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Chen Y, Zhuang X, Wang L, Xu Y, Sun Z, Ren Y, Chen F, Ma X, Tang X, Zhang X. The Role of IL-6, IL-10, and TNF-α in Ocular GVHD Following Allogeneic Transplantation. Ocul Immunol Inflamm 2024:1-8. [PMID: 38252122 DOI: 10.1080/09273948.2024.2302445] [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: 07/18/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024]
Abstract
PURPOSE To figure out the roles of tear inflammatory cytokines in Ocular graft-versus-host disease (oGVHD) symptoms by analyzing tear cytokine levels and related factors. METHODS This prospective study involved 27 post-HSCT patients and 19 controls with dry eye disease. Analyses included tear cytokine (IL-6, IL-10, and TNF-α), ocular surface evaluation, and conjunctival impression cell examination. Tear cytokine levels were evaluated in three grades of corneal epithelial lesions. The study also analyzed the correlation between tear cytokine levels and ocular surface parameters. Tear cytokine levels were then used in a Receiver Operating Characteristic (ROC) curve and linear regression model to predict oGVHD related factors. RESULTS IL-6 has good diagnostic efficacy in oGVHD related dry eye. Elevated levels of tear IL-6 and TNF-α were observed in the group with severe corneal epithelial lesions. IL-6 levels were positively correlated with corneal fluorescein staining (CFS), eyelid margin hyperemia, conjunctival lesions, and meibum secretion. IL-6 showed excellent predictive ability with Area Under the Curve (AUC) values all greater than 0.70 (p < 0.05). IL-10 and TNF-α were negatively correlated with the meibomian gland proportion and conjunctival goblet cell (GC) density, while TNF-α was positively correlated with CFS and eyelid margin hyperemia. CONCLUSION Dry eye symptoms related to ocular GVHD, can be partly diagnosed and assessed using various tear cytokine level detection methods.
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Affiliation(s)
- Yingjie Chen
- Department of Ophthalmology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Xinyu Zhuang
- Department of Ophthalmology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Lei Wang
- Department of Ophthalmology, Suzhou Municipal Hospital, Nanjing Medical University Affiliated Suzhou Hospital, Suzhou, China
| | - Yue Xu
- Department of Ophthalmology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Zhengtai Sun
- Department of Ophthalmology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yaru Ren
- Department of Ophthalmology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Feng Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiao Ma
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaowen Tang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaofeng Zhang
- Department of Ophthalmology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
- Department of Ophthalmology, First Affiliated Hospital of Soochow University, Suzhou, China
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2
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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, 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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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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5
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Jeppesen H, Gjærde LK, Lindegaard J, Julian HO, Heegaard S, Sengeløv H. Ocular Chronic Graft-versus-Host Disease and Its Relation to Other Organ Manifestations and Outcomes after Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2022; 28:833.e1-833.e7. [PMID: 36002105 DOI: 10.1016/j.jtct.2022.08.016] [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: 04/28/2022] [Revised: 06/27/2022] [Accepted: 08/10/2022] [Indexed: 12/24/2022]
Abstract
Ocular chronic graft-versus-host disease (cGVHD) has been shown to significantly reduce quality of life after allogeneic hematopoietic stem cell transplantation (HSCT). To learn more about this bothersome complication, we investigated the relationship between ocular cGVHD and cGVHD in other organs. We also investigated the associations between ocular cGVHD and overall mortality, nonrelapse mortality, and relapse. In this single-center study, we retrospectively included 1221 consecutive adults who underwent allogeneic HSCT. Patients were examined by an ophthalmologist before HSCT and annually for 5 years after HSCT or more frequently if needed. Patients with dry eye disease before HSCT were excluded. The International Chronic Ocular GVHD Consensus Group criteria were used to diagnose ocular cGVHD. Nonocular cGVHD was diagnosed using the National Institute of Health criteria. Out of 601 patients who were diagnosed with systemic cGVHD during follow-up, 279 (46%) developed ocular cGVHD. Ocular cGVHD was more frequent in patients with extensive cGVHD compared to those with limited cGVHD (50% versus 29%; P < .0001) and was associated with cGVHD in skin (P < .0001), oral cavity (P = .0024), genitals (P = .0023), and nails (P = .031). The frequency of ocular cGVHD was higher in patients with skin cGVHD with sclerosis compared to those with skin cGVHD without sclerosis (70% versus 49%; P = .0003). In an adjusted time-dependent Cox model, ocular cGVHD was associated with increased nonrelapse mortality (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.17 to 2.21; P = .003), whereas there was no support for an association with relapse (adjusted HR, .85; 95% CI, .53 to 1.36; P = .5). Special attention to eye problems after HSCT should be given to patients with extensive cGVHD and cGVHD in ectodermal-derived organs (skin, mouth, nails, and genitals). Furthermore, ocular cGVHD is a potential risk factor for nonrelapse mortality. © 2022 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Helene Jeppesen
- Department of Ophthalmology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Lars Klingen Gjærde
- Department of Haematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Steffen Heegaard
- Department of Ophthalmology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Pathology, Eye Pathology Section, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Sengeløv
- Department of Haematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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6
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Zhuang XY, Sun ZT, Xu Y, Ren YR, Chen YJ, Chen F, Ma X, Tang XW, Zhang XF. Correlative factors of ocular surface lesions after allogeneic hematopoietic stem cell transplantation: A retrospective study. Front Oncol 2022; 12:1040679. [PMID: 36479063 PMCID: PMC9719980 DOI: 10.3389/fonc.2022.1040679] [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: 09/09/2022] [Accepted: 11/07/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND Ocular graft-versus-host disease (oGVHD) is one of the complications after allogeneic hematopoietic stem cell transplantation (HSCT), which impairs the quality of life and may indicate poor prognosis. In this retrospective study, the aim was to investigate the characteristics of ocular surface after HSCT, and analyze the risk factors related to the severity of ocular surface lesions. METHODS 248 post-HSCT patients were enrolled in this retrospective study. Subjects were divided into no lesion group, mild lesion group and severe lesion group, according to the severity of ocular surface lesions. The correlations between grades of ocular surface lesions and gender, age, primary disease, donor source, human leukocyte antigen (HLA) type, kinship, donor-recipient relationship, blood type, source of stem cell and systemic GVHD were analyzed. RESULTS The median scores of corneal epitheliopathy, lid margin lesions and meibomian gland loss were 3, 6 and 2 points, respectively. The grade of corneal epitheliopathy was related to donor source (P<0.001), kinship (P=0.033), HLA-matching (P<0.001), and systemic GVHD (P=0.007), especially oral GVHD (P<0.001) and liver GVHD (P=0.002). The grade of lid margin lesions was related to donor source (P=0.019), HLA-matching (P=0.006), and systemic GVHD (P=0.013), especially skin GVHD (P=0.019) and oral GVHD (P=0.019). The grade of meibomian gland loss was related to age (P=0.035) and gastrointestinal GVHD (P=0.007). The grade of corneal epitheliopathy after HSCT was related to the lid margin lesion score (P<0.001). CONCLUSIONS The occurrence and development of ocular GVHD are mostly accompanied by the history of systemic GVHD. While in few cases, ocular surface lesions related to GVHD can be observed prior to the rejection of other tissues and organs. Severe corneal epitheliopathy occurs in patients with severe lid margin lesions in ocular GVHD. The lesions of corneal epithelium and lid margin are milder in HLA partially matching transplantation.
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Affiliation(s)
- Xin-Yu Zhuang
- Department of Ophthalmology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zheng-Tai Sun
- Department of Ophthalmology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yue Xu
- Department of Ophthalmology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Ya-Ru Ren
- Department of Ophthalmology, First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ying-Jie Chen
- Department of Ophthalmology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Feng Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiao Ma
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiao-Wen Tang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiao-Feng Zhang
- Department of Ophthalmology, First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Ophthalmology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
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7
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Levy RB, Mousa HM, Lightbourn CO, Shiuey EJ, Latoni D, Duffort S, Flynn R, Du J, Barreras H, Zaiken M, Paz K, Blazar BR, Perez VL. Analyses and Correlation of Pathologic and Ocular Cutaneous Changes in Murine Graft versus Host Disease. Int J Mol Sci 2021; 23:184. [PMID: 35008621 PMCID: PMC8745722 DOI: 10.3390/ijms23010184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 11/22/2022] Open
Abstract
Graft versus host disease (GVHD) is initiated by donor allo-reactive T cells activated against recipient antigens. Chronic GVHD (cGVHD) is characterized by immune responses that may resemble autoimmune features present in the scleroderma and Sjogren's syndrome. Unfortunately, ocular involvement occurs in approximately 60-90% of patients with cGVHD following allo-hematopoietic stem cell transplants (aHSCT). Ocular GVHD (oGVHD) may affect vision due to ocular adnexa damage leading to dry eye and keratopathy. Several other compartments including the skin are major targets of GVHD effector pathways. Using mouse aHSCT models, the objective was to characterize cGVHD associated alterations in the eye and skin to assess for correlations between these two organs. The examination of multiple models of MHC-matched and MHC-mismatched aHSCT identified a correlation between ocular and cutaneous involvement accompanying cGVHD. Studies detected a "positive" correlation, i.e., when cGVHD-induced ocular alterations were observed, cutaneous compartment alterations were also observed. When no or minimal ocular signs were detected, no or minimal skin changes were observed. In total, these findings suggest underlying cGVHD-inducing pathological immune mechanisms may be shared between the eye and skin. Based on the present observations, we posit that when skin involvement is present in aHSCT patients with cGVHD, the evaluation of the ocular surface by an ophthalmologist could potentially be of value.
