binding site. In cultured mouse DRG neurons, tacrolimus evokes an increase in intracellular calcium almost exclusively in cold-sensitive neurons, and these responses were drastically blunted in Trpm8 KO mice or after the application of TRPM8 antagonists. Cutaneous and corneal cold thermoreceptor endings are also activated by tacrolimus, and tacrolimus solutions trigger blinking and cold-evoked behaviors. Together, our results identify TRPM8 channels in sensory neurons as molecular targets of the immunosuppressant tacrolimus. The actions of tacrolimus on TRPM8 resemble those of menthol but likely involve interactions with other channel residues.SIGNIFICANCE STATEMENT TRPM8 is a polymodal TRP channel involved in cold temperature sensing, thermoregulation, and cold pain. TRPM8 is also involved in the pathophysiology of dry eye disease, and TRPM8 activation has antiallodynic and antipruritic effects, making it a prime therapeutic target in several cutaneous and neural diseases. We report the direct agonist effect of tacrolimus, a potent natural immunosuppressant with multiple clinical applications, on TRPM8 activity. This interaction represents a novel neuroimmune interface. The identification of a clinically approved drug with agonist activity on TRPM8 channels could be used experimentally to probe the function of TRPM8 in humans. Our findings may explain some of the sensory and anti-inflammatory effects described for this drug in the skin and the eye surface.
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Inamoto Y, Petriček I, Burns L, Chhabra S, DeFilipp Z, Hematti P, Rovó A, Schears R, Shah A, Agrawal V, Ahmed A, Ahmed I, Ali A, Aljurf M, Alkhateeb H, Beitinjaneh A, Bhatt N, Buchbinder D, Byrne M, Callander N, Fahnehjelm K, Farhadfar N, Gale RP, Ganguly S, Hashmi S, Hildebrandt GC, Horn E, Jakubowski A, Kamble RT, Law J, Lee C, Nathan S, Penack O, Pingali R, Prasad P, Pulanic D, Rotz S, Shreenivas A, Steinberg A, Tabbara K, Tichelli A, Wirk B, Yared J, Basak GW, Battiwalla M, Duarte R, Savani BN, Flowers MED, Shaw BE, Valdés-Sanz N. Non-Graft-versus-Host Disease Ocular Complications after Hematopoietic Cell Transplantation: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2018; 25:e145-e154. [PMID: 30521975 DOI: 10.1016/j.bbmt.2018.11.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/28/2018] [Indexed: 01/18/2023]
Abstract
Non-graft-versus-host disease (GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT) but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplantation physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We summarize the incidence, risk factors, screening, prevention, and treatment of individual complications and generate evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical signs and symptoms and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplantation physicians and ophthalmologists should be knowledgeable about non-GVHD ocular complications and provide comprehensive collaborative team care.
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Affiliation(s)
- Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan.
| | - Igor Petriček
- Department of Ophthalmology, Zagreb University Clinical Hospital, Zagreb, Croatia
| | - Linda Burns
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be the Match, Minneapolis, Minnesota
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Alicia Rovó
- Inselspital, Bern University Hospital, Bern, Switzerland
| | - Raquel Schears
- Division of Hematology, Mayo Clinic Rochester, Rochester, Minnesota
| | - Ami Shah
- Division of Stem Cell Transplantation and Regenerative Medicine, Lucille Packard Children's Hospital, Stanford School of Medicine, Palo Alto, California
| | - Vaibhav Agrawal
- Indiana University Simon Cancer Center, Indianapolis, Indiana
| | - Aisha Ahmed
- University of California, San Francisco, California
| | - Ibrahim Ahmed
- Department of Hematology Oncology and Bone Marrow Transplantation, The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Asim Ali
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hassan Alkhateeb
- Division of Hematology, Mayo Clinic Rochester, Rochester, Minnesota
| | | | - Neel Bhatt
- Center for International Blood and Marrow Transplant Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Dave Buchbinder
- Division of Pediatrics Hematology, Children's Hospital of Orange County, Orange, California
| | - Michael Byrne
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Kristina Fahnehjelm
- Department of Clinical Neuroscience, Karolinska Institute, St Erik Eye Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nosha Farhadfar
- University of Florida Health Shands Hospital, Gainesville, Florida
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, Kansas
| | - Shahrukh Hashmi
- Department of Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | | | - Erich Horn
- University of Florida Health Shands Hospital, Gainesville, Florida
| | - Ann Jakubowski
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Jason Law
- Tufts Medical Center, Boston, Massachusetts
| | - Catherine Lee
- Utah Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Olaf Penack
