Understanding ocular graft-versus-host disease | Eversight webinar recap

Dr. Sunshine describes the current standards for diagnosis of oGVHD. The gold standard for diagnostic criteria comes from the International Chronic oGVHD Consensus Group. Diagnosis is made by assigning a score in four categories: 

1. Corneal staining 
2. Conjunctival injection 
3. Schirmer’s test 
4. Ocular surface disease (OSD) index score 

Each category is scored by severity and combined for a total score to determine severity. Systemic GVHD is also factored into diagnosis. 

Another diagnosis framework is available from the National Institute of Health. This is a more simplified version that can potentially be performed by non-ophthalmologists.  

Another factor that should be considered which is not present in either diagnosis framework but is a good indicator of oGVHD is conjunctival fibrosis.  

Dr. Sunshine continues to discuss treatment following her discussion of diagnosis. She discusses four pillars of treatment: 

1. Replace moisture 
2. Treat meibomian gland dysfunction 
3. Prevent desiccation 
4. Control inflammation 

She discusses the importance of starting treatment in these areas simultaneously, unlike traditional dry eye disease where therapies may be administered in succession stating, “treat aggressively and early.”  

The first topic that Dr. Sunshine discusses is the gap in diagnosis, i.e. are we diagnosing early enough? The current recommendation is to use the NIH simplified diagnostic tool and to start at 6+ months. She goes on to describe her experience, which is that waiting until a patient is symptomatic is often too late to treat appropriately.  

She then discusses a proposal from the 2020 NIH Chronic GVHD Consensus Project which suggests a baseline eye exam pre-transplant and/or three months post-transplant due to the irreversible nature of the ocular changes and the fact that once symptoms are present it may be too late to intervene effectively. 

Another question Dr. Sunshine poses, is if it is possible to use biomarkers to diagnose. She discusses the possibility of using tears, imaging or both to diagnose. Dr. Sunshine is currently doing a study at the University of Maryland to determine whether this is possible. 

Dr. Sunshine discusses potential future treatment options. The first she discusses is the Janus kinase (JAK) inflammation pathway, citing JAK inhibitors as a potential way to decrease cytokine based inflammation in patients with oGVHD. She cites efficacy in a pilot study in four patients that she performed at the University of Maryland.

She then lays out her current research approach, the goal of which is to better understand the mechanisms of oGVHD in an effort to formulate better targeted treatments. Dr. Sunshine uses both mouse models and an ocular biobank to study the disease.