Long Term Follow-Up Post Allogeneic HSCT
Oral & Ocular

Updated: October 2010

Oral

CGVHD and prior radiotherapy both contribute to the sicca syndrome seen commonly post HSCT. This sicca syndrome increases the risk of caries development in these patients. Ongoing symptomatic CGVHD can be a significant issue. Surveillance for oral malignancy should be done as ongoing GVHD increases the risk in this patient population.

Recommendations:

• Hygiene measures, fluoride treatment and artificial saliva (if appropriate) should be recommended.
• Dental evaluation should be done at 3 months and then subsequently at least annually. Earlier or more frequent assessments may be required based on symptoms.

Ocular

Kerato conjunctivitis sicca occurs as part of a generalized sicca syndrome including xerostomia, vaginitis, and dry skin and occurs with greater frequency in patients with CGVHD (40% vs. 20%). The decreased tear flow also increases the risk of sterile conjunctivitis, corneal epithelial defects and epithelial ulceration. Topical management includes the use of lubricating eye drops, lachrymal duct occlusion, autologous serum drops and possibly sclera lens. In the context of CGVHD topical cyclosporine and topical retinoic acid have been found to be useful. Topical steroids may be associated with sight threatening bacterial and viral keratitis and therefore should be used with caution.

Posterior sub-capsular cataracts occur in the majority (80% at 6-10 yrs) of patients who have received TBI as part of conditioning for transplant. The other risk factors include older age at transplant and corticosteroid therapy longer than 3 months. Cataract surgery offers a simple and excellent solution to this complication.

Posterior chamber complications include ischaemic microvascular retinopathy, hemorrhage, bilateral optic disc edema and infectious retinitis. Risk factors for ischemic micro vascular retinopathy (incidence: 10% post allo-HSCT) include TBI based conditioning, use of cyclosporine for immunosupression and is manifested as disc edema and cotton wool spots. Withdrawal of cyclosporin is often associated with improvement in vision. Infectious retinitis can be due to fungi, herpes viruses (including CMV) and T.gondii.

Recommendations:

• Routine ophthalmological evaluation (including Schrimer’s test) at 3 months and subsequently yearly should be performed particularly in patients with CGVHD. Earlier more frequent assessments will be required in patients with ongoing symptoms.
• New onset of visual symptoms/deterioration in vision should be prompt urgent ophthalmology review. (Please note the patient diagnosis, conditioning therapy and current medications in the consult request).

The information contained in these guidelines is a statement of consensus of Leukemia/BMT Program of BC professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. Use of these guidelines and documents is at your own risk and is subject to the Leukemia/BMT Program of BC’s terms of use available at Terms of Use.