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Affiliation(s)
- Robert B. Levy
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33101, USA; (C.O.L.); (S.D.); (H.B.)
| | - Hazem M. Mousa
- School of Medicine, Duke University, Durham, NC 27708, USA; (H.M.M.); (E.J.S.); (D.L.)
| | - Casey O. Lightbourn
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33101, USA; (C.O.L.); (S.D.); (H.B.)
| | - Eric J. Shiuey
- School of Medicine, Duke University, Durham, NC 27708, USA; (H.M.M.); (E.J.S.); (D.L.)
| | - David Latoni
- School of Medicine, Duke University, Durham, NC 27708, USA; (H.M.M.); (E.J.S.); (D.L.)
| | - Stephanie Duffort
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33101, USA; (C.O.L.); (S.D.); (H.B.)
| | - Ryan Flynn
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Jing Du
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Henry Barreras
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33101, USA; (C.O.L.); (S.D.); (H.B.)
| | - Michael Zaiken
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Katelyn Paz
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Bruce R. Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN 55455, USA; (R.F.); (J.D.); (M.Z.); (K.P.); (B.R.B.)
| | - Victor L. Perez
- School of Medicine, Duke University, Durham, NC 27708, USA; (H.M.M.); (E.J.S.); (D.L.)
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8
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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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Jacobs DS, Carrasquillo KG, Cottrell PD, Fernández-Velázquez FJ, Gil-Cazorla R, Jalbert I, Pucker AD, Riccobono K, Robertson DM, Szczotka-Flynn L, Speedwell L, Stapleton F. CLEAR - Medical use of contact lenses. Cont Lens Anterior Eye 2021; 44:289-329. [PMID: 33775381 DOI: 10.1016/j.clae.2021.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
The medical use of contact lenses is a solution for many complex ocular conditions, including high refractive error, irregular astigmatism, primary and secondary corneal ectasia, disfiguring disease, and ocular surface disease. The development of highly oxygen permeable soft and rigid materials has extended the suitability of contact lenses for such applications. There is consistent evidence that bandage soft contact lenses, particularly silicone hydrogel lenses, improve epithelial healing and reduce pain in persistent epithelial defects, after trauma or surgery, and in corneal dystrophies. Drug delivery applications of contact lens hold promise for improving topical therapy. Modern scleral lens practice has achieved great success for both visual rehabilitation and therapeutic applications, including those requiring retention of a tear reservoir or protection from an adverse environment. This report offers a practical and relevant summary of the current evidence for the medical use of contact lenses for all eye care professionals including optometrists, ophthalmologists, opticians, and orthoptists. Topics covered include indications for use in both acute and chronic conditions, lens selection, patient selection, wear and care regimens, and recommended aftercare schedules. Prevention, presentation, and management of complications of medical use are reviewed.
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Affiliation(s)
- Deborah S Jacobs
- Massachusetts Eye & Ear, Cornea and Refractive Surgery Service, Harvard Medical School, Boston, MA, USA.
| | | | | | | | | | | | | | | | | | - Loretta Szczotka-Flynn
- Department of Ophthalmology & Visual Science, Case Western Reserve University, Cleveland, OH, USA
| | - Lynne Speedwell
- Great Ormond Street Hospital for Children NHS Trust, Moorfields Eye Hospital, London, UK
| | - Fiona Stapleton
- School of Optometry and Vision Science, UNSW Sydney, Australia
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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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11
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Narang P, Basu S. Commentary: Ocular surface involvement heralds graft-versus-host disease: Time to act. Indian J Ophthalmol 2020; 68:1562-1563. [PMID: 32709776 PMCID: PMC7640811 DOI: 10.4103/ijo.ijo_483_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Purvasha Narang
- Consultant, Cornea, Refractive and Ocular Surface Services, L.J. Eye Institute, Ambala, India
| | - Sayan Basu
- Consultant and Research Lead, The Cornea Institute, L. V. Prasad Eye Institute, Hyderabad, Telangana, India
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12
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Singh RB, Yung A, Coco G, Sinha S, Dohlman TH, Yin J, Dana R. Efficacy and retention of silicone punctal plugs for treatment of dry eye in patients with and without ocular graft-versus-host-disease. Ocul Surf 2020; 18:731-735. [PMID: 32738300 DOI: 10.1016/j.jtos.2020.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/10/2020] [Accepted: 07/25/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine the retention rates and efficacy of silicone punctal plugs for the treatment of dry eye disease (DED) in patients with ocular graft-versus-host-disease (oGVHD) in comparison to dry eye disease due to non-oGVHD etiologies. METHODS We reviewed the case-records of 864 consecutive patients with DED who were symptomatic despite topical therapy and had silicone punctal plugs placed over an eight-year- period at a single academic center. We compared plug retention rates in oGVHD and non-oGVHD DED patients using Kaplan-Meier analyses. Furthermore, we analyzed changes in objective ocular surface parameters including tear breakup time (TBUT), Schirmer's test, and corneal fluorescein staining (CFS) score in plug-retaining patients at two-, six- and twelve-month follow-up. RESULTS Median age of dry eye patients was 58 years, and 606 (70%) of patients were women. In the cohort, 264 (31%) patients were diagnosed with oGVHD. Plug retention was significantly lower in oGVHD-DED patients compared to non-oGVHD-DED patients (p < 0.0001). We observed significant improvement in CFS scores in plug retaining-oGVHD and non-oGVHD DED patients at all time points. Tear break-up time was significantly prolonged at six- and twelve-months follow-up in non-oGVHD patients, whereas significant change in TBUT in oGVHD patients was recorded only at twelve months post plug placement. Schirmer's score improved significantly in plug retaining-non-oGVHD DED patients at six- and twelve-months follow-up, however no significant change was observed in Schirmer's score in oGVHD DED patients. CONCLUSIONS An improvement in ocular surface disease parameters was observed in both plug-retaining oGVHD and non-oGVHD DED patients. However, a majority of oGVHD DED patients spontaneously lost their punctal plugs within 90 days of placement. Therefore, regular follow-up after plug placement is recommended to detect plug loss and ensure adequate disease control.
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Affiliation(s)
- Rohan Bir Singh
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
| | - Ann Yung
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
| | - Giulia Coco
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
| | - Shruti Sinha
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
| | - Thomas H Dohlman
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
| | - Jia Yin
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA
| | - Reza Dana
- Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, 02114, USA.
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13
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Chronic ocular graft-versus-host disease after allogeneic haematopoietic stem cell transplantation in Denmark - factors associated with risks and rates in adults according to conditioning regimen. Bone Marrow Transplant 2020; 56:144-154. [PMID: 32655136 DOI: 10.1038/s41409-020-0993-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 06/12/2020] [Accepted: 06/30/2020] [Indexed: 01/27/2023]
Abstract
We investigated risks and hazard rates of developing chronic ocular graft-versus-host disease (oGVHD) in a large nationwide, single centre study by using the criteria proposed by "The International Chronic oGVHD Consensus Group". This retrospective study included 1407 consecutive adults who underwent allogeneic haematopoietic stem cell transplantation (HSCT). Patients were examined by an ophthalmologist according to the hospital's guidelines: baseline examination before HSCT, annually up to 5 years after HSCT. The 186 (13%) had dry eye disease before HSCT. The 5-year cumulative incidence of oGVHD was 18% (95% CI: 15-21) after myeloablative (MA) and 35% (95% CI: 30-39) after non-myeloablative conditioning (NMA). Factors associated with the rate of oGVHD were assessed separately according to conditioning regimen by using multiple Cox regression analyses. Factors that increased the rate in the MA group: Malignant disease, Schirmer's test≤10 mm/5 min before transplantation, use of female donor, matched unrelated donor, peripheral blood as stem cell source, and grade III-IV acute GVHD. Factors that increased the rate in the NMA group: Schirmer's test≤10 mm/5 min before transplantation and higher recipient age. We recommend a baseline ophthalmological examination before HSCT since many of the patients have signs of dry eyes before transplantation which increased the risk and rate of developing oGVHD.
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Yamane M, Sato S, Shimizu E, Shibata S, Hayano M, Yaguchi T, Kamijuku H, Ogawa M, Suzuki T, Mukai S, Shimmura S, Okano H, Takeuchi T, Kawakami Y, Ogawa Y, Tsubota K. Senescence-associated secretory phenotype promotes chronic ocular graft-vs-host disease in mice and humans. FASEB J 2020; 34:10778-10800. [PMID: 32619061 DOI: 10.1096/fj.201900218r] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/30/2020] [Accepted: 06/04/2020] [Indexed: 01/01/2023]
Abstract
Chronic graft-vs-host disease (cGVHD) is a multifactorial inflammatory disease that affects patients undergoing hematopoietic stem cell transplantation. Multiple organs, including the lacrimal glands (LGs), are negatively affected by cGVHD and lose function due to the resultant fibrosis. An abnormal immune response is thought to be a major factor in the development of chronic ocular GVHD, which is currently treated primarily with immunosuppressive therapies. However, all the treatments yield unsatisfactory outcomes, and additional treatment strategies are needed. To meet this unmet medical need, we aimed to elucidate an additional pathway of chronic ocular GVHD. Our findings suggest a potential association between chronic ocular GVHD pathogenesis and stress-induced cellular senescence through the senescence-associated secretory phenotype (SASP). Senescent cells produce cytokines and chemokines, such as IL-6 and CXCL9. Indeed, senescent cell accumulation was presumably associated with cGVHD development in LGs, as evidenced by the improvement in LGs after the selective elimination of senescent cells (senolysis) with ABT-263. Results in the sclerodermatous cGVHD mouse model suggest that inhibiting the major components of the SASP, including IL-6 and CXCL9, with senolytics is a potential novel strategy for treating cGVHD-affected LGs. Taken together, our results indicate a potential association between the SASP and cGVHD development in LGs and suggest that targeted senolytic treatment may be a new therapeutic option for this disease.
