Non-Graft-versus-Host Disease Ocular Complications after Hematopoietic Cell Transplantation: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation.

Non-graft-versus-host disease (GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT) but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplantation physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment and ocular toxicities associated with medications. We summarize the incidence, risk factors, screening, prevention, and treatment of individual complications and generate evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical signs and symptoms and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplantation physicians and ophthalmologists should be knowledgeable about non-GVHD ocular complications and provide comprehensive collaborative team care.

USH1G with unique retinal findings caused by a novel truncating mutation identified by genome-wide linkage analysis.

PURPOSE: Usher syndrome (USH) is an autosomal recessive disorder divided into three distinct clinical subtypes based on the severity of the hearing loss, manifestation of vestibular dysfunction, and the age of onset of retinitis pigmentosa and visual symptoms. To date, mutations in seven different genes have been reported to cause USH type 1 (USH1), the most severe form. Patients diagnosed with USH1 are known to be ideal candidates to benefit from cochlear implantation. METHODS: Genome-wide linkage analysis using Affymetrix GeneChip Human Mapping 10K arrays were performed in three cochlear implanted Saudi siblings born from a consanguineous marriage, clinically diagnosed with USH1 by comprehensive clinical, audiological, and ophthalmological examinations. From the linkage results, the USH1G gene was screened for mutations by direct sequencing of the coding exons. RESULTS: We report the identification of a novel p.S243X truncating mutation in USH1G that segregated with the disease phenotype and was not present in 300 ethnically matched normal controls. We also report on the novel retinal findings and the outcome of cochlear implantation in the affected individuals. CONCLUSIONS: In addition to reporting a novel truncating mutation, this report expands the retinal phenotype in USH1G and presents the first report of successful cochlear implants in this disease.

A study of KIR genes and HLA-C in Vogt-Koyanagi-Harada disease in Saudi Arabia.

PURPOSE: Vogt-Koyanagi-Harada (VKH) disease is a serious ocular inflammatory autoimmune insult directed against antigens associated with melanocytes. The repertoire of killer cell immunoglobulin-like receptors (KIRs) is known to play a significant role in the pathogenesis of various autoimmune disorders. Accordingly, we sought to determine the incidence of KIR genes and KIR ligand (Human leukocytes antigen [HLA-C]) interaction in a cohort of Saudi VKH patients and to compare the findings to normal controls. METHODS: A total of 30 patients with VKH and 125 control subjects were included. PCR using sequence-specific oligonucleotide primers were employed to determine the genotype of the KIR genes and HLA-C alleles. RESULTS: The frequency of KIR2DS3 was significantly higher in the VKH patients than in the control group (p=0.048). Two unique genotypes; VKHN*1 and VKHN*2 were observed in the VKH patients and not in normal controls. In addition, the majority of the VKH patients (82%) in this study carry Bx genotypes that encode 2-5 activating KIR receptors. The genotype Bx5 was found to be positively associated with the VKH patients (p=0.053). Significantly higher homozygosity of HLA-C2 was observed in the VKH patients than in controls (p=0.005). Furthermore, HLA-C alleles-Cw*14 and Cw*17 were significantly prevalent in the VKH patients (p=0.037 and p=0.0001, respectively), whereas, Cw*15 significantly increased in the control group (p=0.0205). Among potential KIR-HLA interactions, we observed KIR2DL2/2DL3+HLA-C1 to be higher in the control subjects compared with the VKH patients (p=0.018). CONCLUSIONS: Our findings indicated that KIR2DS3 and HLA-class I alleles (-Cw*14 and -Cw*17) may play a role in the pathogenesis of VKH disease. Additionally, the predominance of KIR2DL2/2DL3+HLA-C1 in the controls may imply that this KIR-ligand interaction could possibly play a role in the prevention of VKH disease, or could decrease its severity. These observations may contribute to our understanding of the pathogenesis of VKH and other autoimmune diseases.

The association of systemic disorders with Vogt-Koyanagi-Harada and sympathetic ophthalmia.

