Jill Bryant, OD, FAAO

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Jill Bryant, OD, FAAO Director of Contact
Lens Duke Eye Center
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Graft Versus Host Disease

• Graft donor bone marrow and immune cells or
  lymphocytes given to the recipient
• Host recipient body cells
• GVHD complication of bone marrow transplant in
  which functional immune cells in the transplanted
  marrow recognize the recipient as foreign and
  mount an immunologic attack

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Types of GVHD

• Acute GVHD
• ? occurs within the first 3 months
  post-transplant
• ? symptoms happen quickly and may be mild or
  severe
• Chronic GVHD
• ? occurs from 3 months to 1 year or longer
  after transplant
• ? symptoms progress slowly and can be mild or
  severe
• ? symptoms may reoccur
• ? may last a lifetime

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GVHD Type Skin Liver GI Tract Lungs Eyes
Acute ? red palms and soles of feet ? rash ? itchy, dry skin ? liver enlargement ? ? liver function tests ? abdominal tenderness ? nausea ? diarrhea ? abdominal cramps ? appetite loss
Chronic ?darkened, dry skin ? skin peeling ? liver enlargement ? ? liver function tests ? abdominal tenderness ? yellowish color to skin and eyes ? dry mouth ? diarrhea ? weight loss ? appetite loss ? difficulty with taking deep breaths ? shortness of breath ? dry eyes ? light sensitivity
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Rates of GVHD

• 30-40 among related donors and recipients
• 60-80 among unrelated donors and recipients
• the greater the mismatch between donor and
  recipient, the greater the risk of GVHD
• Recipients take medications such as cyclosporine,
  tacrolimus, mycophenolate, methotrexate, and
  steroids to reduce the chance or severity of GVHD
• Recipients are immunosuppressed

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Patient JH

• 44 year old Caucasian female
• Dx myelofibrosis arising from essential
  thrombocytosis
• s/p allogeneic stem cell transplant 12/09/08
• May 2009 dx GVHD after presenting with pruritis
  across upper chest and back of neck dry,
  irritated eyes dry mouth pain when swallowing
• Started on Prednisone, Restasis, Systane for eye
  and mouth GVHD by BMT physician
• Referred to Duke Eye Center

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Patient JH

• Evaluated by cornea specialist who advised pt to
  continue Restasis, preservative free ATs QID OU,
  inserted bilateral lower punctal plugs
• Returned to corneal specialist few weeks later
  reporting no relief and bilateral upper punctal
  plugs inserted
• Returned to corneal specialist again reporting no
  improvement and advised to add Genteal gel qhs OU
• 8 months later returns with increased frustration
  with her dry eyes was referred to CL clinic
• 2/19/10 Patient JH presents to Duke CL Clinic

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February 2010 - CL Clinic

• c/o severe ocular redness, burning OU for 10
  months made statement that her ocular symptoms
  have much more difficult to cope with than having
  gone through a BMT
• Difficulty with air in certain rooms, unable to
  walk outside, unable to read a book, unable to
  work on computer, unable to work
• Currently on short term disability from job as a
  teachers assistant in an elementary school
• Reports compliance with Restasis BID OU, has
  punctal plugs (upper and lower), frequent
  lubrication with preservative free artificial
  tears q 15 minutes, artificial tear ointments,
  humidifier, holding cold compresses over eyes for
  relief, hyperhydration with water, taking
  multiple showers daily just to get moisture
  around her eyes
• Hopeful that scleral lenses would help wants to
  regain her life and wants to return to work

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Current Medications

• Cyclosporine 75mg BID
• Cellcept 1000mg BID
• Prednisone 10mg every other day alternating with
  5 mg
• Fluconazole 400mg daily
• Aspirin 81mg daily
• Septra DS every M, W, F
• Multivitamin daily
• Protonix 40mg daily
• Mag Ox 500mg BID
• Calcium and Vitamin D 600mg daily
• Dexamethasone 0.5mg/5ml swish and spit 1-2 times
  daily
• Premarin vaginal cream 2 times weekly
• Neurontin 300mg TID
• Famvir 500mg TID
• Allergies Meperidine and meningitis vaccine
• Social History no tobacco, alcohol, or
  recreational drug use

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Exam Data

• No current prescription
• Uncorrected VA OD 20/30
• OS 20/30
• Manifest Refraction
• OD -0.75-0.25x016 20/20
• OS -0.75-0.50x106 20/20
• SLE 1-2diffuse corneal SPE OU
• 2 conjunctival staining OU
• immediate tear break-up time OU
• ? IOP OD 14 mmHg EOMs FROM OU
  Pupils OD 5?3mm
• OS 14 mmHg CF FTFC OD, OS
  OS 5?3mm
• 
  No APD
• ? DFE ON 0.1 round pink and distinct OU
• Macula flat and intact FLR OU
• Vessels 2/3 AV ratio OU
• Periphery OD flat and intact OS RPE
  hypertrophy superior nasal

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Corneal Topography
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Patient JH
Jupiter OD -7.25 Sph 7.03 BC 18.2 OAD OS
-6.25 Sph 7.18 BC 18.2 OAD
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2 week f/up after lenses dispensed

• Wearing lenses for 10 hours with no discomfort
• Stopped Restasis and rarely using ATs
• Returned to work
• Life is getting back to normal

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Anxiety and Depression in Dry Eye

• Unremitting pain
• Life Impact
• Financial Impact
• Personal appearance
• Difficulties seeking medical care
• Other variables

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Anxiety and Depression in Dry Eye

• Dry Eye Disease can negatively impact activities
  of daily living
• Documented cases of patients committing suicide
  from dry eye
• Be aware of patients with chronic dry eye
  exhibiting signs of depression