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Outcomes of Cataract Surgery in Graft-Versus-Host Disease

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Outcomes of Cataract Surgery in Graft-Versus-Host Disease CLINICAL SCIENCE Outcomes of Cataract Surgery in Graft-Versus-Host Disease Rafael de Melo Franco, MD,*† Michelle M. Kron-Gray, MD, PhD,* Paola De la Parra-Colin, MD, MSc,* Yan He, MD,*‡ David C. Musch, PhD,* Shahzad I. Mian, MD,* Leslie Niziol, MS,* and H. Kaz Soong, MD* llogeneic hematopoietic stem cell transplantation (HSCT) Purpose: To study the outcomes of cataract surgery in patients with Ais an important treatment modality for hematological graft-versus-host disease (GVHD) after allogeneic hematopoietic malignancies, aplastic anemia, and a number of hereditary, stem cell transplantation (HSCT). immunologic, or metabolic hemoglobinopathies.1–6 It uses Methods: Retrospective review of 72 eyes of 41 patients (age, 17– multipotent hematopoietic stem cells from bone marrow, 69 years at the time of surgery) with chronic GVHD after HSCT, peripheral blood, or umbilical cord. Graft-versus-host disease who underwent cataract surgery between 2008 and 2012 at the (GVHD) is a major cause of morbidity and mortality in Department of Ophthalmology and Visual Sciences, W. K. Kellogg patients after HSCT. Details of the updated criteria and staging of GVHD have been published in a National Institutes of Eye Center, University of Michigan. Ophthalmic data collected 7 included best-corrected visual acuity (BCVA), responses to Ocular Health GVHD consensus workshop. The most common Surface Disease Index (OSDI) questionnaire, dry eye severity, and ocular consequence is dry eye disease (DED) due to the postoperative complications. deleterious effects of GVHD on aqueous tear production, sometimes leading to corneal epithelial defects, ulceration, Results: BCVA improved from 20/49 to 20/25 (P , 0.0001) and perforation.8 These ocular complications may occur in up after surgery. Eight patients (20%) had pretransplantation total to 90% of patients with GVHD.7 body irradiation and 39 patients (95%) received systemic Recent advances in pretransplantation conditioning corticosteroids for the treatment of GVHD. Postoperative com- regimens, GVHD prophylaxis and therapy, and treatment of plications included cystoid macular edema (4 eyes), corneal opportunistic infections after allogeneic HSCT have ulceration with perforation (2 eyes: 1 infected and 1 sterile), and improved patient survival and longevity.9–12 With increased band keratopathy (1 eye). After surgery, subjective OSDI longevity, patients are more apt to encounter late complica- responses and dry eye disease (DED) did not change significantly tions of HSCT, among which is visually significant cata- from before cataract surgery, although OSDI showed a trend ract.5,6 Together with punctate keratopathy from dry eyes, toward worsening. cataract is one of the principal causes of poor vision in HSCT recipients. It is multifactorial in origin, resulting from Conclusions: With careful monitoring and management of DED a combination of toxicity from antimitotic chemotherapeutic and concurrent ocular surface disease, cataract surgery generally has agents, total body irradiation (TBI) during the pre–bone good visual outcomes in patients with GVHD. However, aggravation marrow transplant (BMT) conditioning process, and pro- of the preexisting ocular surface disease is frequent, and despite longed use of high-dose systemic corticosteroids in the meticulous postoperative maintenance therapy, vision-threatening treatment of GVHD.13–19 In older patients with HSCT, complications may occur. additional involutional cataract formation is also to be Key Words: graft-versus-host disease, cataract surgery expected. Comparatively little has been published in the literature (Cornea 2015;34:506–511) concerning the results and complications of cataract extrac- tion in patients with GVHD.10,13,15 This study expands upon our own previous preliminary small study in 2002.13 Received for publication November 12, 2014; revision received January 3, 2015; accepted January 11, 2015. Published online ahead of print March MATERIALS AND METHODS 2, 2015. From the *Department of Ophthalmology and Visual Sciences, W. K. Kellogg A retrospective cohort study was conducted through Eye Center, University of Michigan Medical School, Ann Arbor, MI; a review of the medical records of all patients who underwent † Department of Ophthalmology, Cornea and External Disease Division, allogeneic HSCT, between January 2006 and 2011, at the Santa Casa de Misericórdia, São Paulo, Brazil; and ‡Beijing Ophthalmic and Visual Science Key Laboratory, Beijing Tongren Eye Center, Capital University of Michigan Comprehensive Cancer Center (Ann Medical University, Beijing, China. Arbor, MI). All patients undergoing HSCT at the University