Acta Ophthalmologica 2015
Bandage and scleral contact lenses for ocular graft-versus-host disease after allogeneic haematopoietic stem cell transplantation Elena I. Stoyanova,1 Henny M. Otten,1,2 Robert Wisse,1 Aniki Rothova3 and Anjo Riemens1 1
Department of Ophthalmology, Medical Center Utrecht, Utrecht, The Netherlands; 2Visser Contact Lenses, University Medical Center Utrecht, Utrecht, The Netherlands; 3Department of Ophthalmology, Erasmus Medical Center, Rotterdam, The Netherlands doi: 10.1111/aos.12711
Editor, cular graft-versus-host disease (GvHD) is a frequent complication of allogeneic haematopoietic stem cell transplantation (allo-SCT), occurring in 40–80% of the patients. Keratoconjunctivitis sicca (KCS) is the most common manifestation of ocular GvHD and can lead to severe cases of punctate and filamentary keratitis, causing invalidating discomfort, irreversible ocular surface damage and visual loss (Takahide et al. 2007; Schornack et al. 2008). Gas permeable soft bandage lenses (BL) and rigid scleral lenses (SL) have been increasingly available and can be additionally used in severe ocular GvHD when conventional therapy is insufficient (Jacobs & Rosenthal 2007; Russo et al. 2007). Our single-centre retrospective noncomparative cohort study included forty eyes of 21 adult patients with ocular GvHD after allo-SCT between 2008 and 2013 unresponsive to conventional therapy (lubrication, immunosuppressants and/or modulants) who received same BL and/or SL treatment in both eyes. To investigate the lenses’ effectiveness and adverse effects in ocular GVHD, we collected data from demographic, medical, haematological and ophthalmological records. Three types of silicon hydrogel bandage lenses were used as follows: (i) PureVision (Bausch en Lomb, Rochester, NY, USA) (Balafilcon-A), (ii) Biofinity (Cooper
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Vision, Pleasanton, CA, USA) (Comfilcon-A) and (iii) Air-Optix Night and Day (Ciba Vision, Corp.) (LotrafilconA), and fitted as daily and/or day/night wear. A scleral lens Procornea (Eerbeek, the Netherlands) was fitted as daily wear in patients with more severe corneal surface irregularity when epithelial defects failed to improve during BL use, or when optical correction for irregular astigmatism was needed. Clinical evaluation and replacement of new BLs was performed monthly. Successful effect of the contact lens wear or therapy was based on the objective findings of ocular GvHD (clinical symptoms, reduced fluorescein staining classified according to the Oxford Index for staining and tear film break-up time (BUT). Adverse effects were defined as lens-related negative ocular effects that resulted in discontinuation of therapy. The number of patients in our study was limited; however, we had a long median follow-up period of 5 year and no selection bias (see Table S1). Following the local step-up treatment plan, the cases refractory to various local and systemic medications were fitted with BL first (n = 20) and when unsuccessful with SL (n = 9). One patient received SL primarily, two received additional SL wear simultaneous with BL. Two patients wearing BL failed SL. Ocular GvHD patients after alloSCT showed a 55% (n = 11/20) successful effect of clinical signs using BL. The Oxford Index score of grading staining, however, showed significant improvement at the evaluation end-point of BL wear (p = 0.009) and also at last SL follow-up compared to the score at SL placing (p = 0.001). All patients with BL and SL still used topical lubrication; however, we found that the number of the eye drops used was lower. The most common reasons of unsuccessful therapy were either no or insufficient resolution of corneal/ conjunctival staining (n = 7/20) or termination due to adverse effects and/ or general intolerance to the contact lens (n = 2/20). The total prevalence of infectious adverse effects leading to discontinuation of BL or SL lens wear was 14% (n = 3/21): herpetic keratitis (n = 2, 1 BL and 1 SL) and Pseudomonas keratitis (1 BL). Furthermore, two patients had subconjunctival haemorrhage (1 BL and 1 SL). No other adverse events, such as abra-
sions, neovascularization and papillary conjunctivitis, were observed during BL or SL wear. We conclude that both BL and SL can be efficient treatment modalities that protect the cornea, accelerate the healing process and decrease the frequency of topical lubricant administrations. We advise that patients should be instructed on the risk of infectious keratitis and regularly controlled. The close collaboration of contact lens specialist and ophthalmologist offers a consistent treatment modality that is beneficiary for the patient. Our results illustrate that BL and SL are a therapeutic modality that could be considered in the management of severe dryness-related epitheliopathy associated with ocular GvHD.
References Jacobs DS & Rosenthal P (2007): Boston scleral lens prosthetic device for treatment of severe dry eye in chronic graft-versus-host disease. Cornea 26: 1195–1199. Russo PA, Bouchard CS & Galasso JM (2007): Extended-wear silicone hydrogel soft contact lenses in the management of moderate to severe dry eye signs and symptoms secondary to graft-versus-host disease. Eye Contact Lens 33: 144–147. Schornack MM, Baratz KH, Patel SV & Maguire LJ (2008): Jupiter scleral lenses in the management of chronic graft versus host disease. Eye Contact Lens 34: 302–305. Takahide K, Parker PM, Wu M et al. (2007): Use of fluid-ventilated, gas-permeable scleral lens for management of severe keratoconjunctivitis sicca secondary to chronic graft-versus-host disease. Biol Blood Marrow Transplant 13: 1016–1021.
Correspondence: E.I. Stoyanova, MD, MSc Department of Ophthalmology University Medical Center Utrecht Room E 03.136, PO Box 85500 3508 GA Utrecht, The Netherlands Tel: +31616961550 Fax: +31887555417 Email:
[email protected]
Supporting Information Additional Supporting Information may be found in the online version of this article: Table S1. Characteristics of bandage contact lens (BL) and scleral contact lens (SL) wear treatment.
