Discovery and Verification of Sjögren's Syndrome Protein Biomarkers in Tears by Targeted LC-MRM.

Sjögren's syndrome (SS) is an autoimmune rheumatic disorder characterized by exocrine gland dysfunction, mainly from the lacrimal and salivary glands. The disease causes severe aqueous dry eye syndrome (DED) and is associated with high rates of complications, including corneal ulceration, scaring, and perforation. Systemic complications may occur as well as a higher risk of developing lymphoma. Diagnosis of SS-DED is often delayed and difficult to establish. With the aim of discovering biomarkers to help discriminate SS-DED patients, a combination of untargeted and targeted LC-MS/MS analyses were performed on tear samples collected on Schirmer strips and subjected to tryptic digestion. Following the analysis of three cohorts and the development of two targeted LC-sMRM methods for the verification of putative biomarkers found in the first cohort of samples, 64 proteins could be linked to Sjögren's syndrome, in the hopes of helping to confirm diagnoses as well as potentially stratifying the severity of disease in these patients. Proteins that were increased in SS-DED showed activation of the immune system and alterations in homeostasis. Several proteases and protease inhibitors were found to be significantly changing in SS-DED, as well as a consistent decrease in specific proteins known to be secreted by the lacrimal gland.

Incidence of ocular surface squamous neoplasia in pterygium specimens.

OBJECTIVE: Pterygium and ocular surface squamous neoplasia (OSSN) have been recognized as likely related conditions and share similar risk factors such as ultraviolet radiation and chronic inflammation. The purpose of this study is to review the incidence of OSSN in pathology specimens sent as pterygium at a single tertiary centre between 2010 and 2022. METHODS: This is a retrospective chart review of patients operated on for pterygium between 2010 and 2022 at the University of Montreal Health Centre. Data collected include baseline demographics, results of pathology specimen, and clinical information for cases diagnosed as OSSN on pathology. RESULTS: A total of 1559 patients were operated on for a clinical diagnosis of pterygium between 2010 and 2022, of which 854 patients (55%) were male. A total of 1142 specimens had available pathology reports, and most of the specimens were consistent with pterygium on pathology (1105 of 1142; 97%). There was an unexpected finding of 3 cases of OSSN (3 of 1142; 0.3%). Other diagnosis besides pterygium were seen in 3% of specimens (34 of 1142), including nevus (n = 12), spheroidal degeneration (n = 3), pyogenic granuloma (n = 3), and lymphangiectasia (n = 2). The 3 cases of OSSN included an 81-year-old male of French-Canadian background, a 52-year-old male of South Asian background, and a 59-year-old female of French-Canadian background. The pathology was diagnosed as conjunctival intraepithelial neoplasia (CIN) grade 3, CIN grade 2, and CIN grade 2, respectively. CONCLUSION: The finding of OSSN in pterygium is rare in our population but can be clinically difficult to distinguish. It is important to send all pterygium specimens for pathology.

Survey: Preferred practice patterns in the diagnosis of mucous membrane pemphigoid amongst cornea specialists.

PURPOSE: To evaluate preferred diagnostic tools and treatment decision-making factors in cases suspicious of mucous membrane pemphigoid (MMP) amongst ophthalmologists and cornea specialists. METHODS: Web-based survey, consisting of 14 multiple choice questions, posted to the Cornea Society Listserv Keranet, the Canadian Ophthalmological Society Cornea Listserv, and the Bowman Club Listserv. RESULTS: One hundred and thirty-eight ophthalmologists participated in the survey. Eighty-six percent (86%) of respondents were cornea trained and practiced in either North America or Europe (83%). Most respondents (72%) routinely perform conjunctival biopsies for all suspicious cases of MMP. For those who do not, fear that biopsy will exacerbate inflammation was the most common reason to defer investigation (47%). Seventy-one percent (71%) performed biopsies from perilesional sites. Ninety-seven percent (97%) ask for direct (DIF) studies and 60% for histopathology in formalin. Most do not recommend biopsy at other non-ocular sites (75%), nor do they perform indirect immunofluorescence for serum autoantibodies (68%). Immune-modulatory therapy is started following positive biopsy results for most (66%), albeit most (62%) would not let a negative DIF influence the choice of starting treatment should there be clinical suspicion of MMP. Differences in practice patterns as they relate to level of experience and geographical location are contrasted to the most up-to-date available guidelines. CONCLUSION: Responses to the survey suggest that there is heterogeneity in certain practice patterns for MMP. Biopsy remains an area of controversy in dictating treatment plans. Identified areas of need should be targeted in future research.

