Multicenter prospective validation study for international chronic ocular graft-versus-host disease consensus diagnostic criteria.

PURPOSE: To validate the international chronic ocular graft-versus-host disease (GVHD) diagnostic criteria (ICCGVHD) compared to the National Institute of Health diagnostic criteria 2014 (NIH2014) for chronic ocular GVHD. METHODS: Between 2013 and 2019, the study enrolled 233 patients with or without chronic ocular GVHD combined with the presence or absence of systemic chronic GVHD in an internationally prospective multicenter and observational cohort from 9 institutions. All patients were evaluated for four clinical parameters of ICCGVHD. RESULTS: The relation between the ICCGVHD score (0-11) and NIH2014 eye score (0-4) was relatively high (r = 0.708, 95% CI: 0.637-0.767, p < 0.001). The sensitivity and specificity of ICCGVHD for NIH 2014 for 233 patients were 94.3% (95% CI: 89.6%-98.1%) and 71.7% (95% CI: 63.0-79.5%), respectively (cutoff value of the ICCGVHD score = 6). The positive predictive value was 77.1% (95% CI: 71.1%-82.1%), and the negative predictive value was 87.0% (95% CI:81.6-92.5%). For the patients with systemic GVHD (n = 171), the sensitivity and specificity were 94.2% and 67.2%, respectively (ICCGVHD-score cutoff value = 6). By receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) was 0.903 (95% CI: 0.859-0.948). For patients without systemic GVHD (n = 62), the sensitivity and specificity were 100% and 76.7%, respectively (ICCGVHD-score cutoff value = 6). The AUC was 0.891 (95% CI 0.673-1.000). CONCLUSIONS: Good sensitivity, specificity, predictive value and correlation were found between ICCGVHD and NIH2014. ICCGVHD scores ≥6 can be useful to diagnose ocular GVHD with or without systemic GVHD for clinical research.

Treatment strategies in primary vitreoretinal lymphoma: a 17-center European collaborative study.

IMPORTANCE: The best treatment option for primary vitreoretinal lymphoma (PVRL) without signs of central nervous system lymphoma (CNSL) involvement determined on magnetic resonance imaging or in cerebrospinal fluid is unknown. OBJECTIVE: To evaluate the outcomes of treatment regimens used for PVRL in the prevention of subsequent CNSL. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted at 17 referral ophthalmologic centers in Europe. We reviewed clinical, laboratory, and imaging data on 78 patients with PVRL who did not have CNSL on presentation between January 1, 1991, and December 31, 2012, with a focus on the incidence of CNS manifestations during the follow-up period. INTERVENTIONS: The term extensive treatment was used for various combinations of systemic and intrathecal chemotherapy, whole-brain radiotherapy, and peripheral blood stem cell transplantation. Therapy to prevent CNSL included ocular radiotherapy and/or ocular chemotherapy (group A, 31 patients), extensive systemic treatment (group B, 21 patients), and a combination of ocular and extensive treatment (group C, 23 patients); 3 patients did not receive treatment. A total of 40 patients received systemic chemotherapy. MAIN OUTCOMES AND MEASURES: Development of CNSL following the diagnosis of PVRL relative to the use or nonuse of systemic chemotherapy and other treatment regimens. RESULTS: Overall, CNSL developed in 28 of 78 patients (36%) at a median follow-up of 49 months. Specifically, CNSL developed in 10 of 31 (32%) in group A, 9 of 21 (43%) in group B, and 9 of 23 (39%) in group C. The 5-year cumulative survival rate was lower in patients with CNSL (35% [95% CI, 50% to 86%]) than in patients without CNSL (68% [95% CI, 19% to 51%]; P = .003) and was similar among all treatment groups (P = .10). Adverse systemic effects occurred in 9 of 40 (23%) patients receiving systemic chemotherapy; the most common of these effects was acute renal failure. CONCLUSIONS AND RELEVANCE: In the present series of patients with isolated PVRL, the use of systemic chemotherapy was not proven to prevent CNSL and was associated with more severe adverse effects compared with local treatment.

