Cornea Cases

Title:

Dry eye treatment options in a case of severe graft-versus host disease (GVHD)

Case Report Details

First Author: K.Aggarwal UK

Co Author(s):    M. Leyland                    

Abstract Details

Purpose:

Ocular GVHD has an incidence of 40-60% in all patients receiving an allo-HSCT. Dry eye is the cardinal ocular disease, caused by extensive fibrotic destruction of tubeoalveolar glands causing raised stromal CD4+ fibroblasts and lymphocytic infiltration. Secondary epithelial changes can cause corneal filaments, painful corneal erosions and resultant infections, non-healing ulcers and corneal perforation which are compounded by the tear film and ocular surface abnormalities. Although visual acuity generally remains good, patients continue to have debilitating symptoms affecting their quality of life. As patient’s systemic GVHD status affects their ocular symptoms, ophthalmologists must understand and treat this.

Setting:

Ophthalmology unit in a district general hospital

Report of case or case series:

A 71-year-old-male was referred to the corneal service in 2010 following a HLA matched sibling allograft bone marrow transplant in 2005 for mantle cell non-Hodgkin’s lymphoma. His dry eye was initially treated with punctal plugs and cautery and he was discharged on topical preservative free (PF) lubricants with vision 6/24 in each eye. In 2014, he attended eye casualty with pain, redness and loss of vision (4/60). A deep corneal infiltrate was noted in the left eye and descemetocele. A corneal scrape was negative for all bacterial and fungal keratitis. He was treated with topical steroids (dexafree 0.1% once a day) and oral doxycycline 100mg. 1 week follow up revealed an inferior corneal perforation in the descemetocele underwent emergency corneal gluing. Unfortunately, 1 week post operatively, he had a larger perforation and underwent emergency penetrating keratoplasty (PK) three days afterwards. A corneal button was sent for microscopy, culture and sensitivities and grew pseudomonas. This raised the possibility of a corneal melt and subsequent perforation and he was therefore started on levofloxacin, PF chloramphenicol and dexafree. His left corneal graft remained stable although the right eye subsequently developed a central scar and thinning in 2017. Vision improved from 6/48 to 6/18 with rigid contact lens although he was not able to tolerate them and was referred for CVI registration. 3 months after, he had extensive vascular pannus in both eyes with a vision of CF. Levofloxacin and dexafree were commenced with improvement after 1 week. As a complication of long term steroids, he developed dense cataract and high eye pressure and therefore underwent uncomplicated right cataract surgery in March 2019. He was discharged in August 2019 with CF vision in each eye. He continues PF latanoprost to the left eye, dexafree to the left eye at night and lubricants as required.

Conclusions/Take Home Message:

This case highlights that for patients with severe dry eye disease from GVHD, a multifaceted approach is needed; both medical and surgical to help control symptoms of dry eyes. Co-infection with bacteria has led to a more complicated patient management pathway. Unfortunately, some of the treatment options including topical steroids have side effects including cataract and high intraocular pressure which also need to be treated with glaucoma drops. These can further exacerbate dry eye symptoms. Therefore, a careful and considered expert approach is needed for these patients including a holistic approach to poor visual outcomes. Early involvement of the ECLO and sight impairment registration may help patients with debilitating and sight threatening dry eyes from chronic GVHD.