Development and deployment of a smartphone application for diagnosing trachoma: Leveraging code-free deep learning and edge artificial intelligence.

PURPOSE: Automated machine learning (AutoML) allows clinicians without coding experience to build their own deep learning (DL) models. This study assesses the performance of AutoML in diagnosing trachoma from field-collected conjunctival images and compares it to expert-designed DL models. METHODS: Two ophthalmology trainees without coding experience carried out AutoML model design using a publicly available image data set of field-collected conjunctival images (1656 labeled images). We designed two binary models to differentiate trachomatous inflammation-follicular (TF) and trachomatous inflammation-intense (TI) from normal. We then integrated an Edge model into an Android application using Google Firebase to make offline diagnoses. RESULTS: The AutoML models showed high diagnostic properties in the classification tasks that were comparable or better than the bespoke DL models. The TF model had an area under the precision-recall curve (AuPRC) of 0.945, sensitivity of 87%, specificity of 88%, and accuracy of 88%. The TI model had an AuPRC of 0.975, sensitivity of 95%, specificity of 92%, and accuracy of 93%. Through the Android app and using an external dataset, the AutoML model had an AuPRC of 0.875, sensitivity of 83%, specificity of 81%, and accuracy of 83%. CONCLUSION: AutoML models created by ophthalmologists without coding experience were comparable or better than bespoke models trained on the same dataset. Using AutoML to create models and edge computing to deploy them into smartphone-based apps, our approach brings the whole spectrum of DL model design into the hands of clinicians. This approach has the potential to democratize access to artificial intelligence.

Novel micellar CB2 receptor agonist with anti-inflammatory action for treating corneal alkali burns in a mouse model.

Introduction: Moderate corneal alkali burns such as those sustained from accidental exposure to household chemicals are treated with topical corticosteroids. Side effects include increased intraocular pressure and slowing of wound healing. Here, we compare the effects of a cannabinoid receptor 2 (CB2r) agonist, TA-A001, that is involved in wound healing with that of the corticosteroid, prednisolone. Methods: TA-A001 was encapsulated with a polymeric micelle comprising polyvinylpyrrolidone: polylactide block copolymers referred to as SmartCelle™ to allow delivery of the very hydrophobic drug. Mouse corneas were given moderate alkali burns. Different doses of TA-A001 of 0.125%, 0.25% and 0.5% were used to treat the burns in comparison to the corticosteroid, prednisolone. Results: TA-A001 at 0.25% and 0.5% allowed for faster wound closure. However, the higher 0.5% dose also induced unwanted neovascularization. By comparison, burned corneas treated with prednisolone showed slower healing as well as disorganization of the cornea. Although 0.25% TA-A001 appeared to produce the most-optimal responses, this dose resulted in marked expression of the macrophage chemoattractant protein, MCP-1. However, there was also an increase in CD163 positive stained M2 anti-inflammatory macrophages in the TA-A001 corneas. TA-A001 treated corneas showed the presence of sensory nerve fibers throughout the corneal epithelium including the superficial cell layers as did Substance P staining. Discussion: We found that TA-A001 at the 0.25% doses was able to modulate inflammation resulting from a moderate alkali burn to the cornea. With more extensive testing, TA-A001 might prove to be a potential alternative to corticosteroids for treating alkali burns or other causes of corneal inflammation.

Long-term Stability of Epitheliotropic Factors in Frozen Serum Eye Drops.

The objective of this experimental study was to investigate the stability of functional proteins in human serum eye drops, which are used for the treatment of ocular surface disorders, after prolonged storage of 6 months at -20°C. After obtaining whole blood from 3 volunteers and preparing 100% (S100), 50% (S50), and 20% (S20) serum eye drops, fibronectin was quantified before and after storage for 6 months at -20°C using appropriate enzyme-linked immunoassay kits. The pH and microbial contamination of preparations were also evaluated longitudinally. The fibronectin concentration showed no significant reduction in undiluted (S100) or diluted (S50 and S20) serum after 6 months of frozen storage at -20°C. None of the preparations showed any microbial contamination and no significant changes in pH were noted during storage. Frozen serum eye drops appear stable after prolonged storage at -20°C. Fibronectin in serum is temperature and time resistant after prolonged storage at -20°C. While the impact of individual serum proteins on ocular surface health remains unclear, our results suggest that freezing up to 6 months provides adequate preservation of epitheliotropic factors and a minimal risk of microbial contamination.