BACKGROUND: The aim of this work is to determine the systemic diseases and malignancy associated with Vogt-Koyanagi-Harada (VKH) disease compared to sympathetic ophthalmia (SO). METHODS: We conducted a retrospective comparative observational clinical study where the medical records of patients with the diagnosis of VKH and SO from 1999-2009 were reviewed. The study was carried out at the King Khaled Eye Specialist Hospital and The Eye Center in Riyadh, Saudi Arabia. Investigators recorded the age, gender, history of trauma, associated systemic disorders, and ocular and systemic manifestations. Patients were examined by an ophthalmologist as well as an internist. RESULTS: A total of 316 patients were included: 256 patients had VKH and 60 patients had SO. The age range in the VKH group was 3-62 years with a mean age of 29 ± 13 years. The age range in the SO group was 4-90 years with a mean age of 36 ± 20 years. The mean follow-up period of patients with VKH was 58 ± 50 months and patients with SO was 61 ± 54 months. Out of 256 patients with VKH, there were 41 (16%) with systemic disorders. Comparatively, out of 60 patients with SO, no associated systemic autoimmune disorders or tumors were encountered. The difference between the VKH and SO groups was statistically significant (p = 0.003). CONCLUSIONS: VKH and SO are autoimmune disorders targeting melanin-bearing cells. Both diseases are characterized by immunologic dysregulation. We found a statistically significant association of systemic disorders and malignancy with VKH compared to SO. This finding may suggest that the two disorders may have different etiology with similar ocular and systemic manifestations.

Molecular epidemiology of adenoviral keratoconjunctivitis in Saudi Arabia.

PURPOSE: Adenoviral keratoconjunctivitis is a major cause of ocular morbidity and may lead to visual loss. Adenovirus types 8, 19, and 37 may cause epidemic keratoconjunctivitis. The main objective of this study was to determine the types of adenoviruses causing keratoconjunctivitis in Saudi Arabia. METHODS: We conducted a non-interventional observational clinical study. Seventy three eyes from 65 patients who presented to The Eye Center in Riyadh, Saudi Arabia with clinical features of acute adenoviral keratoconjunctivitis were included. Each patient underwent complete clinical examination and features such as membranous reaction, conjunctival hemorrhage, subepithelial corneal infiltrates, and preauricular lymph node enlargement were recorded. Conjunctival swabs were obtained from patients with presumed acute viral conjunctivitis. Immunochromatography (IC) and restriction fragment length polymorphism polymerase chain reaction (PCR-RFLP) were performed on the conjunctival swabs obtained from each eye. Serotype identification was performed using direct sequencing technique. RESULTS: Forty-nine (67.1%) were adenovirus type 8, 8 (11.0%) were adenovirus type 3, 6 (8.2%) type 37, 5 (6.8%) were adenovirus type 4, and 2 (2.3%) type 19. The remaining 5 were types 14, 19, and 22. The prevalence of membranous conjunctivitis was highest (83%) among eyes with adenovirus type 37 while subepithelial corneal opacities were most commonly seen among eyes with adenovirus type 8 (47%). Immunochromatography tests were positive for adenovirus in 48 (65.7%) out of 73 eyes. CONCLUSIONS: This study determined the types of adenoviruses causing keratoconjunctivitis at one center in Saudi Arabia. Direct sequencing techniques is an efficient, accurate, and rapid means of diagnosing adenoviral keratoconjunctivitis. The most common causes of adenoviral keratoconjunctivitis in Saudi Arabia were adenovirus types 8, 3, and 37. Membranous conjunctivitis and subepithelial opacities had the highest frequency of adenovirus types 37 and 8, respectively. Lymph nodes enlargement was least likely in adenovirus type 4.

A clinical approach to the diagnosis of retinal vasculitis.

Retinal vasculitis is a sight-threatening inflammatory eye condition that involves the retinal vessels. Detection of retinal vasculitis is made clinically, and is confirmed with the help of fundus fluorescein angiography. Active vascular disease is characterized by exudates around retinal vessels resulting in white sheathing or cuffing of the affected vessels. In this review, a practical approach to the diagnosis of retinal vasculitis is discussed based on ophthalmoscopic and fundus fluorescein angiographic findings.

Topical Tacrolimus in Thygeson Superficial Punctate Keratitis.