- Divison of Hematology and Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | | | - Pinki Prasad
- Lousiana State University Children's Hospital, New Orleans, Louisiana
| | - Drazen Pulanic
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia; Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Seth Rotz
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Aditya Shreenivas
- Division of Hematology and Oncology, Mount Sinai Hospital, New York, New York
| | - Amir Steinberg
- Division of Hematology and Oncology, Mount Sinai Hospital, New York, New York
| | - Khalid Tabbara
- Wilmer Eye Institute, Johns Hopkins Medicine, Baltimore, Maryland
| | - André Tichelli
- Hematology, University Hospital Basel, Basel, Switzerland
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, Washington
| | - Jean Yared
- Blood and Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, Maryland
| | - Grzegorz W Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Minoo Battiwalla
- Hematology Branch, Sarah Cannon Center for Blood Cancer, Nashville, Tennessee
| | - Rafael Duarte
- Hematopoietic Transplantation and Hemato-oncology Section, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bronwen E Shaw
- Center for International Blood and Marrow Transplant Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nuria Valdés-Sanz
- Department of Ophthalmology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
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Ocular graft-versus-host disease after hematopoietic cell transplantation: Expert review from the Late Effects and Quality of Life Working Committee of the CIBMTR and Transplant Complications Working Party of the EBMT. Bone Marrow Transplant 2018; 54:662-673. [PMID: 30531954 DOI: 10.1038/s41409-018-0340-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 01/29/2023]
Abstract
Ocular graft-versus-host disease (GVHD) occurs in more than half of patients who develop chronic GVHD after allogeneic hematopoietic cell transplantation (HCT), causing prolonged morbidity, which affects activities of daily living and quality of life. Here we provide an expert review of ocular GVHD in a collaboration between transplant physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Recent updates in ocular GVHD, regarding pathophysiology, preclinical models, risk factors, prevention, screening, diagnosis, response criteria, evaluation measures, and treatment are discussed in this review. Ocular GVHD has at least three biological processes: lacrimal gland dysfunction, meibomian gland dysfunction, and corneoconjunctival inflammation. Preclinical models have found several novel pathogenic mechanisms, including renin angiotensin system and endoplasmic reticulum stress signaling that can be targeted by therapeutic agents. Many studies have identified reliable tests for establishing diagnosis and response assessment of ocular GVHD. Efficacy of systemic and topical treatment for ocular GVHD is summarized. It is important for all health professionals taking care of HCT recipients to have adequate knowledge of ocular GVHD for optimal care.
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Inamoto Y, Valdés-Sanz N, Ogawa Y, Alves M, Berchicci L, Galvin J, Greinix H, Hale GA, Horn B, Kelly D, Liu H, Rowley S, Schoemans H, Shah A, Lupo Stanghellini MT, Agrawal V, Ahmed I, Ali A, Bhatt N, Byrne M, Chhabra S, DeFilipp Z, Fahnehjelm K, Farhadfar N, Horn E, Lee C, Nathan S, Penack O, Prasad P, Rotz S, Rovó A, Yared J, Pavletic S, Basak GW, Battiwalla M, Duarte R, Savani BN, Flowers MED, Shaw BE, Petriček I. Ocular Graft-versus-Host Disease after Hematopoietic Cell Transplantation: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2018; 25:e46-e54. [PMID: 30481594 DOI: 10.1016/j.bbmt.2018.11.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/15/2018] [Indexed: 01/16/2023]
Abstract
Ocular graft-versus-host disease (GVHD) occurs in more than one-half of patients who develop chronic GVHD after allogeneic hematopoietic cell transplantation (HCT), causing prolonged morbidity that affects activities of daily living and quality of life. Here we provide an expert review of ocular GVHD in a collaboration between transplantation physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Recent updates in ocular GVHD regarding pathophysiology, preclinical models, risk factors, prevention, screening, diagnosis, response criteria, evaluation measures, and treatment are discussed. Ocular GVHD involves at least 3 biological processes: lacrimal gland dysfunction, meibomian gland dysfunction, and corneoconjunctival inflammation. Preclinical models have identified several novel pathogenic mechanisms, including the renin angiotensin system and endoplasmic reticulum stress signaling, which can be targeted by therapeutic agents. Numerous studies have identified reliable tests for establishing diagnosis and response assessment of ocular GVHD. The efficacy of systemic and topical treatment for ocular GVHD is summarized. It is important that all health professionals caring for HCT recipients have adequate knowledge of ocular GVHD to provide optimal care.