Drug-induced corneal deposits: an up-to-date review.

This review assesses different clinical aspects of the various known drug-induced corneal deposits, based on the corneal layer involved (epithelium, stroma and/or endothelium), and based on the drug class. The most well-known condition caused by drug deposits is vortex keratopathy, or corneal verticillata, which is a whorl-like opacity in the corneal epithelium. Vortex keratopathy is commonly caused by certain cationic amphiphilic drugs such as amiodarone, antimalarials, suramin, tamoxifen, chlorpromazine and non-steroidal anti-inflammatory drugs. These deposits usually occur once a certain dose of the drug is reached. Most cases present with mild to moderate symptoms with minimal visual impairment. Most of these deposits resolve automatically, after months to years of drug cessation. Notably, other drug classes can cause deposits in all three layers of the cornea. Chlorpromazine, gold, rifabutin, indomethacin and tyrosine kinase inhibitors can cause stromal deposits, with reduced visual acuity when the anterior stroma is involved. Chlorpromazine and rifabutin can also cause deposits in the endothelial layer of the cornea. Regardless of the type of corneal deposit, local therapies such as topical lubricants or corticosteroids may help improve symptoms. Drug cessation or modification can also be helpful but should be weighed against the systemic risks of the underlying disease.

Mid-term prognosis of type I Boston keratoprosthesis reimplantation.

AIM: To examine the mid-term visual and anatomical prognosis of patients who require reimplantation of a second Boston keratoprosthesis type 1 (B-KPro). METHODS: Retrospective observational case series of 122 patients (141 eyes) who received a B-KPro at a single institution were reviewed. Eyes that underwent a second B-KPro were included in the study. Primary endpoints were B-KPro retention, final visual acuity 20/200 and loss of light perception. Secondary endpoints included the occurrence of postoperative complications. RESULTS: Seventeen eyes (12%) required a B-KPro reimplantation. Corneal melt was the most common indication for replacement (88%). Mean follow-up time after the second B-KPro was 4.4±2.1 years. The Kaplan-Meier analysis estimated the second B-KPro retention rate at 79% over 8 years. Retroprosthetic membrane (RPM, 53%) was the most common complication. Forty-one per cent of the eyes suffered from corneal melt following their second B-KPro. One year after the second B-KPro, 47% of the patients retained a vision 20/200. Seven eyes (41.2%) lost light perception, which was secondary to an inoperable retinal detachment in five cases. Four eyes (24%) developed phthisis following inoperable retinal detachment (n=3) or endophthalmitis (n=1). CONCLUSION: B-KPro reimplantation is a potentially sight- and globe-saving procedure for eyes with B-KPro failure, but the prognosis is guarded. B-KPro reimplantation can salvage ambulatory vision in a third of patients while another third of patients progress to loss of light perception. RPM and retinal detachment were important obstacles to visual rehabilitation while recurrent corneal melt was responsible for most cases of anatomical failure.

Cost-effectiveness analysis : fibrin glue versus sutures for conjonctival fixation during pterygion surgery.

OBJECTIVE: Pterygium surgery requires the removal of pterygium tissue and repair of the conjunctiva with either sutures or fibrin glue. The literature suggests that the cost of fibrin glue could be compensated by reducing procedure time and be more cost-effective. However, to our knowledge, no formal studies have examined this hypothesis. METHOD: Retrospective chart review of patients who received pterygium surgery with only sutures between January 2008 and January 2010, and those whose surgeons used fibrin glue with or without sutures, between April 2017 and November 2018. Equipment cost, operating room (OR) maintenance, and surgeon's remuneration were compared between the groups. RESULTS: A total of 164 eyes were included. Three different procedure methods were noted: use of sutures only, combination of sutures and fibrin glue, or application of fibrin glue alone. The equipment cost was $97, $169.50, and $152.10 for the suture group, dual method, and fibrin-only method. Average procedure time was 35.8 minutes for the sutures-only group, 21.1 minutes for the dual method, and 25.6 minutes for the method using only glue. OR maintenance cost was $51.20 CAD per minute. The total cost for the method using only sutures was $2528.90, whereas the average cost for the protocol using only fibrin glue was $2063. CONCLUSION: Although using fibrin glue for conjunctival graft adhesion increases the equipment cost, it significantly decreases procedure time, which allows a reduction of the total surgery cost. Therefore, fibrin glue is a more cost-effective approach than sutures alone.