PURPOSE: To evaluate the efficacy of topical tacrolimus 0.02% eye drops in the treatment of patients with Thygeson superficial punctate keratitis. METHODS: Ten consecutive patients with Thygeson superficial punctate keratitis were included retrospectively. Seven patients were unresponsive to topical steroids and/or lubricants. Diagnosis was made based on the history and clinical findings. All patients were treated with topical tacrolimus 0.02% solution twice daily. Outcome measures included improvement in symptoms of tearing and photophobia, whereas improvement in signs included decrease in the number of the lesions, resolution of the lesions, flattening of the lesions, and decrease in stain of the lesions. RESULTS: There were 3 male and 7 female patients with an age range of 3 to 51 years (mean 17 years). All patients had bilateral ocular involvement. Duration of treatment ranged from 1 to 42 weeks (mean 10 weeks). All patients had subjective improvement in symptoms of tearing and photophobia and resolution of the superficial punctate keratitis. The response to treatment was noted 72 hours after initiation of therapy in all patients. Topical tacrolimus was well tolerated in all patients. CONCLUSIONS: Topical tacrolimus 0.02% is safe and effective in reducing ocular surface inflammation in patients with Thygeson superficial punctate keratitis who are not responsive to conventional therapy. Tacrolimus is helpful as a steroid-sparing agent to avoid vision-threatening complications.

Hydroxychloroquine dosing and toxicity: A real-world experience in Saudi Arabia of 63 patients.

PURPOSE: To assess the ocular toxicity in patients on high doses of hydroxychloroquine (HCQ) per weight, as per the latest American Academy of Ophthalmology (AAO) screening guidelines for HCQ toxicity. METHODS: This is a multi-center study looking at consecutive patients attending the ophthalmology clinics at a tertiary hospital and a private clinic in Saudi Arabia. A data collection sheet was used to collect patient's information regarding the dose per body weight, duration of HCQ use and any risk factors associated with the use of the medication as per the latest AAO guidelines for HCQ screening. Ancillary testing including fundus photography, automated visual field (10-2) and spectral domain ocular coherence tomography were done. Further testing with fundus auto-fluorescence and multifocal ERG were done when needed. The presence or absence of toxicity was recorded. RESULTS: A total of 63 patients were included in the study, 58 females and 5 males. The average patient age was 45 years (range 18-72). The mean dosage of HCQ was 3.9 mg/kg. Fourteen (22%) patients were on doses higher than 5 mg/kg. The duration of treatment ranged from 1-30 years (average 8.3). Thirty six (57%) patients were on the drug for more than 5 years. We found only one (1.58%) patient with HCQ toxic retinopathy over a mean of 8 years treatment period. CONCLUSION: A significant number of our patients were found to be on doses of >5 mg/kg of HCQ, which may put them at a higher risk for retinal toxicity. Low dose HCQ such as 100 mg tablets should be made available to help physicians in adjusting the dose as per the latest reported guidelines by the AAO.

Incidence of posterior capsule opacification following phacoemulsification in patients with uveitis.

PURPOSE: The purpose of this study was to evaluate the incidence of posterior capsule opacification (PCO) in patients with inactive uveitis who underwent phacoemulsification with acrylic hydrophobic intraocular lens. METHODS: Thus was a retrospective review of 25 consecutive patients (31 eyes) with uveitis who underwent phacoemulsification. A group of 100 patients (140 eyes) without uveitis served as historical controls. RESULTS: In patients with uveitis, PCO occurred in 11 eyes (35.5%), 6 (19%) of which were visually significant and required treatment with neodymium-doped yttrium aluminum garnet (Nd: YAG) laser. In the control group, PCO developed in 17 (12%) eyes which required treatment with Nd: YAG laser. The incidence of PCO was significantly higher in uveitis patients compared to the control group (P = 0.001), but the incidence of visually significant PCO requiring laser capsulotomy was not statistically significant (P = 0.3). CONCLUSION: The incidence of PCO in patients with uveitis was significantly higher than those without uveitis, but the need for Nd: YAG laser capsulotomy for visually significant PCO was not statistically significant.

Aqueous penetration of topical tacrolimus.