Impact of ocular graft-versus-host disease on visual quality of life in patients after allogeneic stem cell transplantation: questionnaire study.

PURPOSE: To determine the influence of ocular complications on quality of life (QoL) 3 years after allogeneic stem cell transplantation (allo-SCT). METHODS: All 54 adult patients that underwent and survived allo-SCT in 2006/2007 in our centre received two questionnaires (VFQ-25: visual function questionnaire-25 and OSDI: ocular surface disease index). In addition, the following data were included: gender, age, underlying disease, presence of chronic and/or ocular graft-versus-host disease (GVHD), number of visits to an ophthalmologist, manifestations of dry eye disease, the duration of follow-up and treatment for ocular GVHD. RESULTS: Ocular GVHD developed in 26% (14 of 54) of patients and 71% (10 of 14) received treatment for ocular GVHD. The presence of ocular GVHD correlated with the severity of systemic GVHD (correlation coefficient: 0.52, p = 0.00). The Karnofsky scores were significantly lower in the patients with ocular GVHD compared to the patients with no ocular GVHD (p = 0.001). Karnofsky scores were weakly correlated with the severity of systemic GVHD (correlation coefficient: 0.25, p = 0.03. Three years after the all-SCT, OSDI and VFQ-25 scores were significantly impaired in patients with ocular GVHD [mean: 76.5; range (46.1-100) and mean: 31.1; range (0-72.9)] compared to patients with no ocular GVHD [mean: 89.4; range (45.2-100) and mean: 12.9; range (0-58.3); p = 0.02]. The scores of the VFQ-25 were significantly lower in the domains of general health, ocular pain, social functioning and role difficulties. CONCLUSION: The long-term vision-related QoL measured by the OSDI and VFQ-25 was impaired in patients with ocular GVHD.

Absence of intraocular infections after hematopoietic stem cell transplantation at a single center: the experience with current preventive regimens.

PURPOSE: To investigate the prevalence of intraocular infections after allogeneic stem cell transplantation (allo-SCT). METHODS: The study design was a single institutional retrospective noncomparative cohort of 135 consecutive patients in 2006 and 2007 who underwent allo-SCT for hematological malignancy. The primary outcome was the development of intraocular infections after allo-SCT and secondary outcome consisted of development of other ocular disorders during follow-up. RESULTS: The most frequent ocular sequel to allo-SCT included ocular graft-versus-host disease (GvHD), which developed in 37/135 patients (27%). Intraocular infection occurred in 1 of 135 patients (0.7%). This patient developed infectious chorioretinitis together with osteomyelitis, endocarditis, and brain abscess with fungus Scedosporium and was successfully treated with a combination of voriconazole, amphotericine B, and surgical interventions. Viral and/or bacterial intraocular infections were not observed at all. CONCLUSIONS: Intraocular infections after allo-SCT are currently uncommon due to systematic use of preemptive treatment regimens, frequent controls, and early treatment of systemic infections.

International Chronic Ocular Graft-vs-Host-Disease (GVHD) Consensus Group: proposed diagnostic criteria for chronic GVHD (Part I).

The International Chronic Ocular GVHD Consensus Group held 4 working meetings to define new diagnostic metrics for chronic ocular graft-versus-host disease (GVHD). After considering the factors currently used to diagnose chronic ocular GVHD, the Consensus Group identified 4 subjective and objective variables to measure in patients following allogeneic hematopoietic stem cell transplantation (HSCT): OSDI, Schirmer's score without anesthesia, corneal staining, and conjunctival injection. Each variable was scored 0-2 or 0-3, with a maximum composite score of 11. Consideration was also given to the presence or the absence of systemic GVHD. On the basis of their composite score and the presence or absence of systemic GVHD, patients were assigned to one of three diagnostic categories: NO, PROBABLE, or DEFINITE ocular GVHD. New diagnostic criteria for chronic ocular GVHD are presented by the Consensus Group. Validation studies are needed to identify the best combination of the proposed metrics to maximize diagnostic sensitivity and specificity.

Cytokines in tear fluid of patients with ocular graft-versus-host disease after allogeneic stem cell transplantation.