Lacrimal Gland Hypoplasia and Corneal Anesthesia in MIRAGE Syndrome: A Case Report and Literature Review.

PURPOSE: The purpose of this report was to describe the ocular findings in Myelodysplasia, Infection, Restriction of growth, Adrenal hypoplasia, Genital problems, and Enteropathy (MIRAGE) syndrome, a multisystem congenital disorder. METHODS: This was a case report and literature review. RESULTS: An infant with MIRAGE syndrome (combined immunodeficiency with recurrent infections, growth restriction, adrenal insufficiency, 46,XY karyotype with hypovirilization, dysphagia, gastroesophageal reflux disease, and dysautonomia) underwent ophthalmological evaluation because of persistent conjunctivitis during his 8-month admission in the neonatal intensive care unit. His parents noted absence of tears when crying since birth. Bilateral broad corneal epithelial defects were noted, and treatment was initiated with frequent lubricating ointment. At 9 months, his vision was estimated at 20/380 in both eyes using Teller Acuity Cards. There were persistent bilateral epithelial defects, confluent punctate epithelial erosions, low Schirmer strip wetting (right eye 3 mm and left eye 2 mm), and decreased corneal sensation. Brain magnetic resonance imaging images demonstrated hypoplastic lacrimal glands bilaterally. More aggressive lubrication and installation of punctal plugs in all 4 lids were successful at preventing further epithelial defects. CONCLUSIONS: This case presents deficient lacrimation as a manifestation of MIRAGE syndrome and is the first to identify lacrimal gland hypoplasia and corneal anesthesia. Autonomic and neurologic dysfunction have been proposed to play a role in the pathophysiology of hypolacrimation in similar syndromes and likely contributed to the poor ocular surface in this case. Patients with MIRAGE should undergo ophthalmic assessment as soon as possible after birth because early intervention is essential to preventing irreversible corneal damage.

Comparing ProKera With Amniotic Membrane Transplantation: Indications, Outcomes, and Costs.

PURPOSE: The aim of this study was to compare the outcomes of ProKera versus amniotic membrane transplantation (AMT) in managing ocular surface disease. METHODS: This study is a retrospective case series of patients who received either ProKera or sutured AMT for ocular surface disease. Patient demographics, treatment indications, retention time, percentage healed area, changes in visual acuity, and costs to the health care system were analyzed. RESULTS: Fourteen patients were identified and analyzed for each group. The main indications for using ProKera and AMT were similar, including corneal ulcer or epithelial defect due to chemical burns, neurotropic state, or herpes zoster keratitis. The average time to dissolution or removal was 24.8 days in the ProKera group, compared with 50.1 days in the AMT group. The average percentage of healed corneal area was 59% for ProKera and 73% for AMT. There was no significant difference between the initial and the final visual acuity within groups and when comparing both groups. In our expense analysis, ProKera had a total cost of 699.00 Canadian dollars (CAD), whereas the cost of suture AMT was 1561.52 CAD. ProKera priced at 11.85 CAD for each percentage healed surface area and at 21.39 CAD for AMT. CONCLUSIONS: ProKera allowed for a faster corneal healing than sutured AMT, although its total healed area was less than the latter. Moreover, ProKera is more cost-effective than AMT, thus reducing financial burden to our health care system.

In situ Tissue Regeneration in the Cornea from Bench to Bedside.

Corneal blindness accounts for 5.1% of visual deficiency and is the fourth leading cause of blindness globally. An additional 1.5-2 million people develop corneal blindness each year, including many children born with or who later develop corneal infections. Over 90% of corneal blind people globally live in low- and middle-income regions (LMIRs), where corneal ulcers are approximately 10-fold higher compared to high-income countries. While corneal transplantation is an effective option for patients in high-income countries, there is a considerable global shortage of corneal graft tissue and limited corneal transplant programs in many LMIRs. In situ tissue regeneration aims to restore diseases or damaged tissues by inducing organ regeneration. This can be achieved in the cornea using biomaterials based on extracellular matrix (ECM) components like collagen, hyaluronic acid, and silk. Solid corneal implants based on recombinant human collagen type III were successfully implanted into patients resulting in regeneration of the corneal epithelium, stroma, and sub-basal nerve plexus. As ECM crosslinking and manufacturing methods improve, the focus of biomaterial development has shifted to injectable, in situ gelling formulations. Collagen, collagen-mimetic, and gelatin-based in situ gelling formulas have shown the ability to repair corneal wounds, surgical incisions, and perforations in in-vivo models. Biomaterial approaches may not be sufficient to treat inflammatory conditions, so other cell-free therapies such as treatment with tolerogenic exosomes and extracellular vesicles may improve treatment outcomes. Overall, many of the technologies described here show promise as future medical devices or combination products with cell or drug-based therapies. In situ tissue regeneration, particularly with liquid formulas, offers the ability to triage and treat corneal injuries and disease with a single regenerative solution, providing alternatives to organ transplantation and improving patient outcomes.

