RECURRENT CORNEA AND GRAFT MELTING IN OCULAR GRAFT-VERSUS-HOST DISEASE (GVHD): A REPORT OF TWO CASES
Published 2023 - 27th ESCRS Winter Meeting
Reference: CR16 | Type: Case Report (Cornea Day) | DOI: 10.82333/qdwr-q365
Authors: Tze Wah Dennis Law* 1 , Allie Lee 1
1Department of Ophthalmology,The University of Hong Kong,Hong Kong,Hong Kong
Purpose
We reported the clinical course and treatment outcomes of two cases of severe ocular graft-versus-host disease (GvHD) complicated by recurrent cornea and graft melting. We aim to highlight the treatment strategies and challenges in managing these complex cases.
Setting
Ocular GvHD occurred in up to 70% of patients following allogeneic haematopoietic stem cell transplantation (allo-HSCT). Cornea melting and perforation are uncommon, yet important potential sight-threatening complications. We are a tertiary ophthalmology referral center affiliated with the only adult allo-HSCT facility in the territory.
Report of case
Case 1:
A 57 year-old man, with chronic GVHD of the gastrointestinal tract, skin and eyes, developed a perforated corneal ulcer in the right eye at 18 months post allo-HSCT. Prior to that, he had had bilateral mild dry eyes on artificial tears. Microbiology and systemic autoimmune disease work-up all came back negative. A tectonic corneal graft was performed and melted within three weeks. Despite multi-modality treatments, including bandage contact lens, amniotic membrane, oral antivirals and systemic immunosuppressants, the grafts melted repeated and only stabilized after the fourth graft. His cornea healed with scarring and the final visual acuity was light perception.
His left eye was simultaneously affected with a persistent epithelial defect, which eventually healed with autologous serum and temporary tarsorrhaphy.
Case 2:
A 52 year-old man, with a history of acute GVHD of skin and gastrointestinal tract, developed chronic GVHD of the eyes that responded to artificial tears and punctal occlusion. Subsequently he developed an episode of left eye herpetic corneal ulcer, which recurred twice but responded to oral antiviral. However, at six years post allo-HSCT, he had another recurrent corneal ulcer that progressed to corneal melting, despite multiple ocular and systemic treatments. He received a total of four tectonic corneal grafts within the next 18 months because of repeated melting. All microbiological investigations came back negative. Upon stabilization and after a cataract extraction, his visual acuity went up to 0.7. The eye was stable until six years later, when he developed a new corneal perforation that required another tectonic graft. This time the cornea healed with extensive scarring and his visual acuity was hand movement.
His right eye remained stable on artificial tears throughout the years.
Conclusion / Take home message
These two cases demonstrated bilateral asymmetrical involvement of ocular GvHD with recurrent corneal and graft melting in one eye. These severe complications could develop long after the allo-HSCT and ran a protracted course despite multi-modality treatments. They highlighted the challenges faced by anterior segment specialists in managing very complex ocular surface diseases. Future research to identify high-risk cases and optimize treatment before irreversible visual loss is warranted.