PURPOSE: To evaluate the penetration of topical tacrolimus 0.05% into the aqueous humor. OBSERVATIONS: A total of four patients scheduled for routine cataract surgery were included prospectively. We excluded patients with corneal pathology or ocular surface diseases. Topical tacrolimus 0.05% was compounded at our facility. It was dosed every 1 min for 5 min an hour before the aqueous was sampled. Aqueous samples were collected at the time of cataract surgery and were subjected to detection of presence and level of tacrolimus. There were 2 male and 2 female patients. The age range was 58-73 years with a mean age of 66 years. Tacrolimus was detected in the aqueous humor in all patients. The concentration of tacrolimus in the aqueous ranged from 2.6 to 5.6 ng/ml (mean 4.15 ± 1.18 ng/ml). In all patients, the aqueous tacrolimus concentration was greater than the minimal therapeutic level. The study was registered at clinicaltrials.gov (registration number is NCT02794610). CONCLUSIONS AND IMPORTANCE: Tacrolimus was detected in the aqueous humor following topical application. Topical tacrolimus may be a promising steroid-sparing modality for the treatment of anterior uveitis.

T Regulatory Cells in Rheumatoid Arthritis with Reference to Anti-Citrullinated Peptide Antibody and TNF-alpha Inhibitor Therapy.

T regulatory cells (Tregs) plays an important role in maintaining self-tolerance and preventing autoimmune diseases by inhibiting proliferation and cytokine production of self-reactive T cells. Controversy was reported regarding the frequency of CD4+CD25+ Tregs in the peripheral circulation of rheumatoid arthritis (RA) patients compared to normal controls. Also, some showed that treatment with TNF-α inhibitor restored the capacity of Tregs. This work aimed to study Tregs in the peripheral blood of RA patients versus control in addition to those on TNF-α inhibitor therapy compared to those who have not received it and to correlate with status of anti-cyclic citrullinated peptide antibody (ACPA). Two groups of RA patients were studied; one on TNF-α inhibitor therapy and the other not. Additionally, age-matched apparently healthy controls were studied. The percentage of CD4+CD25+ T cells in the total lymphocytic cell population was determined by flow cytometry analysis while ACPA concentration was measured by a second-generation peptide-based ELISA. Mean level of Tregs was significantly lower in the studied RA patients compared to the control group. Patients in early disease (0-5 years) had low mean Tregs percentage compared to patients with long duration of disease (> 10 years) (P=0.044). Patients on TNF-α blocker therapy had elevated Tregs percentage relative to patients on methotrexate (MTX) (P=0.022) and other therapies. No effect of gender or age was found on Tregs levels. In RA patients, 85.4% were ACPA seropositive and 65.9% of seropositive patients have concentration of > 100U/ml. The mean Treg percentage was significantly lower in ACPA seronegative group compared to the seropositive group (P=0.013). In conclusion, the studied RA patients have low Treg, and TNF-α blocker therapy increased its number, compared to other therapies.

HLA-DRB1 among patients with Vogt-Koyanagi-Harada disease in Saudi Arabia.

PURPOSE: Vogt-Koyanagi-Harada (VKH) disease is an immune-mediated disorder with autoimmune insult directed against antigens associated with melanocytes. The genetic predisposition among VKH has not been explored in Saudi Arabia. So, the purpose of this study was to investigate the association of human leukocyte antigen (HLA)-DRB1 alleles to VKH patients and to clarify the molecular genetic mechanism underlying the susceptibility or resistance to VKH disease. METHODS: Genomic DNA from a total of 30 patients with VKH and 29 control subjects was extracted from peripheral blood, and HLA-DRB1 alleles were typed by polymerase chain reaction and sequence based typing (SBT). RESULTS: We found a statistically significant difference in the prevalence of HLA-DRB1 *0405 between the VKH patients and control subjects (p<0.05). Eleven out of thirty (36.6%) patients with VKH had positive HLA-DRB1 *0405 compared to two out of twenty-nine (6.9%) control subjects. However, there were no statistically significant differences in the HLA-DRB1 alleles *01, *0101, *0102, *0301, *04, *0403, *0404, *0701, *1001, *1101, *1112, *1301, *1302, *1303, *1501, and *1502 between the VKH patients and controls. CONCLUSIONS: Patients with VKH had significantly greater incidence of HLA-DRB1 *0405 when compared to age and sex-matched controls. Consequently, this finding suggests that HLA-DRB1 *0405 allele might play a role in the pathogenesis of VKH disease.