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Affiliation(s)
- Mio Yamane
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Shinri Sato
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Shimizu
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Shinsuke Shibata
- Electron Microscope Laboratory, Keio University School of Medicine, Tokyo, Japan
| | - Motoshi Hayano
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Tomonori Yaguchi
- Division of Cellular Signaling, Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
| | - Hajime Kamijuku
- Division of Cardiology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mamoru Ogawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Suzuki
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Shin Mukai
- Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shigeto Shimmura
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Okano
- Department of Physiology, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yutaka Kawakami
- Division of Cellular Signaling, Institute for Advanced Medical Research, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Ogawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Kazuo Tsubota
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
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Shamloo K, Barbarino A, Alfuraih S, Sharma A. Graft Versus Host Disease-Associated Dry Eye: Role of Ocular Surface Mucins and the Effect of Rebamipide, a Mucin Secretagogue. Invest Ophthalmol Vis Sci 2020; 60:4511-4519. [PMID: 31675422 DOI: 10.1167/iovs.19-27843] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The present study was designed to investigate the role of ocular surface glycocalyx and mucins in graft versus host disease (GVHD)-associated dry eye. The ameliorative effect of topical rebamipide, a mucin secretagogue, on GVHD-associated dry eye was also tested. Methods A mouse model of allogeneic transplantation was used to induce ocular GVHD with C57BL/6 as donors and B6D2F1 as recipient mice. Phenol red thread method and fluorescein staining was used to quantify tear secretion and corneal keratopathy. At 8 weeks after the allogeneic transplantation, corneas were harvested to perform glycocalyx staining and confocal microscopy. Goblet cell staining was performed using periodic acid Schiff's staining. Corneal and tear film levels of Mucin 1, 4, 16, 19, and 5AC were quantified using ELISA and real-time PCR. Rebamipide was applied topically twice daily to mice eyes. Results Allogeneic transplantation resulted in ocular GVHD-associated dry eye characterized by a significant decrease in tear film volume and the onset of corneal keratopathy. Ocular GVHD caused a significant decrease in the area and thickness of corneal glycocalyx. A significant decrease in the goblet cells was also noted. A significant decrease in mucin 4 and 5AC levels was also observed. Topical treatment with rebamipide partially attenuated ocular GVHD-mediated decrease in tear film volume and significantly reduced the severity of corneal keratopathy. Conclusions Ocular GVHD has detrimental impact on ocular surface glycocalyx and mucins. Rebamipide, a mucin secretagogue, partially prevents ocular GVHD-associated decrease in tear film and reduces the severity of corneal keratopathy.
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Affiliation(s)
- Kiumars Shamloo
- Chapman University School of Pharmacy, Chapman University, Irvine, California, United States
| | - Ashley Barbarino
- Chapman University School of Pharmacy, Chapman University, Irvine, California, United States
| | - Saleh Alfuraih
- Chapman University School of Pharmacy, Chapman University, Irvine, California, United States
| | - Ajay Sharma
- Chapman University School of Pharmacy, Chapman University, Irvine, California, United States
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Chhabra S, Jerkins JH, Conto JE, Zellner K, Shah NN, Hari PN, Hamadani M. Lifitegrast ophthalmic solution for treatment of ocular chronic graft-versus-host disease. Leuk Lymphoma 2019; 61:869-874. [PMID: 31762357 DOI: 10.1080/10428194.2019.1695049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Ocular chronic graft-versus-host disease (oGVHD) is a relatively common complication that occurs following allogeneic hematopoietic cell transplantation. Keratoconjunctivitis sicca (KCS) is the most common manifestation of oGVHD. Lifitegrast is a lymphocyte function-associated antigen-1 antagonist approved to reduce inflammation and symptoms in patients with dry eye disease. We evaluated the efficacy and safety of lifitegrast (5% ophthalmic solution) in patients with ocular GVHD in a single-institution retrospective cohort study of eighteen allogeneic transplant recipients who received topical lifitegrast for oGVHD treatment. The outcome of interest was improvement in oGVHD severity score by National Institutes of Health (NIH) criteria. Lifitegrast was well-tolerated and no serious adverse events were observed. Lifitegrast significantly improved NIH severity scores in 8 (44%) patients. The findings of this study suggest lifitegrast is safe, well-tolerated and is an effective option for oGVHD manifesting as KCS. Prospective evaluation is warranted to confirm efficacy of lifitegrast in this population.HighlightsIn this single-institution retrospective cohort study of eighteen patients who received allogeneic transplant between 2013 and 2018, and received topical lifitegrast for treatment of ocular GVHD, the results demonstrate that lifitegrast eye drops were well-tolerated and led to improvement in symptoms of KCS in 8 (44%) patients.Lifitegrast has the potential to fulfill an unmet need in allogeneic transplant patients with ocular GVHD. Further prospective study is warranted for confirmation.
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Affiliation(s)
- Saurabh Chhabra
- Division of Hematology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - James H Jerkins
- Division of Hematology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John E Conto
- Division of Hematology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Katie Zellner
- Division of Hematology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Nirav N Shah
- Division of Hematology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Parameswaran N Hari
- Division of Hematology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mehdi Hamadani
- Division of Hematology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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17
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Fung SSM, Elbaz U, Mireskandari K, Ali A. Graft versus host disease: a pediatric perspective. EXPERT REVIEW OF OPHTHALMOLOGY 2019. [DOI: 10.1080/17469899.2019.1598860] [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: 10/27/2022]
Affiliation(s)
- Simon SM Fung
- Department of Ophthalmology, Stein Eye Institute, University of California, Los Angeles, CA, USA
| | - Uri Elbaz
- Department of Ophthalmology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kamiar Mireskandari
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Asim Ali
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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18
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Nair S, Vanathi M, Mahapatra M, Seth T, Kaur J, Velpandian T, Ravi A, Titiyal JS, Tandon R. Tear inflammatory mediators and protein in eyes of post allogenic hematopoeitic stem cell transplant patients. Ocul Surf 2018; 16:352-367. [PMID: 29723628 DOI: 10.1016/j.jtos.2018.04.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/21/2018] [Accepted: 04/24/2018] [Indexed: 10/17/2022]
Abstract
AIM To analyze tear cytokines levels and their correlation to ocular surface parameters in allogenic hematopoietic stem cell transplants (allo-HSCT) patients. METHODS Prospective longitudinal study of allo-HSCT patients and controls for ocular surface evaluation (OSDI, TBUT, Schirmer's test, staining scores), tear biochemical analysis for protein, cytokines [IL-10, IL-12, IL-2, IL-4, IL-6, IL-17, interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, VEGF], MMPs [MMP 2, 9, 7, 13, 10 and chemokine (IL-8)], & VEGF on three consecutive follow up visits (at three monthly interval) was done. RESULTS Of 24 post allo-HSCT patients (19 males, 5 females) & 12 controls (mean age 34.3 + 5.8 years) enrolled, 20 patients [mean age 33.4 + 7.77 years; mean time of recruitment of 5.2 + 2.12 months following alloHSCT] who completed three consecutive follow up visits were included for analysis. Ocular GVHD (oGVHD) was seen in 8 patients (33.3%). Tears biochemical analysis showed elevated levels of interferon γ, IL 6, IL 8, IL 10, IL 12AP70, IL 17A, MMP 9 and VEGF in oGVHD eyes as compared to non-oGVHD & control eyes. Non-oGVHD eyes showed elevated tear MMP 7 and MMP 9 as compared to healthy controls. Tear protein levels were significantly decreased in oGVHD eyes and were equivocal in nonGVHD and control eyes. TBUT and ocular staining scores to correlate best with tear interleukins and MMPs. CONCLUSION Evaluation of levels of tear VEGF, total protein & MMP 9 can be of significance in identifying oGVHD in post alloHSCT patients.
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Affiliation(s)
- Sridevi Nair
- Cornea & Ocular Surface Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Murugesan Vanathi
- Cornea & Ocular Surface Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Manoranjan Mahapatra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Tulika Seth
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Jasbir Kaur
- Ocular Biochemistry Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - T Velpandian
- Ocular Pharmacology Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Alok Ravi
- Ocular Biochemistry Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Jeewan Singh Titiyal
- Cornea & Ocular Surface Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Radhika Tandon
- Cornea & Ocular Surface Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, 110029, India
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Kheirkhah A, Coco G, Satitpitakul V, Dana R. Subtarsal Fibrosis Is Associated With Ocular Surface Epitheliopathy in Graft-Versus-Host Disease. Am J Ophthalmol 2018; 189:102-110. [PMID: 29505774 DOI: 10.1016/j.ajo.2018.02.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/24/2017] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate occurrence of subtarsal fibrosis in patients with graft-vs-host disease (GVHD) and to determine its association with ocular surface epitheliopathy. DESIGN Cross-sectional study. METHODS We enrolled 40 patients with moderate or severe dry eye disease, including 20 patients with chronic ocular GVHD and 20 patients without (as the control group). All patients had a comprehensive ophthalmic assessment including evaluation for subtarsal fibrosis, corneal and conjunctival staining, tear break-up time (TBUT), and Schirmer test. Furthermore, meibomian gland drop-out area and densities of epithelial and stromal immune cells were measured using meibography and in vivo confocal microscopy, respectively. RESULTS Subtarsal fibrosis was not seen in any eye of the non-GVHD group. However, 16 eyes (40%) of 10 patients (50%) in the GVHD group had subtarsal fibrosis (P < .001) with an average involvement of 28.9% ± 13.7% of the tarsal area. Fibrosis was more frequent in the upper lids (35%) than in the lower lids (5%). Regression analyses showed that corneal fluorescein staining was significantly associated with the extent of fibrosis (P < .001, β = 0.14) and TBUT (P < .001, β = -0.53) but not with other clinical or imaging parameters. Conjunctival lissamine green staining also had a statistically significant association with the extent of fibrosis (P = .04, β = 0.12) but not other clinical or imaging parameters. Eyes with subtarsal fibrosis had a more severe ocular surface epitheliopathy compared with eyes without fibrosis. CONCLUSIONS Subtarsal fibrosis is present in a significant percentage of patients with chronic ocular GVHD, likely contributing to the ocular surface damage in these patients.
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Functional Role of Lacrimal Gland Fibroblasts in a Mouse Model of Chronic Graft-Versus-Host Disease. Cornea 2018; 37:102-108. [PMID: 29053559 DOI: 10.1097/ico.0000000000001411] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE This study aimed to clarify the mechanisms and assess the characteristics of the chronic graft-versus-host disease (cGVHD) fibrosis in the lacrimal gland (LG) of mice. METHODS Histopathology of LG tissues was examined by immunohistochemistry and electron microscopy. Cultured fibroblasts derived from the LG were analyzed by phase-contrast microscopy, immunocytochemistry, flow cytometry, proliferation assay, and invasion and migration assays. RESULTS Cultured murine LG fibroblasts in cGVHD were spindle-shaped and relatively small, whereas those from syngeneic controls were polygon-shaped and relatively large. Flow cytometric analysis showed that the LG fibroblasts in cGVHD had elevated HSP47 levels. The LG fibroblasts in cGVHD also showed increased expression of major histocompatibility complex class II. Furthermore, the proportion of Sca-1PDGFR-α cells among the LG fibroblasts in cGVHD was considerably increased compared with controls. Cell counting kit-8 assays demonstrated that the LG fibroblasts in cGVHD were highly proliferative, and cell invasion assays indicated that they were highly invasive with high migration ability. CONCLUSIONS LG fibroblasts in cGVHD can be aberrantly activated, thereby eliciting fibrosis by producing excessive extracellular matrix, leading to LG dysfunction in mice.