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Affiliation(s)
- Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan.
| | - Nuria Valdés-Sanz
- Department of Ophthalmology, Puerta de Hierro University Hospital, Madrid, Spain
| | - Yoko Ogawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Monica Alves
- Department of Ophthalmology, University of Campinas, Campinas, Brazil
| | - Luigi Berchicci
- Ophthalmology Department, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - John Galvin
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Hildegard Greinix
- Bone Marrow Transplantation Unit, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Gregory A Hale
- Department of Hematology/Oncology, Johns Hopkins All Children's Hospital, St Petersburg, Florida
| | - Biljana Horn
- UFHealth Shands Cancer Hospital, University of Florida, Gainesville, Florida
| | - Debra Kelly
- UFHealth Shands Cancer Hospital, University of Florida, Gainesville, Florida
| | - Hien Liu
- H. Lee Moffitt Cancer Center, Cleveland, Ohio
| | - Scott Rowley
- Hackensack University Medical Center, Washington, DC
| | - Helene Schoemans
- Department of Hematology, University Hospital Leuven, Leuven, Belgium
| | - Ami Shah
- Division of Stem Cell Transplantation and Regenerative Medicine, Lucille Packard Children's Hospital, Stanford School of Medicine, Palo Alto, California
| | | | - Vaibhav Agrawal
- Simon Cancer Center, Indiana University, Indianapolis, Indiana
| | - Ibrahim Ahmed
- Department of Hematology Oncology and Bone Marrow Transplantation, The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Asim Ali
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Neel Bhatt
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Byrne
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Saurabh Chhabra
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristina Fahnehjelm
- Department of Clinical Neuroscience, Karolinska Institute, St Erik Eye Hospital, Stockholm, Sweden
| | - Nosha Farhadfar
- UFHealth Shands Cancer Hospital, University of Florida, Gainesville, Florida
| | - Erich Horn
- UFHealth Shands Cancer Hospital, University of Florida, Gainesville, Florida
| | - Catherine Lee
- Utah Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Olaf Penack
- Division of Hematology and Oncology, Department of Internal Medicine, Charité University Medicine, Campus Rudolf Virchow, Berlin, Germany
| | - Pinki Prasad
- Lousiana State University Children's Hospital, New Orleans, Louisiana
| | - Seth Rotz
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Jean Yared
- Blood and Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | - Steven Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Grzegorz W Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Minoo Battiwalla
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Rafael Duarte
- Hematology Branch, Sarah Cannon BMT Program, Nashville, Tennessee
| | - Bipin N Savani
- Hematopoietic Transplantation and Hemato-oncology Section, Puerta de HierroUniversity Hospital, Madrid, Spain
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bronwen E Shaw
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Igor Petriček
- Department of Ophthalmology, University Clinical Hospital Zagreb, Zagreb, Croatia
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Ogawa M, Inomata T, Shiang T, Tsubota K, Murakami A. Method for selective quantification of immune and inflammatory cells in the cornea using flow cytometry. J Biol Methods 2018; 5:e102. [PMID: 31453252 PMCID: PMC6706157 DOI: 10.14440/jbm.2018.237] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 01/19/2023] Open
Abstract
The cornea serves as a protective surface against the environment (i.e., allergens, pollutants, desiccation and microorganisms) and promotes vision, made possible by corneal transparency. This protocol describes corneal preparation for flow cytometry to assess cells localized in the cornea. Our model details the process, from determining how many corneas are needed in the experiment to corneal excision to digestion and staining of the cornea cells. The simplicity of the model allows for systematic analysis of different corneal mechanisms of immunity, inflammation, angiogenesis and wound healing. In corneal transplantation, residential immune and inflammatory cells are key to the mechanisms that underlie angiogenesis, opacity, and graft rejection. In addition, this model can also elucidate cellular mechanisms mediating corneal graft outcomes and wound healing. Lastly, this model can be used to analyze the efficacy of new medications such as instillation and subconjunctival injections and assess the potential of therapeutic molecules to enhance graft survival and wound healing in vivo.
