Scleral Lens and Prosthetic Replacement of the Ocular Surface Ecosystem Utilization in Ocular Graft-versus-Host Disease: A Survey Study

Sustained descemetocele management with Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment

Purpose

To report a case of a 67-year-old male who was successfully managed over a 7-year period for descemetocele secondary to ocular graft versus host disease (oGVHD) using Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment.

Observations

We previously reported on a patient managed with a PROSE device for severe dry eyes secondary to oGVHD, who subsequently developed a central corneal descemetocele. The patient was deemed a poor surgical candidate due to limbal stem cell deficiency secondary to oGVHD. Therefore, we elected to closely monitor the descemetocele as the patient continued PROSE therapy. The patient's descemetocele has been managed successfully without perforation throughout a 7-year follow-up period with corrected distance visual acuity remaining stable at 20/50 in the affected eye.

Conclusions and importance

Descemetoceles are an uncommon complication of ocular graft versus host disease. This is the longest published report of a corneal descemetocele managed with PROSE. Our report suggests that in appropriate patients who are at high-risk for post-surgical complications, PROSE in conjunction with other medical management should be considered as an alternative to corneal transplantation.

Epidemiology and risk factors for the development of cicatrizing conjunctivitis in chronic ocular graft-versus-host disease

PURPOSE

To evaluate the incidence of chronic cicatrizing conjunctivitis (CCC) and its associated risk factors in the context of chronic ocular graft-vs-host disease (coGVHD).

METHODS

A retrospective chart review of individuals diagnosed with coGVHD following hematopoietic stem cell transplantation (HSCT) who were seen at the Bascom Palmer Eye Institute between May 2010 and November 2021 was performed. Data regarding baseline demographic characteristics, systemic co-morbidities, lid margin abnormalities, ocular cicatricial changes, transplant information, immunosuppressive therapy, and GVHD severity assessments were collected. The incidence of cicatricial conjunctivitis was estimated with Kaplan-Meier survival analysis. A Cox regression model was used to assess the contribution of demographic and systemic variables to the development of CCC.

RESULTS

167 individuals were included (53.9 ± 14.7 years old; 60.5 % male). 65 individuals presented with features suggestive of CCC an average of 60.9 ± 53.8 months after HSCT, with 60-month and 120-month incidences of 29.3 % and 48.9 %, respectively. Multivariable analysis demonstrated that age younger than 50 at the time of the first eye visit was associated with a higher chance of CCC development (Hazard Ratio (HR): 2.14, 95 % Confidence Interval (CI): 1.16-3.97, p = 0.02).

CONCLUSION

Clinically detected cicatrizing conjunctivitis is an ocular manifestation of coGVHD, with an incidence that increases over time. Younger individuals may be at higher risk for CCC development.

Advances in the ocular complications after hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) has benefited an increasing number of patients with hematological disease in the clinic. It is a curative therapy for malignant and nonmalignant hematological diseases. With the advancement and further clinical application of HSCT in recent years, the life expectancy of patients has increased, but complications have become more common. The occurrence of ocular complications is receiving increasing attention because they can seriously affect the quality of life of patients. Ocular complications require increased attention from clinicians because of their negative impact on patients and increasing incidence. Most of recent reports on posttransplant ocular complications involve ocular manifestations of graft-versus-host disease (GVHD), and a few ocular complications that do not originate from GVHD have also been reported. This review summarizes the diagnosis, scoring criteria, pathophysiology, and clinical manifestations of and common therapies for ocular graft-versus-host disease(oGVHD) after HSCT, and includes a description of some rare cases and novel therapies.

Understanding Ocular Graft-versus-Host Disease to Facilitate an Integrated Multidisciplinary Approach

Ocular graft-versus-host disease (oGVHD) remains a challenging and potentially devastating complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Although oGVHD significantly impacts the quality of life of affected survivors, it often goes unrecognized, particularly in the early stages. Targeting all providers in the HSCT community who see patients regularly and frequently for their post-allo-HSCT care, this review and opinion piece introduces the basic concepts of ocular surface pathophysiology, dissects the different stages of clinical presentation of oGVHD, explains why the current diagnostic criteria tend to capture the late disease stages, and highlights the warning signs of early disease development to facilitate prompt referral of oGVHD suspects for ocular specialist care. Along with introducing a comprehensive list of treatment options, this review emphasizes basic therapeutic strategy and options that can be safely and effectively initiated by any care provider. We believe in empowering patients as well as care providers beyond disciplinary boundaries to provide the most cohesive and integrated care in a multidisciplinary approach.

Scleral Lenses for Managing Dry Eye Disease in the Absence of Corneal Irregularities: What Is the Current Evidence?

