1. Jill Bryant, OD, FAAO Director of Contact Lens Duke Eye Center

2. Graft Versus Host Disease Graft = donor bone marrow and immune cells or lymphocytes given to the recipient Host = recipient body cells GVHD = complication of bone marrow transplant in which functional immune cells in the transplanted marrow recognize the recipient as “foreign” and mount an immunologic attack

3. Types of GVHD Acute GVHD ▪ occurs within the first 3 months post-transplant ▪ symptoms happen quickly and may be mild or severe Chronic GVHD ▪ occurs from 3 months to 1 year or longer after transplant ▪ symptoms progress slowly and can be mild or severe ▪ symptoms may reoccur ▪ may last a lifetime

4. GVHD Type SkinLiverGI TractLungsEyes Acute ▪ red palms and soles of feet ▪ rash ▪ itchy, dry skin ▪ liver enlargement ▪ ↑ liver function tests ▪ abdominal tenderness ▪ nausea ▪ diarrhea ▪ abdominal cramps ▪ appetite loss Chronic ▪darkened, dry skin ▪ skin peeling ▪ liver enlargement ▪ ↑ liver function tests ▪ abdominal tenderness ▪ yellowish color to skin and eyes ▪ dry mouth ▪ diarrhea ▪ weight loss ▪ appetite loss ▪ difficulty with taking deep breaths ▪ shortness of breath ▪ dry eyes ▪ light sensitivity

5. Rates of GVHD 30-40% among related donors and recipients 60-80% among unrelated donors and recipients the greater the mismatch between donor and recipient, the greater the risk of GVHD Recipients take medications such as cyclosporine, tacrolimus, mycophenolate, methotrexate, and steroids to reduce the chance or severity of GVHD Recipients are immunosuppressed

6. Patient JH 44 year old Caucasian female Dx: myelofibrosis arising from essential thrombocytosis s/p allogeneic stem cell transplant 12/09/08 May 2009 dx GVHD after presenting with pruritis across upper chest and back of neck; dry, irritated eyes; dry mouth; pain when swallowing Started on Prednisone, Restasis, Systane for eye and mouth GVHD by BMT physician Referred to Duke Eye Center

7. Patient JH Evaluated by cornea specialist who advised pt to continue Restasis, preservative free AT’s QID OU, inserted bilateral lower punctal plugs Returned to corneal specialist few weeks later reporting no relief and bilateral upper punctal plugs inserted Returned to corneal specialist again reporting no improvement and advised to add Genteal gel qhs OU 8 months later returns with increased frustration with her dry eyes; was referred to CL clinic 2/19/10 Patient JH presents to Duke CL Clinic

8. February 2010 - CL Clinic c/o severe ocular redness, burning OU for 10 months; made statement that her ocular symptoms have much more difficult to cope with than having gone through a BMT Difficulty with air in certain rooms, unable to walk outside, unable to read a book, unable to work on computer, unable to work Currently on short term disability from job as a teacher’s assistant in an elementary school Reports compliance with Restasis BID OU, has punctal plugs (upper and lower), frequent lubrication with preservative free artificial tears q 15 minutes, artificial tear ointments, humidifier, holding cold compresses over eyes for relief, hyperhydration with water, taking multiple showers daily just to get moisture around her eyes Hopeful that scleral lenses would help; wants to regain her life and wants to return to work

9. Current Medications Cyclosporine 75mg BID Cellcept 1000mg BID Prednisone 10mg every other day alternating with 5 mg Fluconazole 400mg daily Aspirin 81mg daily Septra DS every M, W, F Multivitamin daily Protonix 40mg daily Mag Ox 500mg BID Calcium and Vitamin D 600mg daily Dexamethasone 0.5mg/5ml swish and spit 1-2 times daily Premarin vaginal cream 2 times weekly Neurontin 300mg TID Famvir 500mg TID Allergies: Meperidine and meningitis vaccine Social History: no tobacco, alcohol, or recreational drug use

10. Exam Data No current prescription Uncorrected VA: OD 20/30 OS 20/30 Manifest Refraction OD: -0.75-0.25x016 20/20 OS: -0.75-0.50x106 20/20 SLE: 1-2+diffuse corneal SPE OU; 2+ conjunctival staining OU immediate tear break-up time OU ● IOP: OD 14 mmHg EOM’s: FROM OU Pupils: OD 5  3mm OS 14 mmHg CF: FTFC OD, OS OS 5  3mm No APD ● DFE: ON 0.1 round pink and distinct OU Macula flat and intact; +FLR OU Vessels 2/3 AV ratio OU Periphery OD flat and intact; OS RPE hypertrophy superior nasal

11. Corneal Topography

12. Patient JH Jupiter OD: -7.25 Sph; 7.03 BC; 18.2 OAD OS: -6.25 Sph; 7.18 BC; 18.2 OAD

13. 2 week f/up after lenses dispensed Wearing lenses for 10 hours with no discomfort Stopped Restasis and rarely using AT’s Returned to work Life is getting back to normal

14. Anxiety and Depression in Dry Eye Unremitting pain Life Impact Financial Impact Personal appearance Difficulties seeking medical care Other variables

15. Anxiety and Depression in Dry Eye Dry Eye Disease can negatively impact activities of daily living Documented cases of patients committing suicide from dry eye Be aware of patient’s with chronic dry eye exhibiting signs of depression