Frozen versus fresh corneal graft carriers in Boston keratoprosthesis surgery: 10-year outcomes.

OBJECTIVE: To compare 10-year clinical outcomes of frozen versus fresh corneal graft carriers for the Boston Keratoprosthesis type 1 (KPro). DESIGN: Prospective, non-masked randomized controlled trial. PARTICIPANTS: Nineteen eyes of 19 patients having undergone Boston KPro type 1 implantation using a fresh or frozen graft carrier. METHODS: All patients that underwent Boston KPro type 1 implantation by a single experienced surgeon using an allograft carrier between October 2008 and March 2010 at the Centre Hospitalier de l'Université de Montréal were considered. Patients were excluded if they had a history of prior KPro implantation in the same eye. A subset of the patient cohort enrolled in the initial study protocol of 24 months continued follow-up to 120 months. Participants were randomized to receive either a fresh or frozen corneal graft carrier depending on tissue availability from the eye bank on the day of KPro implantation. RESULTS: Nineteen eyes of 19 patients were included, with 11 in the fresh group and 8 in the frozen group. At 10 years, in the fresh and frozen groups respectively, device retention was 91% and 75%; mean best corrected visual acuity increased from counting fingers preoperatively to 20/300 and 20/125; and incidence of complications per patient was 2.36 and 2.37. There were no statistically significant differences between groups for any of these outcome measures (p > 0.05 for all analyses). CONCLUSIONS: Fresh and frozen corneal graft carriers offer similar clinical outcomes for KPro implantation in terms of device retention, change in visual acuity, and rate of complications at 10 years.

Perspectives for preclinical mouse models of glaucoma after Boston keratoprosthesis type 1.

Animal models of the Boston keratoprosthesis type 1 (KPro) are needed to study glaucoma damage after KPro implantation to control for confounding comorbidities common in human KPro recipients. The purpose of this study was to determine the feasibility of establishing a reproducible mouse model of glaucoma after KPro surgery, specifically that of a miniaturized mouse model of KPro (mKPro). In the present study, a total of 20 corneas of donor C57BL/6 mice (n = 10) were implanted in one eye of each recipient BALB/C mouse (n = 20), assembled as part of the mKPro, either with or without intraoperative lensectomy. Main feasibility outcomes consisted in incidence rates of loss of tone, capsule nicking, and lens extrusion, as well as acquisition of posterior segment optical coherence tomography (OCT) images. With lensectomy (n = 10), loss of ocular tone and retinal detachment occurred in 100% of mice. Without lensectomy (n = 10), capsule nicking and opening, as well as lens extrusion, occurred in 80% of mice. Causes of these complications included the large proportion of intraocular volume occupied by the lens, the shallow anterior chamber, and thus the lack of available intraocular volume to implant the KPro if the lens remains present. Successful mouse KPro surgery may require a great deal of practice to be useful as a reproducible model. Animal KPro models ought to be pursued further by research teams in future studies.

Collagen analogs with phosphorylcholine are inflammation-suppressing scaffolds for corneal regeneration from alkali burns in mini-pigs.

The long-term survival of biomaterial implants is often hampered by surgery-induced inflammation that can lead to graft failure. Considering that most corneas receiving grafts are either pathological or inflamed before implantation, the risk of rejection is heightened. Here, we show that bioengineered, fully synthetic, and robust corneal implants can be manufactured from a collagen analog (collagen-like peptide-polyethylene glycol hybrid, CLP-PEG) and inflammation-suppressing polymeric 2-methacryloyloxyethyl phosphorylcholine (MPC) when stabilized with the triazine-based crosslinker 4-(4,6-Dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium chloride. The resulting CLP-PEG-MPC implants led to reduced corneal swelling, haze, and neovascularization in comparison to CLP-PEG only implants when grafted into a mini-pig cornea alkali burn model of inflammation over 12 months. Implants incorporating MPC allowed for faster nerve regeneration and recovery of corneal sensation. CLP-PEG-MPC implants appear to be at a more advanced stage of regeneration than the CLP-PEG only implants, as evidenced by the presence of higher amounts of cornea-specific type V collagen, and a corresponding decrease in the presence of extracellular vesicles and exosomes in the corneal stroma, in keeping with the amounts present in healthy, unoperated corneas.

