Management Of Severe Dry Eye Disease Secondary To Graft V/S Host Reaction Post Bone Marrow Transplantation

Step wise immunomodulatory approach in a case of severe, refractory dry eye disease secondary to chronic Graft-versus-host disease (GVHD) following allogeneic bone marrow transplantation.

Tertiary referral ocular surface center managing post–bone marrow transplant GVHD in collaboration with immunology services.

A 55-year-old male with Acute Myeloid Leukemia underwent allogeneic bone marrow transplantation, developed chronic systemic GVHD 7 months post-transplant with dermatologic, neurologic, and ocular involvement.

He presented with severe ocular symptoms including persistent redness, dryness, gritty sensation, photophobia, and blurred vision. Ocular Surface Disease Index (OSDI) score was 75. Slit-lamp examination revealed conjunctival congestion,diffuse punctate erosions,conjunctival staining,reduced tear meniscus height and meibomian gland dysfunction. Schirmer’s test measured 1 mm in both eyes. TBUT was 4 seconds bilaterally. Corneal fluorescein staining was Oxford Grade 5.

Ocular management included the use of topical steroids in tapering dose,sodium hyaluronate with trehalose lubricants (10–12 times/day), and cyclosporine 0.09% eye drops. 3 sittings of Intense Pulse Light therapy was also given. After 3 months, partial improvement was observed with reduction in corneal staining to Oxford Grade 3; symptoms reduced, however, recurrent exacerbations persisted.

Lifitegrast 5% ophthalmic solution was added twice daily as adjunct therapy. After 6 weeks, significant clinical improvement was noted. OSDI improved to 35. Schirmer’s test increased to 5 mm in both eyes.TBUT improved to 9 seconds.Corneal staining reduced to Grade1(OD) and Grade 2(OS). Lubricants usage decreased to 3–4 times daily. Sustained improvement was maintained for over 6 months without flare-ups.

Ocular GVHD represents one of the most severe immune-mediated dry eye phenotypes, often refractory to standard therapy. In this case, adjunctive Lifitegrast resulted in rapid, sustained symptomatic and objective improvement after conventional immunomodulation plateaued.

Targeted inhibition of the LFA-1/ICAM-1 pathway may provide synergistic benefit when combined with corticosteroids and cyclosporine in GVHD-associated DED. These findings support further controlled studies evaluating Lifitegrast as part of combination immunotherapy in severe inflammatory dry eye.