PURPOSE: To investigate the profile of cytokines in tear fluid of patients after allogeneic stem cell transplantation (allo-SCT) and determine their relation to the presence and manifestations of ocular graft-versus-host disease (GvHD). METHODS: In this cross sectional study tear fluid was collected in 34 consecutive adult patients that previously underwent allo-SCT (16 with ocular GvHD and 18 without) and 16 age- and gender-matched healthy controls using the Schirmer test under local anesthesia. Tear fluid was analyzed by multiplex immunoassay for the presence of interleukin (IL)-2, IL-4, IL-6, IL-10, IL-17, tumor necrosis factor (TNF)-α and interferon (IFN)-γ. Levels of measured cytokines were correlated with the findings in slit lamp examination and the Ocular Surface Disease Index (OSDI). RESULTS: The levels of IL-6 and IFN-γ in tear fluid in ocular GvHD patients were significantly elevated in comparison to patients without ocular GvHD and healthy controls (p<0.005 for each) The levels of IFN-γ correlated with the Schirmer score (r=-0.48, p<0.0001) and tear break up time (TBUT; r=-0.38, p=0.03). Tear IL-6 levels correlated with complaints of dry eyes (r=0.39, p=0.02), tear production (r=-0.59, p<0.0001), fluorescent staining of the cornea (r=0.42, p=0.01), and with the OSDI score (r=0.40, p=0.005). CONCLUSIONS: IL-6 and IFN-γ were elevated in tear fluid of patients with ocular GvHD and correlated with different symptoms of dry eye disease, suggesting that IFN-γ is elevated during the early stages and IL-6 is involved in later stages of ocular GVHD and exhibits moreover an association with its severity.

Intraocular and plasma HIV-1 RNA loads and HIV uveitis.

OBJECTIVE: The objective of this study was to analyze human immunodeficiency virus (HIV) dynamics across the blood-retinal barrier and to determine whether the high levels of HIV in the eye are associated with any ocular disorders in HIV-infected patients. DESIGN: This study included a prospective case series of 40 HIV-positive patients with uveitis. INTERVENTION: Clinical and laboratory examinations included plasma and intraocular HIV-1 RNA loads as well as the clinical manifestations of uveitis. RESULTS: Intraocular HIV-1 RNA was detected in 32% (13/40) of HIV-positive patients with uveitis. Intraocular HIV-1 RNA loads were associated with high HIV-1 RNA plasma loads (P < 0.001) and not being on HAART therapy (P = 0.005). In addition, detectable intraocular HIV-1 RNA levels were higher in patients with the absence of retinal lesions (P = 0.008). In three patients, the HIV load in the eye largely exceeded that of plasma. These three patients had all bilateral anterior uveitis and/or vitritis without retinal lesions and exhibited no evidence of other intraocular infectious agents causing uveitis than HIV itself. CONCLUSION: The eye can form a sanctuary where HIV might replicate and cause an inflammatory reaction.

Current insights into ocular graft-versus-host disease.

PURPOSE OF REVIEW: To update our knowledge on hematopoietic stem cell transplantation (SCT) and graft-versus-host disease (GVHD) and summarize the current treatment options for ocular GVHD. RECENT FINDINGS: Allogeneic (allo)-SCT represents a treatment option for a number of hematological malignancies and bone marrow disorders; the indications for this procedure are still increasing. Ocular GVHD develops in 40-60% of patients after allo-SCT, can cause severe ocular surface disease and has a negative impact on quality of life. There are no widely accepted guidelines for the treatment of ocular GVHD. In addition to the usual treatment with artificial tears, topical steroids, punctal occlusion and contact lenses, recent treatment options include anti-inflammatory medications including topical cyclosporine A and tacrolimus. Unfortunately, none of the treatment regimens are completely satisfactory and systematic data on the efficacy of these agents are lacking. The preventive treatment possibilities for ocular GVHD have not been defined. SUMMARY: This review summarizes current data on ocular GVHD and focuses on novel treatment options for this severe ocular disorder. More data on the impact of ocular GVHD and the development of therapeutic and preventive measures are needed.