Ocular findings after allogeneic hematopoietic stem cell transplantation.

OBJECTIVE: To study the incidence, causes, and outcome of major ocular complications in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). DESIGN: Retrospective, noncomparative, observational clinical study. PARTICIPANTS: The study included a total of 620 patients who underwent allogeneic HSCT in the period from 1997 to 2007 at King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. INTERVENTION: Allogeneic HSCT. MAIN OUTCOME MEASURES: Patients with ocular complications were referred to the ophthalmology division for complete ophthalmologic examination, including visual acuity, tonometry, Schirmer test, biomicroscopy, and dilated ophthalmoscopy. Laboratory investigations were performed whenever indicated. The incidence and causes of major ocular complications after allogeneic HSCT were determined. Visual acuity at 1 year after allogeneic HSCT was recorded. RESULTS: Major ocular complications occurred in 80 (13%) of 620 patients who underwent allogeneic HSCT. There were 36 male patients (45%) and 44 female patients (55%) with a mean age of 29 years and an age range of 9 to 65 years. Prophylaxis for graft-versus-host disease (GVHD) consisted of cyclosporine and methotrexate in 69 patients, and cyclosporine, methotrexate and corticosteroids, or mycophenolate mofetil in 11 patients. The most frequently encountered ocular complications were chronic GVHD, dry eye syndrome without GVHD, corneal ulcers, cataract, glaucoma, cytomegalovirus retinitis, fungal endophthalmitis, and acquisition of allergic conjunctivitis from atopic donors. There was no correlation between the pattern of ocular complications and the transplanted stem cell source. Best-corrected visual acuity (BCVA) at 1 year after transplantation was less than 20/200 in 13 patients (16%), less than 20/50 in 17 patients (21%), and better than 20/50 in 50 patients (63%). CONCLUSIONS: Ocular complications are common in patients undergoing allogeneic HSCT. Early recognition and prompt treatment are important. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Initial misdiagnosis of Vogt-Koyanagi-Harada disease.

PURPOSE: To report the initial misdiagnosis of patients with Vogt-Koyanagi-Harada (VKH) disease. METHODS: The medical records of 76 consecutive patients diagnosed with VKH disease were reviewed retrospectively at The Eye Center, Riyadh, Saudi Arabia. Patients were referred to The Eye Center from Saudi Arabia and other Middle Eastern countries. The initial diagnosis was made by an ophthalmologist or neurologist. The main outcome measure was to evaluate cases with VKH disease who were initially misdiagnosed. RESULTS: In 7 (9.2%) out of the 76 patients the initial diagnosis was incorrect. Patients were initially misdiagnosed as optic neuritis (1.3%), intracranial hypertension (1.3%), brain tumor (1.3%), Susac disease (1.3%), migraine (1.3%), rhegmatogenous retinal detachment (1.3%) or anterior granulomatous uveitis of unknown etiology (1.3%). Patients underwent unnecessary tests including MRI and invasive procedures including CSF analysis and anterior chamber paracentesis. CONCLUSION: The initial diagnosis of patients with VKH disease was incorrect in 9 % of the cases. Delay in the diagnosis of VKH disease may lead to delay in management and may cause irreversible damage to the photoreceptors with poor visual outcome.

Assessment of Ophthalmology Residency Programs in Saudi Arabia: A Trainee-Based Survey.

PURPOSE: To assess the satisfaction and competency of Saudi ophthalmology residents and compare their performance against International Council of Ophthalmology (ICO) standards. METHODS: A cross-sectional web-based survey of senior ophthalmology residents (postgraduate years [PGY] 3-4) and recent graduates (from 2010 to 2015) assessed various aspects of training. The questionnaire was sent to the participants and was divided into 3 main domains: demographics, training program evaluation, and preparedness for board exams and clinical practice. RESULTS: Out of the 145 invitees, 120 (82.8%) responded. Fifty percent of respondents reported an overall satisfaction with the program. Adequate clinical exposure was reported in most subspecialties except refraction and low vision rehabilitation with inadequate exposure reported by 55.8% and 95.8%, respectively. Surgical exposure was reported as adequate for phacoemulsification (58.3%) and strabismus surgery (68.3%) only. Eighty-nine percent of respondents reported performing less than 80 cases of phacoemulsification. Of the respondents who had graduated, most (89.7%) passed the final board exam at the first attempt. There were 73.5% of respondents who reported that residency training prepared them well for the board exam. Ongoing clinical and call duties were reported as having a negative impact on exam performance. CONCLUSIONS: Saudi ophthalmology residents demonstrate a high level of clinical competency. However, additional efforts should aim at improving surgical training to increase the level of satisfaction among residents and improve the quality of training to meet international standards.

