Manifestation of Clinical Categories of Ocular Graft-versus-Host Disease

Abstract

This study aims at improving the understanding of the subjective symptoms and signs of two different clinical categories of ocular graft-versus-host disease. After reviewing and screening 193 posthematopoietic stem cell transplantation (HSCT) patients of Peking University Third Hospital, we enrolled 148 (21 acute ocular GVHD, 127 chronic ocular GVHD). Patients' subjective symptoms, ocular parameters, and typical ocular signs were collected and evaluated at the same visit. Classic acute ocular GVHD patients had variable levels of conjunctival involvement but few had keratopathy; increased mucus secretion (21 of 21, 100.0%), red eye (19 of 21, 90.5%), and lacrimation (11 of 21, 52.4%) were the characteristic symptoms. The classic chronic ocular group had severe eye dryness and further corneal lesions, including filamentary keratitis, corneal ulcer, and corneal vascularization. Eye dryness (115 of 127, 90.6%), increased fibrous secretion (53 of 127, 41.7%), photophobia (50 of 127, 39.4%), and alacrimia (45 of 127, 35.4%) were the most common symptoms. Although 44.1% (56 of 127) of these patients had a history of acute ocular GVHD episodes, most were overlooked, so they did not receive stepwise evaluation and treatment. Management of ocular GVHD is very challenging and requires cooperation among disciplines.

Figure 1

Flow diagram of patient selection. ^∗These patients reported onset of dry eye symptoms, including irritation, burning sensation, dryness, or foreign body sensation that required treatment with frequent topical lubricants. However, signs of ocular surface abnormalities including decreased Schirmer's test (≤5 mm), tear break-up time (≤5 seconds), presence of conjunctivitis, and corneal fluorescein staining were absent.

Figure 2

Symptoms of different clinical ocular GVHD categories. (a) Frequencies of different subjective symptoms. (b) Secretion compositions of different ocular disease GVHD categories. cGVHD = chronic graft-versus-host disease; aGVHD = acute graft-versus-host disease.

Figure 3

Typical ocular signs of ocular GVHD. (a)–(f) Signs of acute ocular GVHD and differential diagnosis: (a) mucus secretion (arrow) and conjunctival injection of acute ocular GVHD; (b) mucus secretion using fluorescein dye and visualized under a cobalt blue light; (c) and (d) conjunctiva and cornea signs of mild acute ocular GVHD; (e) and (f) conjunctiva and cornea signs of a post allo-HSCT patient who complained of red eye, lacrimation, and increased eye discharge and was diagnosed with viral corneal dermatitis eventually. (g)–(k) Signs and complications of chronic ocular GVHD: (g) and (h) typical fibrous secretion (arrow) of chronic ocular GVHD; (i) filamentary keratitis; (j) corneal perforation; and (k) corneal vascularization.