Ocular Graft-Versus-Host Disease (GVHD) is an eye complication arising after certain medical procedures. It occurs when transplanted cells react against the recipient’s tissues, leading to inflammation and damage within various eye structures. This can significantly impact vision and overall quality of life.
The Basis of Graft-Versus-Host Disease
Graft-Versus-Host Disease (GVHD) is a systemic disorder where transplanted immune cells recognize and attack the recipient’s body. It commonly arises following an allogeneic hematopoietic stem cell transplant (bone marrow transplant), where healthy donor stem cells replace a patient’s damaged cells, often for conditions like leukemia or lymphoma.
GVHD stems from the immune system’s recognition mechanisms. Every individual’s cells carry unique protein markers called human leukocyte antigens (HLAs), which identify cells as belonging to the body. While transplant teams strive to find a close HLA match, perfect matches are rare outside of identical twins. Donor immune cells, particularly T cells, perceive the recipient’s HLA markers as unfamiliar, initiating an immune response that targets healthy tissues. This attack leads to inflammation and damage in various organs, including the skin, gastrointestinal tract, liver, and eyes.
Identifying Ocular GVHD
Ocular GVHD leads to a range of noticeable eye symptoms. Patients frequently experience persistent dry eyes, often described as a gritty, burning, or foreign body sensation. This dryness results from inflammation of the tear glands and conjunctiva (the clear tissue covering the white part of the eye and inside the eyelids), hindering tear production.
Beyond dryness, redness and irritation are common signs. Patients may also experience discomfort and difficulty keeping their eyes open, particularly in the morning due to dried mucous secretions. Light sensitivity (photophobia) and blurred vision are frequently reported symptoms, impacting daily activities. Excessive tearing or mucous discharge can occur, sometimes paradoxically, as a reflex to severe dryness. In some cases, the eyelids may appear red, swollen, or crusted, with a feeling of itchiness.
Confirming Ocular GVHD
Confirming ocular GVHD involves a thorough evaluation by an ophthalmologist, especially with a history of allogeneic bone marrow transplantation. The diagnostic process includes several specialized examinations to assess the ocular surface and tear film.
The diagnostic process includes several specialized examinations:
- Slit-lamp examination: This standard procedure allows the ophthalmologist to view eye structures like the conjunctiva and cornea in magnified detail. Dyes such as fluorescein, lissamine green, or rose bengal stains may be applied to highlight areas of damage or dryness, revealing conditions like punctate epithelial keratopathy.
- Schirmer’s test: This measures tear production by placing a filter paper strip inside the lower eyelid to quantify wetting over five minutes. A low reading (e.g., ≤ 5 mm) indicates reduced tear production.
- Tear osmolarity tests: These measure the salt concentration in tears; higher osmolarity often indicates dry eye disease.
- Other assessments: These may include tear break-up time, which measures how quickly the tear film evaporates, and corneal sensitivity testing.
Treatment Approaches for Ocular GVHD
Treatment for ocular GVHD focuses on alleviating symptoms, controlling inflammation, and protecting the ocular surface. Initial approaches involve topical treatments for lubrication and irritation reduction. Preservative-free artificial tears are a common first-line therapy, used frequently to keep eyes moist and improve superficial punctate keratitis.
Topical anti-inflammatory medications, such as corticosteroid eye drops, are often prescribed to reduce ocular surface inflammation and prevent scarring. Less potent steroids may be considered due to potential long-term side effects like increased intraocular pressure and cataracts. Other topical immunosuppressants, such as cyclosporine eye drops, help regulate the immune response on the ocular surface and can improve tear function. Lifitegrast 5% eye drops have also shown promise in improving symptoms.
Beyond eye drops, other supportive and advanced treatments include:
- Punctal plugs: These can be inserted into tear drainage ducts to keep tears on the eye surface longer, though their use in GVHD can be debated.
- Scleral lenses: Custom-designed hard contact lenses that rest on the white part of the eye, creating a fluid reservoir over the cornea, significantly improving comfort and vision in severe cases.
- Autologous serum eye drops: Made from a patient’s own blood serum, these provide growth factors and vitamins that support ocular surface healing.
- Warm compresses and oral doxycycline: Used for meibomian gland dysfunction to improve tear film quality.
- Systemic immunosuppressive therapies: Considered if other organs are affected or if topical treatments are insufficient.