Scleral lenses (SLs) are large-diameter rigid contact lenses that are a mainstay treatment for eyes with corneal irregularities. In recent years, there has been increased interest in the role of managing dry eye disease (DED) with SLs, as many patients with DED have reported symptomatic relief with SL wear. The role of SLs for DED management when there are associated corneal irregularities is supported by individual case reports and studies. This has prompted practitioners to begin advocating using SLs in DED cases, even in the absence of associated corneal irregularities and other ocular surface diseases (OSDs). There have also been discussions on potentially placing SLs earlier in the treatment hierarchy of DED, where it currently sits at a more advanced level of intervention (Step 3) in the TFOS DEWS II Report. This review will present the currently available, albeit sparse, evidence that supports and suggests this practice, as well as ancillary evidence supporting the purported benefits of SL wear in DED. The advantages of SL wear, such as corneal healing, absence of tear evaporation and contact lens dehydration, and improved visual acuity with associated increased wear comfort, and how this will benefit DED patients will be explored. Conversely, the challenges associated with fitting SLs in DED patients, including increased midday fogging, poor wettability, and subjective patient satisfaction, will also be presented, as well as a discussion on the key considerations for SL fitting in this population. Overall, while more research is needed to support the use of SLs in DED patients without associated corneal irregularities and other forms of OSD, the use of these lenses may prove to have a potentially wider role given their reported ancillary benefits in these populations.

How does ocular graft-versus-host disease fit under the dry eye umbrella? A review

Graft-versus-host disease (GVHD) is a systemic disease that can affect multiple organs as a consequence of an allogeneic haematopoietic stem cell transplant. One organ system that is often affected in GVHD is the eyes. Ocular GVHD (oGVHD) may involve various structures within the eye including the lacrimal glands, eyelids, conjunctiva, cornea, and nasolacrimal ducts, and is a source of morbidity in patients with GVHD. Common presenting features of GVHD overlap with dry eye disease (DED), including decreased tear production, epithelial disruption, and Meibomian gland dysfunction (MGD). In this review, we aim to compare oGVHD and DED to better understand the similarities and differences between the conditions, with a focus on pathophysiology, risk factors, clinical features, and treatments.

Corneal Descemetocele Management with Multi-Layer Amniotic Membrane Transplantation in an Ocular Graft-versus-Host Disease Case

Background: Chronic ocular graft-versus-host disease (oGVHD) is a common ocular complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT), characterized by progressive inflammation of the ocular surface and refractory dry eye. In severe cases, sterile corneal perforation can occur, which poses a significant challenge, due to the low survival rate of grafts after corneal transplantation. Case Presentation: A 47-year-old female presented to our hospital with persistent dryness, foreign body sensation, and blurred vision in her left eye. Diagnosis of graft-versus-host disease with corneal descemetocele in the left eye was made after detailed history review and thorough examination. Multi-layer amniotic membrane transplantation was performed in the affected eye, resulting in amelioration of the patient's symptoms. This amelioration of symptoms provided the patient with a level of comfort that permitted additional time while awaiting corneal transplantation. Conclusions: We report a successful case of multi-layer amniotic membrane transplantation for the management of corneal descemetocele following allo-HSCT.

Development of corneal contact lens materials and current clinical application of contact lenses: A review

Unlike conventional glasses, corneal contact lenses (CLs) can directly contact the surface of the tear film through the application of biopolymer materials, to achieve therapeutic and cosmetic purposes. Since the advent of polymethylmethacrylate, a material that has gained widespread use and attention, statistically, there are now more than 150 × 106 people around the world who wear corneal contact lenses. However, the associated complications caused by the interaction of contact lenses with the ocular surface, tear film, endogenous and environmental microorganisms, and components of the solution affect nearly one-third of the wearer population. The application of corneal contact lenses in correcting vision and myopia control has been widely recognized. With the development of related materials, corneal contact lenses are applied to the treatment of ocular surface diseases, including corneal bandage lenses, drug-loaded corneal contact lenses, biosensors, and other new products, while minimizing the side effects associated with CL wear. This paper summarized the development history and material properties of CLs, focused on the current main clinical applications and mechanisms, as well as clarified the possible complications in wearing therapeutic contact lenses and the direction for improvement in the future.

Role of therapeutic contact lenses in management of corneal disease

PURPOSE OF REVIEW

The current review highlights areas of innovation and research in the use of contact lenses in the treatment of corneal ectasia and ocular surface disease.

RECENT FINDINGS

A series of academic reports were published by a committee of experts reviewing evidence-based practice patterns of contact lens use. There continues to be active research in the use of contact lenses in the management of keratoconus, including mini-scleral lenses, custom impression-based scleral lenses and wavefront-guided scleral lenses. Recent reports on contact lenses for ocular surface disease were primarily reviews, retrospective case reports or case series, with publications on contact lens use in corneal epithelial defects, graft-vs.-host disease, limbal stem cell deficiency and neurotrophic keratitis. There are recent publications on advances in drug-eluting contact lenses.

SUMMARY

Corneal specialists should be aware of current advances in the field of contact lens expanding their use in corneal ectasia and ocular surface disease.