Correction: Non-GVHD ocular complications after hematopoietic cell transplantation: expert review from the Late Effects and Quality of Life Working Committee of the CIBMTR and Transplant Complications Working Party of the EBMT.

In the original version of this article, author 'Aisha Al-Khinji' was incorrectly listed as 'Aisha Ahmed'. This has now been corrected in both the PDF and HTML versions of the article to 'Aisha Al-Khinji'.

Non-GVHD ocular complications after hematopoietic cell transplantation: expert review from the Late Effects and Quality of Life Working Committee of the CIBMTR and Transplant Complications Working Party of the EBMT.

Non-graft-vs.-host disease (non-GVHD) ocular complications are generally uncommon after hematopoietic cell transplantation (HCT), but can cause prolonged morbidity affecting activities of daily living and quality of life. Here we provide an expert review of non-GVHD ocular complications in a collaboration between transplant physicians and ophthalmologists through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. Complications discussed in this review include cataracts, glaucoma, ocular infections, ocular involvement with malignancy, ischemic microvascular retinopathy, central retinal vein occlusion, retinal hemorrhage, retinal detachment, and ocular toxicities associated with medications. We have summarized incidence, risk factors, screening, prevention and treatment of individual complicastions and generated evidence-based recommendations. Baseline ocular evaluation before HCT should be considered in all patients who undergo HCT. Follow-up evaluations should be considered according to clinical symptoms, signs and risk factors. Better preventive strategies and treatments remain to be investigated for individual ocular complications after HCT. Both transplant physicians and ophthalmologists should be knowledgeable of non-GVHD ocular complications and provide comprehensive collaborative team care.

Acquisition of vernal and atopic keratoconjunctivitis after bone marrow transplantation.

PURPOSE: Vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) result from genetic and environmental factors. We present patients who had no history of atopic disorders before bone marrow transplantation (BMT) and who seem to have acquired VKC or AKC from their donors, who had atopic disorders. DESIGN: Observational case series. METHODS: The patients in this study were part of a cohort of patients who had undergone allogeneic hemapoietic stem cell transplantation (HSCT) from January 1997 through December 2007. Of 621 HSCT recipients, four recipients who were free of allergic disorders acquired VKC or AKC from their afflicted donors after HSCT. Each patient underwent complete ophthalmologic examination, determination of the total serum immunoglobulin (Ig) E, and conjunctival scrapings. RESULTS: Four (0.64%) of 621 patients who had undergone HSCT acquired VKC or AKC after BMT. The donors had VKC or atopic dermatitis. In addition, in two of these four patients, asthma developed. One patient had elevated total serum IgE. Conjunctival scrapings of all four patients revealed the presence of eosinophils. One patient had concurrent graft-versus-host disease. CONCLUSIONS: VKC and AKC are systemic allergic disorders characterized by local ocular manifestations. This report suggests the possibility of the acquisition of VKC or AKC after BMT by adoptive transfer.

Corneal endothelial cytotoxicity of the Calotropis procera (ushaar) plant.

PURPOSE: To report 6 eyes of 5 patients with transient corneal edema after exposure to the milky latex of Calotropis procera (ushaar). METHODS: Interventional case series. RESULTS: Intracorneal penetration of ushaar latex can lead to permanent endothelial cell loss with morphologic alteration. Corneal edema resolved completely in approximately 2 weeks in all cases, despite reduced endothelial cell count and abnormal morphology. CONCLUSIONS: Corneal endothelial toxicity of ushaar latex is caused by its ability to penetrate the corneal stroma and induce permanent loss of endothelial cells. Corneal edema resolves if sufficient endothelial cell viability is still present after resolution of ushaar keratitis.