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Affiliation(s)
- Mamoru Ogawa
- Laboratory for Metabolomics, RIKEN Center for Integrative Medical Sciences, Tsurumi-ku, Yokohama 230-0045, Japan.,Department of Ophthalmology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Takenori Inomata
- Department of Ophthalmology, Juntendo University Faculty of Medicine, Tokyo, 113-0033, Japan.,Department of Strategic Operating Room Management and Improvement, Juntendo University Faculty of Medicine, Tokyo, 113-0033, Japan
| | - Tina Shiang
- University of Massachusetts Medical School, Department of Radiology, MA 01655, USA
| | - Kazuo Tsubota
- Department of Ophthalmology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Akira Murakami
- Department of Ophthalmology, Juntendo University Faculty of Medicine, Tokyo, 113-0033, Japan
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Chen L, Zhong J, Li S, Li W, Wang B, Deng Y, Yuan J. The long-term effect of tacrolimus on alkali burn-induced corneal neovascularization and inflammation surpasses that of anti-vascular endothelial growth factor. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:2959-2969. [PMID: 30254425 PMCID: PMC6140698 DOI: 10.2147/dddt.s175297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Purpose To investigate the effect of tacrolimus in alkali burn-induced corneal neovascularization (NV) and inflammation and to compare with anti-vascular endothelial growth factor (anti-VEGF). Methods After corneal alkali-burn, 84 Wistar rats were randomly divided into three groups and received either saline solution or 0.05% tacrolimus (0.5 mg/mL) four times daily, or subconjunctival anti-VEGF injection (0.5 mg/0.05 mL). Corneal NV, opacity and epithelial defects, the status of inflammation, and the levels of proinflammatory and angiogenic cytokines were assessed on Days 3, 7, 14 and 28 post-injury. Results Compared with the control, tacrolimus significantly reduced corneal NV on Days 7, 14 and 28 post-injury, and anti-VEGF significantly reduced corneal NV at each assessment. Nevertheless, the tacrolimus group had significantly less corneal NV than the anti-VEGF group on Days 14 and 28. Furthermore, both tacrolimus and anti-VEGF significantly decreased the VEGF-A expression on Days 7 and 14, with no significant difference between the two groups. Moreover, corneal inflammatory response was alleviated, and corneal opacity and epithelial defects were significantly reduced by tacrolimus. Additionally, the expression of IL-1β, IL-6, monocyte chemotactic protein-1, macrophage inflammatory protein-1α and TGF-β were significantly decreased by tacrolimus. Conclusion Our findings suggested that 0.05% tacrolimus suspension eye drops effectively reduced alkali burn-induced corneal NV and inflammation, with a better effect than subconjunctival anti-VEGF injections on Days 14 and 28.
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Affiliation(s)
- Ling Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China,
| | - Jing Zhong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China,
| | - Saiqun Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China,
| | - Weihua Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China,
| | - Bowen Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China,
| | - Yuqing Deng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China,
| | - Jin Yuan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China,
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Mawardi H, Hashmi SK, Elad S, Aljurf M, Treister N. Chronic graft‐versus‐host disease: Current management paradigm and future perspectives. Oral Dis 2018; 25:931-948. [DOI: 10.1111/odi.12936] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/04/2018] [Accepted: 07/04/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Hani Mawardi
- Faculty of Dentistry King AbdulAziz University Jeddah Kingdom of Saudi Arabia
- AlFarabi Private College Jeddah Kingdom of Saudi Arabia
| | - Shahrukh K. Hashmi
- Department of Medicine Mayo Clinic Rochester Minnesota
- Oncology Center KFSHRC Riyadh Kingdom of Saudi Arabia
| | - Sharon Elad
- Department of Dentistry University of Rochester Rochester New York
| | | | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital Boston Massachusetts
- Department of Oral Medicine, Infection and Immunity Harvard School of Dental Medicine Boston Massachusetts
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Manifestation of Clinical Categories of Ocular Graft-versus-Host Disease. J Ophthalmol 2018; 2018:6430953. [PMID: 30159166 PMCID: PMC6109493 DOI: 10.1155/2018/6430953] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/07/2018] [Indexed: 12/27/2022] Open
Abstract
This study aims at improving the understanding of the subjective symptoms and signs of two different clinical categories of ocular graft-versus-host disease. After reviewing and screening 193 posthematopoietic stem cell transplantation (HSCT) patients of Peking University Third Hospital, we enrolled 148 (21 acute ocular GVHD, 127 chronic ocular GVHD). Patients' subjective symptoms, ocular parameters, and typical ocular signs were collected and evaluated at the same visit. Classic acute ocular GVHD patients had variable levels of conjunctival involvement but few had keratopathy; increased mucus secretion (21 of 21, 100.0%), red eye (19 of 21, 90.5%), and lacrimation (11 of 21, 52.4%) were the characteristic symptoms. The classic chronic ocular group had severe eye dryness and further corneal lesions, including filamentary keratitis, corneal ulcer, and corneal vascularization. Eye dryness (115 of 127, 90.6%), increased fibrous secretion (53 of 127, 41.7%), photophobia (50 of 127, 39.4%), and alacrimia (45 of 127, 35.4%) were the most common symptoms. Although 44.1% (56 of 127) of these patients had a history of acute ocular GVHD episodes, most were overlooked, so they did not receive stepwise evaluation and treatment. Management of ocular GVHD is very challenging and requires cooperation among disciplines.