The authors have no funding or conflicts of interest to disclose. of Michigan are referred before HSCT to the cornea clinic Presented at the Annual Association for Research in Vision and Ophthal- GVHD specialists (H.K.S., S.I.M.) for a baseline eye mology conference, May 6, 2014, Orlando, FL. Reprints: H. Kaz Soong, MD, W.K. Kellogg Eye Center, 1000 Wall St, Ann examination and are followed at 3-month intervals after Arbor, MI 48105 (e-mail: [email protected]). HSCT for the first year and then every 6 to 8 months Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. thereafter, depending on the degree of severity. All 41 506 | www.corneajrnl.com Cornea Volume 34, Number 5, May 2015 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 34, Number 5, May 2015 Outcomes of Cataract Surgery patients in our series had underlying systemic GVHD (skin, cataract surgery, for example, frequency of artificial tear and mucosa, gastrointestinal tract, liver, and/or lungs) diagnosed lubricating ointment, use of moisture chamber goggles, by our specialists on the bone marrow transplant service of topical corticosteroids or 0.05% cyclosporine A eye drops, the oncology division. Ocular GVHD was diagnosed by serum eye drops, punctal occlusion with either plugs or severe dry eyes (low Schirmer, low tear meniscus, increased cautery, and Prosthetic Replacement of the Ocular Surface debris in the tear film, increased superficial punctate kerat- Ecosystem (PROSE) scleral contact lens (previously known opathy with Rose Bengal or lissamine green dye in a DED as the Boston Rosenthal Scleral Contact Lens; Boston distribution, and filamentary keratitis) occurring months after Foundation for Sight, Needham, MA).21 BCVA was con- HSCT. Two of our patients with ocular GVHD also had verted to logarithm of the minimum angle of resolution madarosis and conjunctival scarring (blunting of the cul-de- (logMAR) equivalent to facilitate statistical study. Subjective sac or symblepharon or trichiasis) after the onset of systemic Ocular Surface Disease Index (OSDI) questionnaire re- GVHD. Of the 261 patients who developed chronic ocular sponses were obtained by a technician and recorded from GVHD during this period, 72 eyes of 41 patients underwent the preoperative and final postoperative visit, with higher cataract extraction by phacoemulsification and implantation scores indicating worse dry eye symptoms. of an injectable acrylic intraocular lens through a temporal, clear corneal, sutureless incision between 2008 and 2012. Postoperatively, patients were started on combined cortico- Statistical Methods steroid/antibiotic eye drops (either tobramycin/dexametha- Descriptive statistics of the sample were provided using sone or neomycin/polymyxin B/dexamethasone) 4 times means and SDs for continuous variables and frequencies and a day with weekly taper. Beginning in 2011, patients received percentages for categorical variables. intracameral cefuroxime 1.0 mg in addition for endophthal- BCVA was converted to LogMAR equivalent for mitis prophylaxis. Four surgeons, including 2 of the authors statistical analysis. Preoperative to postoperative cataract (S.I.M. and H.K.S.) from the Cornea Service of the W.K. surgery change in BCVA, clinical DED severity grade, and Kellogg Eye Center, University of Michigan, performed the OSDI scores were tested using paired t tests for continuous operations. Patients were scheduled for surgery only if their measures and the Bowker test for categorical measures. cataracts caused significant visual loss and disabling glare, Linear mixed regression modeling was also used to test and were confirmed by slit-lamp biomicroscopy and graded preoperative to postoperative change while accounting for for clinical severity (on a scale of 1–4 of nuclear sclerosis, intereye dependency. Kaplan–Meier analysis was used to cortical change, and/or posterior subcapsular cataract). estimate the time-related probability of BCVA 20/25 or better A brightness acuity tester (BAT; Marco, Jacksonville, FL) following cataract surgery. SAS version 9.3 statistical soft- was used to assess the drop in visual acuity under glare ware (SAS, Cary, NC) was used. conditions. The presence and degree of superficial punctate Retrospective review of medical records and the clinical keratopathy were assessed in relation to the severity of study protocol were approved by the Institutional Review cataract, and retinas were carefully examined to rule out the Board of the University of Michigan Medical School presence of disease, particularly viral retinitis and macular (IRBMED). disease. Cataract surgery was performed only after ocular inflammation, DED, and other ocular surface disorders were well controlled. RESULTS Data collected included patient demographics, such as A total of 72 eyes of 41 patients were identified for
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