Transcript dry eyes
Jill Bryant, OD, FAAO Director of Contact Lens Duke Eye Center 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 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 GVHD Type Skin Liver GI Tract Acute ▪ red palms and soles of feet ▪ rash ▪ itchy, dry skin ▪ liver enlargement ▪ ↑ liver function tests ▪ abdominal tenderness ▪ nausea ▪ diarrhea ▪ abdominal cramps ▪ appetite loss ▪ liver enlargement ▪ ↑ liver function tests ▪ abdominal tenderness ▪ yellowish color to skin and eyes ▪ dry mouth ▪ diarrhea ▪ weight loss ▪ appetite loss Chronic ▪darkened, dry skin ▪ skin peeling Lungs Eyes ▪ difficulty with taking deep breaths ▪ shortness of breath ▪ dry eyes ▪ light sensitivity 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 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 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 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 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 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 OS 14 mmHg EOM’s: FROM OU CF: FTFC OD, OS Pupils: OD 53mm OS 53mm 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 Corneal Topography Patient JH Jupiter OD: -7.25 Sph; 7.03 BC; 18.2 OAD OS: -6.25 Sph; 7.18 BC; 18.2 OAD 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 Anxiety and Depression in Dry Eye • • • • • • Unremitting pain Life Impact Financial Impact Personal appearance Difficulties seeking medical care Other variables 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