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21
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Tepelus TC, Chiu GB, Maram J, Huang J, Chopra V, Sadda SR, Lee OL. Corneal features in ocular graft-versus-host disease by in vivo confocal microscopy. Graefes Arch Clin Exp Ophthalmol 2017; 255:2389-2397. [PMID: 28875340 DOI: 10.1007/s00417-017-3759-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 07/17/2017] [Indexed: 12/19/2022] Open
Abstract
PURPOSE The purpose of our study was to determine the morphological features of the corneal epithelial layers, sub-basal nerve plexus and anterior stroma in patients with ocular graft-versus-host disease (oGVHD) compared to non-GVHD dry eyes and normal controls, using in vivo confocal microscopy (IVCM). METHODS IVCM was used to capture central cornea images from eight volunteers with normal healthy eyes, ten patients with non-GVHD dry eye syndrome (DES) and 15 patients with clinically diagnosed oGVHD, in a cross-sectional study. Morphological changes of the corneal epithelial layers and anterior stroma, characteristics of corneal nerves and presence of dendritic cells (DCs) were then evaluated. RESULTS IVCM images obtained from 66 eyes were analyzed. The density of superficial epithelial cells was 636.07 ± 101.05 cells/mm2 in the oGVHD group, 827 ± 99.62 cells/mm2 in the DES group and 1277.2 ± 121.42 cells/mm2 in the control group (P < 0.001). The density of wing cells was 4499.79 ± 976.36 cells/mm2 in the oGVHD group, 4662.85 ± 319.72 cells/mm2 in DES group and 6556.38 ± 503.99 cells/mm2 in the control group (p < 0.001). The density of basal cells was 7850.93 ± 723.51 cells/mm2 in the oGVHD group, 8570 ± 913.32 cells/mm2 in DES group and 9759.8 ± 251.99 cells/mm2 in the control group (p < 0.01). The density of nerve fibers was 11.22 ± 5.46 mm/mm2 in the oGVHD group, 14.50 ± 4.27 mm/mm2 in DES group and 19.56 ± 4.75 mm/mm2 in the control group (p < 0.01). The DC density was 67.88 ± 71.82 cells/mm2 in the oGVHD group, 40.06 ± 31.95 cells/mm2 in the DES group and 29.45 ± 8.1 cells/mm2 in the control group (P > 0.05). Visible networks of activated keratocytes were seen in the anterior stroma of eyes with oGVHD and DES, but not in normal controls. CONCLUSIONS IVCM revealed distinct microstructural changes in the corneas of patients with oGVHD and DES, similar between the two groups. Our findings suggest implications for use of IVCM to evaluate and monitor patients with dry eyes associated or not with GVHD.
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Affiliation(s)
- Tudor C Tepelus
- Doheny Image Reading Center, Doheny Eye Institute, 1355 San Pablo Street, DVRC 211, Los Angeles, CA, 90033, USA.,Department of Ophthalmology, David Geffen School of Medicine at UCLA, 100 Stein Plaza UCLA, Los Angeles, CA, 90095, USA
| | - Gloria B Chiu
- USC Roski Eye Institute, Keck School of Medicine, 1450 San Pablo Street, Los Angeles, CA, 90033, USA
| | - Jyotsna Maram
- Doheny Image Reading Center, Doheny Eye Institute, 1355 San Pablo Street, DVRC 211, Los Angeles, CA, 90033, USA
| | - Jianyan Huang
- Doheny Image Reading Center, Doheny Eye Institute, 1355 San Pablo Street, DVRC 211, Los Angeles, CA, 90033, USA.,Department of Ophthalmology, David Geffen School of Medicine at UCLA, 100 Stein Plaza UCLA, Los Angeles, CA, 90095, USA
| | - Vikas Chopra
- Doheny Image Reading Center, Doheny Eye Institute, 1355 San Pablo Street, DVRC 211, Los Angeles, CA, 90033, USA.,Department of Ophthalmology, David Geffen School of Medicine at UCLA, 100 Stein Plaza UCLA, Los Angeles, CA, 90095, USA
| | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute, 1355 San Pablo Street, DVRC 211, Los Angeles, CA, 90033, USA.,Department of Ophthalmology, David Geffen School of Medicine at UCLA, 100 Stein Plaza UCLA, Los Angeles, CA, 90095, USA
| | - Olivia L Lee
- Doheny Image Reading Center, Doheny Eye Institute, 1355 San Pablo Street, DVRC 211, Los Angeles, CA, 90033, USA. .,Department of Ophthalmology, David Geffen School of Medicine at UCLA, 100 Stein Plaza UCLA, Los Angeles, CA, 90095, USA.
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A Case of a Bilateral Cicatricial Upper Eyelid Entropion After Hematopoietic Stem Cell Transplantation in Mucopolysaccharidosis Type I. Ophthalmic Plast Reconstr Surg 2017; 33:S75-S77. [PMID: 26588207 DOI: 10.1097/iop.0000000000000592] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Minor eyelid abnormalities are commonly encountered in mucopolysaccharidosis, but only rarely leading to a clinically relevant situation. The authors report a clinical case of severe bilateral cicatricial entropion of the upper eyelids, leading to recurrent conjunctival infections, corneal erosion, persistent epiphora, and a major decline in life quality in a 7-year-old boy with mucopolysaccharidosis type I who underwent hematopoietic stem cell transplantation at 1.6 years old. A bilateral anterior lamellar repositioning including eyelid split and cryoepilation was performed to correct bilateral upper eyelid entropium and trichiasis. Three months after the surgical intervention, the patient showed a persistent regular eyelid position with only mild recurrent right-sided lateral upper eyelid entropion. A significant reduction in conjunctival infections and epiphora with complete discontinuation of topical therapy was achieved. Although mucopolysaccaridosis is associated with eyelid abnormalities, the authors conclude that the described case is most likely due to chronic graft versus host disease.
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Abstract
: Graft-versus-host disease (GVHD) is a major complication that occurs following allogeneic hematopoietic stem cell transplantation, which is a potential curative therapy used in a variety of malignant or benign hematological diseases. Graft-versus-host disease primarily occurs in many organs, but most notably in the skin, lungs, gastrointestinal tract, liver, eyes, mucosa, and musculoskeletal system. Ocular manifestations of GVHD may precede other systemic GVHD findings, and it may be a poor prognosis for mortality. While all parts of the eye may be affected, ocular GVHD occurs primarily in the ocular surface. Dry eye disease or keratoconjunctivitis sicca is the most common presenting manifestation of chronic ocular GVHD. Dry eye disease in ocular GVHD is a multifactorial process, which involves destruction and fibrosis of lacrimal glands and conjunctiva, leading to tear film deficiency and instability. Depending on the severity of ocular involvement and response to treatment, ocular GVHD may cause decreased quality of life. Management of GVHD begins with prevention by understanding risk factors and by implementing prophylactic treatment after allogeneic hematopoietic stem cell transplantation. A multidisciplinary approach to the prevention and treatment of GVHD is important, and there are currently no preventive therapies available for ocular GVHD. Once diagnosed, ocular GVHD treatment strategies target ocular surface lubrication and support, tear film stabilization, inflammation reduction, and surgical intervention. The goal of this review is to define ocular GVHD and its categorical manifestations, as well as to describe the importance of comprehensive assessment, diagnosis, and ophthalmologic treatment and management of ocular GVHD with a multidisciplinary approach.
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PROSE Treatment for Ocular Chronic Graft-Versus-Host Disease as a Clinical Network Expands. Eye Contact Lens 2017; 42:262-6. [PMID: 26448446 DOI: 10.1097/icl.0000000000000186] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Keratoconjunctivitis sicca occurs in 40% to 90% of patients with ocular chronic graft-versus-host disease (cGVHD). Ocular symptoms can have profound effects in both the visual function and quality of life of patients with GVHD. We report the impact of prosthetic replacement of the ocular surface ecosystem (PROSE) treatment in patients with cGVHD as a clinical network expands. METHODS We queried the BostonSight PROSE manufacturing database from January 2002 to December 2011. Patients treated for ocular cGVHD were reported by age, gender, year, and network site where the treatment was undertaken. The baseline and six-month follow-up scores of visual function using a standardized validated instrument, the National Eye Institute Visual Function Questionnaire (NEI VFQ-25), were evaluated for a period in 2006 and again in 2010 after network expansion had occurred. RESULTS A total of 407 patients with a male:female ratio of 226:181, mean age was 51 years with ocular cGVHD underwent PROSE treatment from January 2002 to December 2011. By 2011, 67% of all cases were treated at network clinics. Baseline characteristics of patients treated throughout the network in 2010 were similar to that of 2006 and 2010 cohorts from the main center. There was a significant improvement of 41 points (P<0.001) in composite NEI VFQ score among patients treated across the network in 2010, similar to the improvement of 30 points (P<0.001) seen among the patients treated at the main center in 2010. There was a trend toward lower baseline self-reported general health status (SRGHS) and VFQ scores among patients treated at network clinics, suggesting that expansion of the network allows treatment of sicker patients (lower general health status) or those more severely affected by ocular cGVHD. CONCLUSIONS PROSE treatment of ocular cGVHD has increased in the last decade with the establishment of BostonSight network clinics across the United States. Patients treated at network clinics showed similar levels of baseline visual function and SRGHS, and achieved a similar high level of improvement in visual function as those treated at the main center. Patient-reported measures of functional status are useful in evaluating treatment options for patients with cGVHD. PROSE treatment has significant positive impact on the visual function of patients with ocular cGVHD regardless of whether the patient is treated at the main center or at a network site.