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48
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Amparo F, Shikari H, Saboo U, Dana R. Corneal fluorescein staining and ocular symptoms but not Schirmer test are useful as indicators of response to treatment in chronic ocular GVHD. Ocul Surf 2018; 16:377-381. [DOI: 10.1016/j.jtos.2018.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/08/2018] [Accepted: 05/11/2018] [Indexed: 01/29/2023]
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Voitena J, Cunha O, Fukushima F, Carvalho G, Ramos L, Henriques V, Costa D. Eficácia dos colírios ciclosporina e tacrolimo no tratamento de ceratoconjuntivite seca em cães. ARQ BRAS MED VET ZOO 2018. [DOI: 10.1590/1678-4162-9849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO O objetivo deste estudo foi avaliar os efeitos do tacrolimo e da ciclosporina na produção lacrimal de cães com ceratoconjuntivite seca (CCS) durante 90 dias. Para tanto, foram utilizados colírios de tacrolimo 0,02% (TcL) e ciclosporina 0,1% (CsA) em 14 cães com CCS. Os animais foram distribuídos em dois grupos e avaliados antes do início do tratamento (T0) e aos 15 (T1), 30 (T2), 45 (T3), 60 (T4), 75 (T5) e 90 (T6) dias após o início do tratamento. Na avaliação clínica, observou-se maior redução da secreção ocular, da opacidade e do edema corneano e da vascularização conjuntival. no grupo tacrolimo. No teste de Schirmer, verificou-se produção basal de 6(4,07 e 5,86(2,85mm/min no TcL e CsA, respectivamente, com aumento significativo da produção lacrimal em ambos os grupos, contudo houve aumento significativo da produção lacrimal a partir dos 15 dias de tratamento no grupo TcL (17,88(5,51mm/min), mas apenas a partir dos 45 dias no grupo CsA (11,86(4,74mm/min). Conclui-se que o uso do colírio tacrolimo aumentou em 68,83% a produção lacrimal em 90 dias de tratamento, comparado com a ciclosporina (56,82%), além de diminuir as manifestações clínicas inerentes à CCS, quando comparado à terapia com ciclosporina.
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Affiliation(s)
| | - O. Cunha
- Universidade Federal do Paraná, Brazil
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50
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Yin J, Kheirkhah A, Dohlman T, Saboo U, Dana R. Reduced Efficacy of Low-dose Topical Steroids in Dry Eye Disease Associated With Graft-versus-Host Disease. Am J Ophthalmol 2018; 190:17-23. [PMID: 29572107 DOI: 10.1016/j.ajo.2018.03.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/21/2018] [Accepted: 03/11/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE To compare the response of dry eye disease (DED) to treatment with topical steroid in patients with and without graft-vs-host disease (GVHD). DESIGN Post hoc analysis of a double-masked, randomized clinical trial. METHODS This single-center study included 42 patients with moderate-to-severe DED associated with (n = 21) or without (n = 21) chronic GVHD. In each group, patients received either loteprednol etabonate 0.5% ophthalmic suspension or artificial tears twice daily for 4 weeks. Clinical data, including Ocular Surface Disease Index (OSDI) questionnaire, corneal fluorescein staining (CFS), conjunctival lissamine green staining, tear break-up time (TBUT), and Schirmer test, were evaluated before and after treatment. RESULTS There were no significant differences in signs and symptoms of DED between the groups at baseline. In non-GVHD patients receiving loteprednol treatment, the average OSDI score decreased by 34% from 49.5 ± 5.9 to 32.6 ± 4.8 (mean ± standard error of the mean, P = .001) and the average CFS score decreased by 41% from 5.6 ± 0.6 to 3.3 ± 0.9 (P = .02). On the other hand, loteprednol treatment in GVHD patients resulted in minimal change in OSDI (59.2 ± 6.7 to 61.1 ± 7.1, 3% increase, P = .66) and CFS (5.5 ± 0.5 to 5.3 ± 1.1, 4% decrease, P = .85) scores. Treatment with artificial tears resulted in 22% decrease of OSDI (P = .10) and 32% decrease of CFS (P = .02) scores in non-GVHD patients, and had minimal effect in patients with GVHD. CONCLUSIONS DED patients with ocular GVHD have a less favorable response to a low-dose topical steroid regimen compared with those without ocular GVHD even with similar baseline disease severity.
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Affiliation(s)
- Jia Yin
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmad Kheirkhah
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Dohlman
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ujwala Saboo
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Reza Dana
- Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA.
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