Tear Film Cytokine Profile of Patients With the Boston Keratoprosthesis Type 1: Comparing Patients With and Without Glaucoma.

Purpose: Inflammatory cytokines are involved in glaucoma pathogenesis. The purpose is to compare cytokine levels in the tear film of Boston keratoprosthesis (KPro) patients with and without glaucoma, relative to controls, and correlate levels with clinical parameters. Methods: This cross-sectional study enrolled 58 eyes (58 patients): 41 KPro eyes with glaucoma, 7 KPro eyes without glaucoma, and 10 healthy controls. Twenty-seven cytokines were measured by multiplex bead immunoassay. Intraocular pressure (IOP), cup-to-disk ratio (CDR), retinal nerve fiber layer, visual acuity, topical medications, and angle closure were assessed in all KPro eyes. Cytokine levels between groups were analyzed by nonparametric tests, and correlations with clinical parameters by Spearman's test. Results: Levels of TNF-ɑ, IL-1ß, FGF-basic, and IFN-É£ were significantly higher in KPro with glaucoma compared to KPro without (P = 0.020; 0.008; 0.043; 0.018, respectively). KPro groups had similar characteristics and topical antibiotic/steroid regimen. Levels of IL-1Ra, IL-15, VEGF, and RANTES were significantly higher in KPro with glaucoma compared to controls (P < 0.001; = 0.034; < 0.001; = 0.001, respectively). IL-1ß and IFN-É£ levels were positively correlated with CDR (r = 0.309, P = 0.039 and r = 0.452, P = 0.006, respectively) and IOP (r = 0.292, P = 0.047 and r = 0.368, P = 0.023, respectively). TNF-α and FGF-basic levels were positively correlated with CDR (r = 0.348, P = 0.022 and r = 0.344, P = 0.021, respectively). Conclusions: TNF-α, IL-1ß, FGF-basic, IFN-É£ are elevated in tears of KPro patients with glaucoma and correlate with CDR and IOP. These results show, for the first time in humans, concordance with documented elevations of TNF-α and IL-1ß in the murine KPro model. Ocular surface inflammation may reflect inflammatory processes of KPro glaucoma.

Risk Factors for Ocular Involvement in Pediatric Graft-Versus-Host Disease.

PURPOSE: To identify risk factors for ocular graft-versus-host disease (oGVHD) in children with graft-versus-host disease (GVHD). METHODS: This retrospective cohort study identified 38 children diagnosed with GVHD who underwent an ophthalmological examination. Survival to onset of oGVHD after transplant was analyzed using Kaplan-Meier analyses with log-rank tests. A multivariable Cox proportional hazards model was run for time to oGVHD using univariate risk factors. RESULTS: The average age was 10.0 ± 5.4 years at the time of transplant. Underlying illness was acute lymphoblastic leukemia in 19 (50%) and acute myeloid leukemia in 8 (21%). Nonocular GVHD organ involvement included skin (84%), lungs (16%), intestines (50%), liver (24%), and bone marrow (3%). Fifteen children (39%) had oGVHD, of which 47% were asymptomatic. oGVHD was diagnosed 601 ± 878 days after GVHD. A significant association between risk of oGVHD and diagnosis of acute lymphoblastic leukemia (P = 0.10) or acute myeloid leukemia (P = 0.08) was not found. Organ involvement associated with oGVHD included skin (P = 0.03) and lungs (P = 0.02). Survival curves were significantly influenced by GVHD organ involvement (P = 0.02), but not underlying disease (P = 0.51). The adjusted Cox regression model yielded an independent hazard ratio of 8.82 (95% CI: 1.51-51.49; P = 0.016) for the presence of concomitant GVHD involvement of skin, lungs, and another organ. CONCLUSIONS: Children with multiorgan GVHD involvement including skin and lung disease are at increased risk for oGVHD. Given the proportion of asymptomatic cases found in this series, regular eye examinations are warranted in this population.