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Arafat SN, Robert MC, Abud T, Spurr-Michaud S, Amparo F, Dohlman CH, Dana R, Gipson IK. Elevated Neutrophil Elastase in Tears of Ocular Graft-Versus-Host Disease Patients. Am J Ophthalmol 2017; 176:46-52. [PMID: 28073648 DOI: 10.1016/j.ajo.2016.12.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/27/2016] [Accepted: 12/30/2016] [Indexed: 12/20/2022]
Abstract
PURPOSE To investigate the levels of neutrophil elastase (NE), matrix metalloproteinases (MMPs), and myeloperoxidase (MPO) in tear washes of patients with ocular graft-vs-host disease (oGVHD). DESIGN Case-control study. METHODS Based on established criteria, oGVHD patients (n = 14; 28 eyes) and age-/sex-matched healthy controls (n = 14; 28 eyes) were enrolled. Tear washes were collected and analyzed for NE using a single-analyte enzyme-linked immunosorbent assay (ELISA). MMPs (1, 2, 3, 7, 8, 9, 12), MPO, and tissue inhibitor of matrix metalloproteinase (TIMP)-1 were analyzed using multianalyte bead-based ELISA assays. Total MMP activity was measured using a fluorimetric assay. Correlation studies were performed between NE, MMP-8, MMP-9, and MPO within study groups. RESULTS NE, MMP-8, MMP-9, and MPO levels were elevated in oGVHD tears when compared with controls (P < .0001). NE was the most elevated analyte. MMP activity was higher and TIMP-1 levels were lower in oGVHD than in control (P < .0001). In oGVHD, NE significantly correlated with MMP-8 (r = 0.92), MMP-9 (r = 0.90), and MPO (r = 0.79) (P < .0001). MMP-8 correlated with MMP-9 (r = 0.96, P < .0001), and MPO (r = 0.60, P = .001). MMP-9 correlated with MPO (r = 0.55, P = .002). In controls, NE, MMP-9, and MPO significantly correlated with each other (P < .0001). CONCLUSIONS The marked increase in NE in oGVHD tears that correlated strongly with elevated MMP-8, MMP-9, and MPO suggests a common neutrophilic source and provides evidence of neutrophil activity on the ocular surface of oGVHD patients.
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Affiliation(s)
- Samer N Arafat
- Schepens Eye Research Institute-Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts; Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Marie-Claude Robert
- Schepens Eye Research Institute-Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts; Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Tulio Abud
- Schepens Eye Research Institute-Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology and Visual Sciences, Paulista School of Medicine, Federal University of Sao Paulo-UNIFESP, Sao Paulo, Brazil
| | - Sandra Spurr-Michaud
- Schepens Eye Research Institute-Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Francisco Amparo
- Schepens Eye Research Institute-Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts; Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Claes H Dohlman
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Reza Dana
- Schepens Eye Research Institute-Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts; Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Ilene K Gipson
- Schepens Eye Research Institute-Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.
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Ogawa Y, He H, Mukai S, Imada T, Nakamura S, Su CW, Mahabole M, Tseng SCG, Tsubota K. Heavy Chain-Hyaluronan/Pentraxin 3 from Amniotic Membrane Suppresses Inflammation and Scarring in Murine Lacrimal Gland and Conjunctiva of Chronic Graft-versus-Host Disease. Sci Rep 2017; 7:42195. [PMID: 28165063 PMCID: PMC5292704 DOI: 10.1038/srep42195] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 01/06/2017] [Indexed: 12/21/2022] Open
Abstract
Chronic graft-versus-host disease (cGVHD) is a major complication of hematopoietic stem cell transplantation. Dry eye disease is the prominent ocular sequel of cGVHD and is caused by excessive inflammation and fibrosis in the lacrimal glands. Heavy chain-Hyaluronan/Pentraxin 3 (HC-HA/PTX3) is a complex purified from human amniotic membrane (AM) and known to exert anti-inflammatory and anti-scarring actions. In this study, we utilized a mouse model of cGVHD to examine whether HC-HA/PTX3 could attenuate dry eye disease elicited by cGVHD. Our results indicated that subconjunctival and subcutaneous injection of HC-HA/PTX3 preserved tear secretion and conjunctival goblet cell density and mitigated inflammation and scarring of the conjunctiva. Such therapeutic benefits were associated with suppression of scarring and infiltration of inflammatory/immune cells in the lacrimal glands. Furthermore, HC-HA/PTX3 significantly reduced the extent of infiltration of CD45+ CD4+ IL-17+ cells, CD45+ CD34+ collagen I+ CXCR4+ fibrocytes, and HSP47+ activated fibroblasts that were accompanied by upregulation of collagen type Iα1, collagen type IIIα1 and NF-kB in lacrimal glands. Collectively, these pre-clinical data help prove the concept that subcutaneous and subconjunctival injection of HC-HA/PTX3 is a novel approach to prevent dry eye disease caused by cGVHD and allow us to test its safety and efficacy in future human clinical trials.
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Affiliation(s)
- Yoko Ogawa
- Department of Ophthalmology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hua He
- TissueTech, Inc., Miami, FL 33173, USA
| | - Shin Mukai
- Department of Ophthalmology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Toshihiro Imada
- Department of Ophthalmology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shigeru Nakamura
- Department of Ophthalmology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
| | | | | | | | - Kazuo Tsubota
- Department of Ophthalmology, Keio University School of Medicine, 35 Shinanomachi Shinjuku-ku, Tokyo, 160-8582, Japan
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Khan R, Nair S, Seth T, Mishra P, Mahapatra M, Agarwal T, Tandon R, Vanathi M. Ocular graft versus host disease in allogenic haematopoetic stem cell transplantation in a tertiary care centre in India. Indian J Med Res 2016; 142:543-8. [PMID: 26658588 PMCID: PMC4743340 DOI: 10.4103/0971-5916.171280] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives: This study was aimed to report the occurrence of ocular graft versus host disease (oGVHD) in allogeneic haematopoietic stem cell transplantation (allo-HSCT) patients in a tertiary care hospital setting. Methods: A cross-sectional study of ocular surface of allo-HSCT patients was done. Slit lamp biomicroscopy, symptom score, tear meniscus height, fluorescein tear break-up time, Schirmer's test I, ocular surface staining, dry eye severity, ocular surface disease index score were done. Indications for allo-HSCT, human leukocyte antigen (HLA) matching, GVHD risk factor, systemic manifestation and treatment were also noted. Results: GVHD occurred in 44.4 per cent of 54 allo-HSCT patients (mean age 26.7 ± 12 yr) included in the study. GVHD risk factors identified included female gender, relapse, older age of donor, cytomagelo virus (CMV) reactivation, and multiparous female donors. oGVHD was noted in 31.5 per cent with mean time to occurrence being 17.8 ± 21.9 months after the allo-HSCT and was observed in 89.5 per cent of chronic GVHD cases. Acute GVHD (oral and dermatological) involvement showed a significant association with GVHD in our patients (P< 0.001, 0R 23.0, CI 6.4-82.1). Chronic GVHD was observed to be associated with the occurrence of oGVHD (dry eye) (P<0.001, OR = 24.0, CI 0.02 - 0.29). Of the 34 eyes with oGHVD, dry eye of level 3 severity was seen in 16, level 2 in six, level 1 in 12 eyes. Interpretation & conclusions: GVHD occurred in 44.4 per cent of the patients studied in the present study. Acute and chronic GVHD showed a strong association with oGVHD. Dry eye disease due to chronic oGVHD was observed in 17 (31.5%) of 54 allo-HSCT patient with chronic oGVHD occurring in 17 (89.4%) of chronic GVHD cases in allo-HSCT patients. Our study on oGVHD in post allo-HSCT patients in tertiary care centre points towards the fact that ocular morbidity due to dry eye disease as a result of oGVHD is a cause for concern in these patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Murugesan Vanathi
- Cornea & Ocular Surface, Cataract & Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, India
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Perez VL, Barsam A, Duffort S, Urbieta M, Barreras H, Lightbourn C, Komanduri KV, Levy RB. Novel Scoring Criteria for the Evaluation of Ocular Graft-versus-Host Disease in a Preclinical Allogeneic Hematopoietic Stem Cell Transplantation Animal Model. Biol Blood Marrow Transplant 2016; 22:1765-1772. [PMID: 27492793 PMCID: PMC5580988 DOI: 10.1016/j.bbmt.2016.07.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/20/2016] [Indexed: 12/16/2022]
Abstract
Ocular complications occur after transplantation in 60% to 90% of chronic graft-versus-host disease (GVHD) patients and significantly impair vision-related quality of life. Ocular surface inflammation and dry eye disease are the most common manifestations of ocular GVHD. Ocular GVHD can be viewed as an excellent preclinical model that can be studied to understand the immune pathogenesis of this common and debilitating disease. A limitation of this is that only a few experimental models mimic the ocular complications after hematopoietic stem cell transplantation (HSCT) and have focused on the acute GVHD process. To address this issue, we used a preclinical animal model developed by our group where ocular involvement was preceded by systemic GVHD to gain insight regarding the contributing immune mechanisms. Employing this "matched unrelated donor" model enabled the development of clinical scoring criteria, which readily identified different degrees of ocular pathology at both the ocular surface and adnexa, dependent on the level of conditioning before HSCT. As far as we are aware, we report for the first time that these clinical and immune responses occur not only on the ocular surface, but they also heavily involve the lid margin region. In total, the present study reports a preclinical scoring model that can be applied to animal models as investigators look to further explore GVHD's immunologic effects at the level of the ocular surface and eyelid adnexa compartments. We speculate that future studies will use this clinical scoring index in combination with what is recognized histologically and correlated with serum biomarkers identified in chronic/ocular GVHD.
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Affiliation(s)
- Victor L Perez
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida; Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
| | - Alexander Barsam
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Stephanie Duffort
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Maitee Urbieta
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Henry Barreras
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida
| | - Casey Lightbourn
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida
| | - Krishna V Komanduri
- Sylvester Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Robert B Levy
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida; Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, Florida; Sylvester Cancer Center, University of Miami Miller School of Medicine, Miami, Florida.
