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Late Effects

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Graft vs Host related Orbital injury (GvHD)

 

Ocular complications occur in 60 - 80% of patients with chronic GvHD5

Many of these side effects are long-lasting or permanent

 

Keratoconjunctivitis sicca (KCS):

  • Most common complication (affects 60 - 75% of patients with GvHD
  • Secondary to conjunctival and lacrimal gland involvement
  • Due to:
    • Initial therapy (intensive chemotherapy and often low dose whole body radiation therapy as part of conditioning regime)
    • GvHD with PAS positive material deposited in ductules
    • Lymphocyte infiltration of lacrimal gland (related to GvHD) leading to inflammation followed by fibrosis
    • Hemorrhagic pseudomembranous conjunctivitis
      • Generally self limiting
      • May lead to fibrotic scarring of tarsus and secondary destruction of the accessory lacrimal glands

Typical presentation of eye related effects include6

  • Dry or gritty eyes (sicca syndrome)
  • Photophobia
  • Erythema
  • Edema

KCS can result in corneal breakdown with6:

  • Epithelial defects
  • Keratinization
  • Punctate keratitis
  • Ulcers (chronic, may be sterile or secondary to infection)
  • Perforation (rare)

GvHD lid changes such as entropion and ectropion exacerbate these corneal changes

 

Cataracts:

  • Most common complication of bone marrow transplant (BMT)
  • Range of incidence large (10 - 80%)
  • Secondary to radiation therapy (RT), corticosteroids, busulfan and GvHD

 

Uveitis

  • Iridocyclitis and choroiditis can be caused by GvHD
  • Due to direct immunological reaction of donor lymphocytes against host histocompatibility agents.
  • This can lead to glaucoma

 

Retinal complications:

  • Occur in about 10 - 15% of BMT patients
  • Retinal hemorrhages may occur when patients are pancytopenic and generally resolve completely after.
  • Ischemic  retinopathy may develop a year or so after BMT and some patients may not have had RT
  • Linked to cyclosporine therapy

 

Infections:

  • BMT recipients develop immune deficiency and are more susceptible to infection
  • Immunosuppressant medication for GvHD increase the risk of infection further
  • Ocular infections may include:
    • Herpes simplex keratitis
    • Herpes zoster retinitis
    • Cytomegalovirus chorioretinitis
    • Pseudomonal corneal ulcers
    • Toxoplasma chorioretinitis
    • Fungal endophthalmitis
    • Subretinal abscesses

 

 

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