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Anitua E, Muruzabal F, de la Fuente M, Riestra A, Merayo-Lloves J, Orive G. PRGF exerts more potent proliferative and anti-inflammatory effects than autologous serum on a cell culture inflammatory model. Exp Eye Res 2016; 151:115-21. [DOI: 10.1016/j.exer.2016.08.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 07/26/2016] [Accepted: 08/23/2016] [Indexed: 01/15/2023]
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Zallio F, Mazzucco L, Monaco F, Astori MR, Passera R, Drago G, Tamiazzo S, Rapetti M, Dolcino D, Guaschino R, Pini M, Ladetto M. A Single-Center Pilot Prospective Study of Topical Application of Platelet-Derived Eye Drops for Patients with Ocular Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2016; 22:1664-1670. [DOI: 10.1016/j.bbmt.2016.05.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 05/25/2016] [Indexed: 02/05/2023]
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Mohammadpour M, Maleki S, Hashemi H, Beheshtnejad AH. Recurrent Corneal Perforation due to Chronic Graft versus Host Disease; a Clinicopathologic Report. J Ophthalmic Vis Res 2016; 11:108-11. [PMID: 27195094 PMCID: PMC4860975 DOI: 10.4103/2008-322x.180705] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Purpose: To describe a case of chronic graft versus host disease (GVHD) leading to severe dry eye and recurrent corneal perforation in both eyes, its stepwise management and histopathological reports. Case Report: A 22-year-old woman with a history of thalassemia and subsequent high-dose chemotherapy followed by allogeneic bone marrow transplant (BMT) was referred to Farabi Eye Hospital. Despite aggressive medical and surgical intervention, corneal vascularization in her right eye progressed and led to corneal perforation. Cyanoacrylate glue was applied to seal the perforation, however it recurred. Multilayer amniotic membrane transplantation (AMT) was performed to seal the corneal perforation, which was effective for a short period. Subsequently, the corneal perforation recurred and penetrating keratoplasty was performed. After a few months deep vascularization and descemetocele occurred in the fellow left eye and the patient finally underwent therapeutic lamellar keratoplasty. Conclusion: Patients with GVHD are at risk of severe dry eye and subsequent corneal vascularization. Recurrent and recalcitrant corneal perforation resistant to cyanoacrylate glue and multilayer AMT may occur. Proper systemic and ocular management alongside close collaboration with the hematologist is strongly recommended to control the condition.
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Affiliation(s)
- Mehrdad Mohammadpour
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Siamak Maleki
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Hashemi
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
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Hallberg D, Stenberg K, Hanson C, Stenevi U, Brune M. Conjunctival polyploid cells and donor-derived myofibroblasts in ocular GvHD. Bone Marrow Transplant 2016; 51:692-7. [DOI: 10.1038/bmt.2015.347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 11/09/2022]
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Herretes S, Ross DB, Duffort S, Barreras H, Yaohong T, Saeed AM, Murillo JC, Komanduri KV, Levy RB, Perez VL. Recruitment of Donor T Cells to the Eyes During Ocular GVHD in Recipients of MHC-Matched Allogeneic Hematopoietic Stem Cell Transplants. Invest Ophthalmol Vis Sci 2015; 56:2348-57. [PMID: 25655798 DOI: 10.1167/iovs.14-15630] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The primary objective of the present study was to identify the kinetics and origin of ocular infiltrating T cells in a preclinical model of graft-versus-host disease (GVHD) that induces eye tissue damage. METHODS Graft-versus-host disease was induced using an major histocompatibility complex (MHC)-matched, minor histocompatibility-mismatched hematopoietic stem cell transplant (HSCT) model. This approach, which utilized congenic and EGFP-labeled donor populations, mimics a matched, clinically unrelated donor (MUD) cell transplant. Systemic and ocular GVHD were assessed at varying time points using clinical examination, intravital microscopy, immune phenotype via flow cytometric analyses, and immunohistochemical staining. RESULTS Following transplant, we observed characteristic changes in GVHD-associated immune phenotype as well as clinical signs present in recipients post transplant. Notably, the kinetics of the systemic changes and the ocular damage paralleled what is observed clinically, including damage to the cornea as well as the conjunctiva and lacrimal gland. Importantly, the infiltrate contained predominantly donor CD4 as well as CD8 T cells with an activated phenotype and macrophages together with effector cytokines consistent with the presence of a TH1 alloreactive population. CONCLUSIONS Overall, the findings here unequivocally demonstrated that donor T cells compose part of the corneal and ocular adnexa infiltrate in animals undergoing ocular GVHD. In total, the results describe a novel and promising preclinical model characterized by both systemic and ocular changes as detected in significant numbers of patients undergoing GVHD following allo-HSCT, which can help facilitate dissecting the underlying immune mechanisms leading to damage associated with ocular GVHD.
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Affiliation(s)
- Samantha Herretes
- Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Duncan B Ross
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine Sylvester Comprehensive Cancer Center, Miami, Florida, United States
| | - Stephanie Duffort
- Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Henry Barreras
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine Sylvester Comprehensive Cancer Center, Miami, Florida, United States
| | - Tan Yaohong
- Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Ali M Saeed
- Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Juan C Murillo
- Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Krishna V Komanduri
- Adult Stem Cell Transplant Program, University of Miami Miller School of Medicine Sylvester Comprehensive Cancer Center, Miami, Florida, United States 4Department of Medicine, University of Miami Miller School of Medicine Sylvester Comprehensive Cancer Ce
| | - Robert B Levy
- Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, United States 2Department of Microbiology and Immunology, University of Miami Miller School of Medicine Sylvester Comprehensive Cancer Center, Miami, Florida, Unit
| | - Victor L Perez
- Department of Ophthalmology, University of Miami Miller School of Medicine, Miami, Florida, United States 2Department of Microbiology and Immunology, University of Miami Miller School of Medicine Sylvester Comprehensive Cancer Center, Miami, Florida, Unit
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Use of Prosthetic Replacement of the Ocular Surface Ecosystem Scleral Lenses in Patients with Ocular Chronic Graft-versus-Host Disease. Biol Blood Marrow Transplant 2015; 21:2180-2184. [PMID: 26234721 DOI: 10.1016/j.bbmt.2015.07.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 07/27/2015] [Indexed: 11/23/2022]
Abstract
The purpose of this study was to evaluate the impact of prosthetic replacement of the ocular surface ecosystem (BostonSight PROSE, Boston Foundation for Sight, Needham, MA) treatment, utilizing customized scleral devices, on visual acuity, visual function, and ocular surface changes in patients with ocular chronic graft-versus-host disease (cGVHD). A retrospective analysis was performed on 79 eyes of 40 patients with cGVHD referred to the University of Southern California department of ophthalmology between November 2009 and July 2013 for PROSE treatment. This analysis included an assessment of ocular symptoms and visual function before and after treatment using the Ocular Surface Disease Index (OSDI) survey. Pre- and post-treatment visual acuity and clinical data were also compared. Twenty-eight male patients and 12 female patients were included in this study. The average age was 56.1 years (range, 27 to 74). Of the 79 eyes treated, 71 (90%) showed improved visual acuity with PROSE treatment. Fifty-seven eyes (72%) experienced a 2- or greater line visual acuity improvement and 14 eyes (18%) experienced a 1-line improvement. Average logarithm of the minimal angle of resolution improved from .49 ± .52 to .16 ± .44 (P < .0001), which correlates to a Snellen score improvement of approximately 20/60 to 20/30. Sixty-six of 79 eyes (84%) showed decreased corneal staining after treatment. All 9 eyes presenting with filamentary keratitis and 3 eyes with epithelial defects demonstrated complete healing of the epithelial surface after PROSE fitting. At post-treatment follow-up, 8 patients had died and 3 stopped wearing their devices. Of the remaining 29 patients, average OSDI scores improved from 72.6 ± 20.1 to 21.1 ± 14.9 (P < .0001). PROSE therapy, utilizing customized scleral lenses, can reduce ocular symptoms, improve visual acuity, and improve ocular surface integrity or appearance in patients with ocular cGVHD.
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Tear Osmolarity and Ocular Surface Parameters as Diagnostic Markers of Ocular Graft-Versus-Host Disease. Am J Ophthalmol 2015; 160:143-9.e1. [PMID: 25870935 DOI: 10.1016/j.ajo.2015.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 04/01/2015] [Accepted: 04/01/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate the diagnostic value of tear osmolarity and several ocular surface parameters in screening for ocular surface alterations in ocular graft-vs-host disease (GVHD) patients. DESIGN Case-control study. METHODS Sixty-three patients with ocular GVHD and 74 healthy participants were screened for ocular surface changes using the Ocular Surface Disease Index (OSDI), tear osmolarity, Schirmer test, tear break-up time (TBUT), and fluorescein corneal staining. The severity of ocular GVHD was diagnosed according to the National Institutes of Health (NIH) grading system. The diagnostic sensitivity and specificity and cutoff values were determined for each ocular parameter using a receiver operating characteristic (ROC) curve and area under the curve (AUC) analysis. Significance was defined at P < .05. RESULTS The tear osmolarity, corneal staining score, and OSDI score gradually increased as the severity of ocular GVHD increased, and Schirmer value gradually decreased as the GVHD grade increased in severity. The Schirmer test showed greatest diagnostic sensitivity and specificity for ocular GVHD (92.1% sensitivity, 85.7% specificity, cutoff = 9 mm), followed by the TBUT (87.3% sensitivity, 75.0% specificity, cutoff = 6 s), tear osmolarity (98.4% sensitivity, 60.7% specificity, cutoff = 311 mOsm/L), corneal staining score (66.7% sensitivity, 82.1% specificity, cutoff = 2), and OSDI score (77.8% sensitivity, 66.1% specificity, cutoff = 20.8). CONCLUSIONS Multiple diagnostic modalities should be used to detect ocular surface changes in GVHD patients. The severity of ocular GVHD can be effectively monitored using tear osmolarity; however, additional studies are required.
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Pezzotta S, Rossi GC, Scudeller L, Antoniazzi E, Bianchi PE, Perotti C, Del Fante C. A cross-sectional study on vision-related quality of life in patients with ocular GvHD. Bone Marrow Transplant 2015; 50:1224-6. [DOI: 10.1038/bmt.2015.24] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 12/30/2014] [Accepted: 01/06/2015] [Indexed: 11/09/2022]
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Kinori M, Bielorai B, Souroujon D, Hutt D, Ben-Bassat Mizrachi I, Huna-Baron R. Ocular complications in children after hematopoietic stem cell transplantation without total body irradiation. Graefes Arch Clin Exp Ophthalmol 2015; 253:1397-402. [DOI: 10.1007/s00417-015-2964-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 12/24/2014] [Accepted: 02/04/2015] [Indexed: 10/24/2022] Open
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Li P, Sun Y, Hariri S, Zhou Z, Inamoto Y, Lee SJ, Shen TT, Wang RK. Anterior segment optical coherence tomography evaluation of ocular graft-versus-host disease: a case study. Quant Imaging Med Surg 2015; 5:163-70. [PMID: 25694966 DOI: 10.3978/j.issn.2223-4292.2014.11.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 10/20/2014] [Indexed: 11/14/2022]
Abstract
To explore ocular graft-versus-host disease (GVHD), anterior segment optical coherence tomography (AS-OCT) imaging of eyelids, tear meniscus, cornea and conjunctiva is performed in subsequent sessions on a patient who has ocular GVHD after allogeneic related donor stem cell transplant. The OCT results are presented together with those from a normal subject. OCT imaging is promising in visualizing several ocular GVHD manifestations, such as abnormal meibomian gland orifice (MGO), conjunctival keratinization, conjunctival hyperemia and chemosis, corneal epithelium opacification, thinning and sloughing. This case study demonstrates the capability of AS-OCT in the imaging and monitoring of ocular GVHD, which may be useful in the development of current ocular GVHD staging system and the clinical management for GVHD treatment.
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Affiliation(s)
- Peng Li
- 1 Department of Bioengineering, 2 Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA ; 3 Buddhist Tzu Chi General Hospital, Taipei Division, New Taipei, Taiwan ; 4 Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
| | - Yichen Sun
- 1 Department of Bioengineering, 2 Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA ; 3 Buddhist Tzu Chi General Hospital, Taipei Division, New Taipei, Taiwan ; 4 Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
| | - Sepideh Hariri
- 1 Department of Bioengineering, 2 Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA ; 3 Buddhist Tzu Chi General Hospital, Taipei Division, New Taipei, Taiwan ; 4 Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
| | - Zhehai Zhou
- 1 Department of Bioengineering, 2 Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA ; 3 Buddhist Tzu Chi General Hospital, Taipei Division, New Taipei, Taiwan ; 4 Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
| | - Yoshihiro Inamoto
- 1 Department of Bioengineering, 2 Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA ; 3 Buddhist Tzu Chi General Hospital, Taipei Division, New Taipei, Taiwan ; 4 Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
| | - Stephanie J Lee
- 1 Department of Bioengineering, 2 Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA ; 3 Buddhist Tzu Chi General Hospital, Taipei Division, New Taipei, Taiwan ; 4 Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
| | - Tueng T Shen
- 1 Department of Bioengineering, 2 Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA ; 3 Buddhist Tzu Chi General Hospital, Taipei Division, New Taipei, Taiwan ; 4 Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
| | - Ruikang K Wang
- 1 Department of Bioengineering, 2 Department of Ophthalmology, University of Washington, Seattle, WA 98195, USA ; 3 Buddhist Tzu Chi General Hospital, Taipei Division, New Taipei, Taiwan ; 4 Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA
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Newman RG, Ross DB, Barreras H, Herretes S, Podack ER, Komanduri KV, Perez VL, Levy RB. The allure and peril of hematopoietic stem cell transplantation: overcoming immune challenges to improve success. Immunol Res 2014; 57:125-39. [PMID: 24272856 DOI: 10.1007/s12026-013-8450-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Since its inception in the mid-twentieth century, the complication limiting the application and utility of allogeneic hematopoietic stem cell transplantation (allo-HSCT) to treat patients with hematopoietic cancer is the development of graft-versus-host disease (GVHD). Ironically, GVHD is induced by the cells (T lymphocytes) transplanted for the purpose of eliminating the malignancy. Damage ensuing to multiple tissues, e.g., skin, GI, liver, and others including the eye, provides the challenge of regulating systemic and organ-specific GVH responses. Because the immune system is also targeted by GVHD, this both: (a) impairs reconstitution of immunity post-transplant resulting in patient susceptibility to lethal infection and (b) markedly diminishes the individual's capacity to generate anti-cancer immunity--the raison d'etre for undergoing allo-HSCT. We hypothesize that deleting alloreactive T cells ex vivo using a new strategy involving antigen stimulation and alkylation will prevent systemic GVHD thereby providing a platform for the generation of anti-tumor immunity. Relapse also remains the major complication following autologous HSCT (auto-HSCT). While GVHD does not complicate auto-HSCT, its absence removes significant grant anti-tumor responses (GVL) and raises the challenge of generating rapid and effective anti-tumor immunity early post-transplant prior to immune reconstitution. We hypothesize that effective vaccine usage to stimulate tumor-specific T cells followed by their amplification using targeted IL-2 can be effective in both the autologous and allogeneic HSCT setting. Lastly, our findings support the notion that the ocular compartment can be locally targeted to regulate visual complications of GVHD which may involve both alloreactive and self-reactive (i.e., autoimmune) responses.
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Affiliation(s)
- Robert G Newman
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL, 33131, USA
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Ocular surface evaluation in allogenic hematopoietic stem cell transplantation patients. Eur J Ophthalmol 2014; 24:655-66. [PMID: 24604604 DOI: 10.5301/ejo.5000451] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate ocular surface of chronic graft versus host disease (GVHD) patients in allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS Cross-sectional study of allo-HSCT patients. Data recorded included Ocular Surface Disease Index (OSDI) score, fluorescein tear break-up time (FTBUT), Schirmer I test, ocular surface staining, dry eye severity, and conjunctival impression cytology (CIC). RESULTS Of 40 allo-HSCT patients (mean age 25.7 ± 11.03 years) studied, dry eye disease was noted in 30%. The OSDI was mild in 16.67%, moderate in 45.83%, and severe in 20.83% ocular GVHD (oGVHD) eyes; mild in 94.64%, moderate in 5.36% non-oGVHD eyes (p<0.001). The FTBUT was ≤5 seconds in 45.83%, >5 seconds in 54.17% of eyes with chronic oGVHD. Schirmer I test score was ≤5 mm in 58.33% of eyes with oGVHD. Conjunctival staining score was <3 in 25%, ≥3 in 75% of oGVHD eyes. Corneal staining score of <3 in 79.17%, ≥3 in 20.83% was seen in oGVHD eyes. Chronic oGVHD was seen in 24 eyes, with dry eye severity of level 3 in 17.5%, level 2 in 2.5%, level 1 in 10%. The CIC was abnormal in 75% with altered morphology seen in 22 eyes with oGVHD (91.7%) and 38 eyes without oGVHD (67.9%) (p = 0.024). CONCLUSIONS Significant ocular surface changes occur due to chronic oGVHD in allo-HSCT patients. The OSDI score, corneal involvement, and Schirmer I test are indicative of ocular morbidity in post allo-HSCT eyes. Conjunctival impression cytology abnormality is also seen in eyes without oGVHD.
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Riemens A, Te Boome LCJ, Kalinina Ayuso V, Kuiper JJW, Imhof SM, Lokhorst HM, Aniki R. Impact of ocular graft-versus-host disease on visual quality of life in patients after allogeneic stem cell transplantation: questionnaire study. Acta Ophthalmol 2014; 92:82-7. [PMID: 23601505 DOI: 10.1111/aos.12047] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine the influence of ocular complications on quality of life (QoL) 3 years after allogeneic stem cell transplantation (allo-SCT). METHODS All 54 adult patients that underwent and survived allo-SCT in 2006/2007 in our centre received two questionnaires (VFQ-25: visual function questionnaire-25 and OSDI: ocular surface disease index). In addition, the following data were included: gender, age, underlying disease, presence of chronic and/or ocular graft-versus-host disease (GVHD), number of visits to an ophthalmologist, manifestations of dry eye disease, the duration of follow-up and treatment for ocular GVHD. RESULTS Ocular GVHD developed in 26% (14 of 54) of patients and 71% (10 of 14) received treatment for ocular GVHD. The presence of ocular GVHD correlated with the severity of systemic GVHD (correlation coefficient: 0.52, p = 0.00). The Karnofsky scores were significantly lower in the patients with ocular GVHD compared to the patients with no ocular GVHD (p = 0.001). Karnofsky scores were weakly correlated with the severity of systemic GVHD (correlation coefficient: 0.25, p = 0.03. Three years after the all-SCT, OSDI and VFQ-25 scores were significantly impaired in patients with ocular GVHD [mean: 76.5; range (46.1-100) and mean: 31.1; range (0-72.9)] compared to patients with no ocular GVHD [mean: 89.4; range (45.2-100) and mean: 12.9; range (0-58.3); p = 0.02]. The scores of the VFQ-25 were significantly lower in the domains of general health, ocular pain, social functioning and role difficulties. CONCLUSION The long-term vision-related QoL measured by the OSDI and VFQ-25 was impaired in patients with ocular GVHD.
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Affiliation(s)
- Anjo Riemens
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The NetherlandsDepartment of Hematology, University Medical Center Utrecht, Utrecht, The NetherlandsDepartment of Ophthalmology, Erasmus Medical Center, Rotterdam, The Netherlands
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Ogawa Y, Kim SK, Dana R, Clayton J, Jain S, Rosenblatt MI, Perez VL, Shikari H, Riemens A, Tsubota K. International Chronic Ocular Graft-vs-Host-Disease (GVHD) Consensus Group: proposed diagnostic criteria for chronic GVHD (Part I). Sci Rep 2013; 3:3419. [PMID: 24305504 PMCID: PMC3851919 DOI: 10.1038/srep03419] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 10/01/2013] [Indexed: 02/01/2023] Open
Abstract
The International Chronic Ocular GVHD Consensus Group held 4 working meetings to define new diagnostic metrics for chronic ocular graft-versus-host disease (GVHD). After considering the factors currently used to diagnose chronic ocular GVHD, the Consensus Group identified 4 subjective and objective variables to measure in patients following allogeneic hematopoietic stem cell transplantation (HSCT): OSDI, Schirmer's score without anesthesia, corneal staining, and conjunctival injection. Each variable was scored 0-2 or 0-3, with a maximum composite score of 11. Consideration was also given to the presence or the absence of systemic GVHD. On the basis of their composite score and the presence or absence of systemic GVHD, patients were assigned to one of three diagnostic categories: NO, PROBABLE, or DEFINITE ocular GVHD. New diagnostic criteria for chronic ocular GVHD are presented by the Consensus Group. Validation studies are needed to identify the best combination of the proposed metrics to maximize diagnostic sensitivity and specificity.
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Affiliation(s)
- Yoko Ogawa
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
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Stoyanova EI, Riemens A, Lokhorst HM, te Boome L, Rothova A. Absence of intraocular infections after hematopoietic stem cell transplantation at a single center: the experience with current preventive regimens. Ocul Immunol Inflamm 2013; 22:116-20. [PMID: 24102631 DOI: 10.3109/09273948.2013.827216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To investigate the prevalence of intraocular infections after allogeneic stem cell transplantation (allo-SCT). METHODS The study design was a single institutional retrospective noncomparative cohort of 135 consecutive patients in 2006 and 2007 who underwent allo-SCT for hematological malignancy. The primary outcome was the development of intraocular infections after allo-SCT and secondary outcome consisted of development of other ocular disorders during follow-up. RESULTS The most frequent ocular sequel to allo-SCT included ocular graft-versus-host disease (GvHD), which developed in 37/135 patients (27%). Intraocular infection occurred in 1 of 135 patients (0.7%). This patient developed infectious chorioretinitis together with osteomyelitis, endocarditis, and brain abscess with fungus Scedosporium and was successfully treated with a combination of voriconazole, amphotericine B, and surgical interventions. Viral and/or bacterial intraocular infections were not observed at all. CONCLUSIONS Intraocular infections after allo-SCT are currently uncommon due to systematic use of preemptive treatment regimens, frequent controls, and early treatment of systemic infections.
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Graft versus host disease: clinical evaluation, diagnosis and management. Graefes Arch Clin Exp Ophthalmol 2013; 251:1257-66. [PMID: 23504086 DOI: 10.1007/s00417-013-2301-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 01/23/2013] [Accepted: 02/25/2013] [Indexed: 10/27/2022] Open
Abstract
Graft versus H\host disease (GVHD) can be a devastating complication following bone marrow transplantation. Acute or chronic systemic GVHD can be lethal, and severe damage of different organs and tissues can occur with both types of GVHD. Ocular involvement, either in an acute or chronic presentation, may range from mild to severe with accompanying vision loss present in 60-90 % of patients. Chronic ocular GVHD, the most common form of GVHD, affects mainly the lacrimal gland, meibomian glands, cornea and conjunctiva, mimicking other immunologically mediated inflammatory diseases of the ocular surface without specific symptoms or signs. However, dry eye disease is the main manifestation of GVHD. The long-term treatment of ocular GVHD continues to be challenging and involves a multidisciplinary approach wherein the ophthalmologist plays a major role. Besides systemic immunosuppression and ocular lubricants, topical steroids and topical cyclosporine are commonly prescribed. Newer therapeutic interventions for moderate and severe ocular GVHD include the use of serum eye drops and scleral contact lenses. In this manuscript, we review the mechanisms, clinical findings, and treatment of ocular GVHD.
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Abstract
PURPOSE OF REVIEW This review was carried out to study the frequency, and severity of ocular surface involvement at the setting of allogeneic hematopoietic stem cell transplantation and subsequent graft-versus-host disease (GVHD) and evaluate the clinical outcomes of newer treatments. RECENT FINDINGS Ocular involvement has been reported in 60-90% of patients with chronic GVHD. Although dry eye is the most frequent finding occurring in the great majority of patients (up to 90%), posterior segment complications are also not infrequent, seen in 12.8% of patients after bone marrow transplantation. Anti-inflammatory treatments particularly T-cell suppressants seem to have a beneficial effect in managing GVHD. Corticoteroids, calcineurin inhibitors, such as cyclosporine and tacrolimus, as well as antifibrotic agents such as tranilast are available options for topical application. Cyclosporine ophthalmic drop seems to be a well tolerated and effective treatment modality; favorable results have been demonstrated with increased dosage. SUMMARY GVHD is an increasingly frequent cause of ocular surface morbidity with the potential of visual loss from corneal involvement. Early diagnosis and aggressive local as well as systemic treatment can be vision saving.
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Na KS, Kim MS. Allogeneic serum eye drops for the treatment of dry eye patients with chronic graft-versus-host disease. J Ocul Pharmacol Ther 2012; 28:479-83. [PMID: 22731244 DOI: 10.1089/jop.2012.0002] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To evaluate the therapeutic effect of allogeneic serum eye drops for the treatment of dry eye in patients with chronic graft-versus-host disease (cGVHD) following bone marrow transplantation. METHODS Sixteen patients with cGVHD following allogeneic hematological stem cell transplantation (allo-SCT) and diagnosed with dry eye syndrome refractory to conventional treatment were prospectively enrolled in this study. Allogeneic serum eye drops were obtained from healthy related donors after serologic testing. Symptom scores, tear breakup time (tBUT), the Schirmer test without anesthesia (Schirmer I test), tear osmolarity, corneal staining score, impression cytology grade, and goblet cell densities were evaluated before and 4 weeks after administration of allogeneic serum eye drops. RESULTS Enrolled patients included 6 females and 10 males between 20 and 61 years of age (mean age, 37.2±11.6 years). After 4 weeks of treatment, the Ocular Surface Disease Index (OSDI) symptom scores decreased significantly (32.5-8.9). Tear osmolarity showed a significant decrease from 311.1 to 285.1 milliosmol. The corneal staining scores significantly decreased from 2.5 to 1.8. Impression cytology grade and goblet cell density improved from 3.4 to 2.4 and from 90.6 to 122.6 cell/mm(2), respectively. tBUT also significantly improved from 2.9 to 4.4 s, and the Schirmer I test results showed improvement, but lacked statistical significance (1.7-2.4 mm). No significant side effects were detected as a result of the allogeneic serum treatment during the follow-up period. CONCLUSIONS Allogeneic serum can be used for the treatment of severe dry eye in patients with cGVHD when autologous serum is unavailable. Care should be taken to avoid the risk of blood-borne diseases.
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Affiliation(s)
- Kyung-Sun Na
- Department of Health Promotion Center, College of Medicine, The Catholic University of Korea, Seoul, St. Mary's Hospital, Seoul, Korea
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Abstract
Current treatment of ocular GVHD (oGVHD), represented by systemic immunosuppressive regimens and local therapies (mainly artificial tears and corticosteroids), gives unsatisfactory results. We investigated the safety and efficacy of autologous plasma rich in PDGFs to treat oGVHD unresponsive to standard medications. A total of 23 patients with refractory oGVHD (grade II-IV) unresponsive to standard therapy were treated with autologous plasma rich in PDGFs eye drops (PRGD) four times/day for 6 months. Symptoms and signs (best visual acuity, Schirmer's test and tear break up time (TBUT), evaluation of the anterior segment and fluorescein and lissamine staining) were always assessed by the same ophthalmologist. Patients were defined as 'responders' when showing improvement for total complaints and at least one sign. At 30 days of treatment, 17 patients (73.9%) were classified as responders. The symptom that improved most was photophobia (improved in 19 patients, 82.6%). TBUT improved in 20 patients (86.9%) and anterior segment score in 19 patients (82.6%). Response was maintained over time. No serious adverse events occurred. PRGD proved to be safe and effective in treating oGVHD and may be a valid treatment option from the early stages of the disease to avoid irreversible ocular damage.
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Park SU, Lee SJ, Lee SC. Hafnia Alvei Keratitis after Using a Therapeutic Contact Lens in a Patient with Graft-Versus-Host Disease. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2012. [DOI: 10.3341/jkos.2012.53.8.1163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sang Uk Park
- Department of Ophthalmology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seung Jun Lee
- Department of Ophthalmology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seung Chan Lee
- Department of Ophthalmology, Kangwon National University School of Medicine, Chuncheon, Korea
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Townley JR, Dana R, Jacobs DS. Keratoconjunctivitis sicca manifestations in ocular graft versus host disease: pathogenesis, presentation, prevention, and treatment. Semin Ophthalmol 2011; 26:251-60. [PMID: 21958171 DOI: 10.3109/08820538.2011.588663] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- J Richard Townley
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Sabti S, Halter JP, Braun Fränkl BC, Goldblum D. Punctal occlusion is safe and efficient for the treatment of keratoconjunctivitis sicca in patients with ocular GvHD. Bone Marrow Transplant 2011; 47:981-4. [PMID: 22041848 DOI: 10.1038/bmt.2011.205] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The use of punctal plugs in the treatment of keratoconjunctivitis sicca (KCS) in inflammatory eye disease remains controversial because of the potentially increased retention time of tears enriched with inflammatory cytokines that may aggravate eye inflammation. We describe the safety and efficacy of punctal occlusion in a retrospective analysis of 19 patients (16 men) with KCS due to chronic GvHD (cGvHD). Efficacy and safety were assessed by subjective and objective criteria (symptoms, corneal fluorescein staining, tear film break-up time (BUT), Schirmer I test, Jones test and visual acuity). Follow-up was from plug insertion until maximum one year after punctal occlusion. After punctal occlusion, patients reported a significant increase in subjective comfort (1.10 vs 0.59 on a scale ranging from no symptoms (0) to severe impairment (2), P<0.001). Pathological corneal fluorescein staining decreased significantly (P<0.001) and tear film BUT remained unchanged (5.98 vs 4.0 s, P=0.79). Measurement of tear secretion or retention time showed a non-significant trend for improvement in the Schirmer I (3.0 vs 3.40 mm, P=0.08) and Jones (1.36 vs 2.8 mm, P=0.08) tests. The logMAR visual acuity remained unchanged. Punctal occlusion achieved a significant improvement in subjective symptoms and objective findings in ocular GvHD without increasing ocular inflammation.
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Affiliation(s)
- S Sabti
- Department of Ophthalmology, University Hospital Basel, University of Basel, Basel, Switzerland
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