Bilateral Corneal Trophic Ulcers and Subsequent Infectious Keratitis in a

Patient with Graft-versus-host Disease

Yonca Aydın Akova, MD

Bayındır Hospital,Ankara, Turkey

Financial interest Alcon, Allergan, Bausch& Lomb, Thea, Deva

Purpose

• To report the clinical picture, complications and therapeutic approach in a patient with chronic graft versus host disease (GVHD)

Case Presentation• 54-year-old men with

chronic myeloid leukemia• Bone marrow

transplantation • He developed chronic GVHD

– Severe dry eye, Schirmer test without anesthesia 1 mm, OU

– Bilateral trophic corneal ulcers involving the whole cornea

– Crystalline keratopathy in the right eye

Therapy

• Topical therapy– Autologous serum

50 %– Unpreserved topical

steroids 3x1 – Topical cyclosporine

A, 0.05% 4x1– Unpreserved

artificial tears 8x1

• Therapeutic soft contact lenses

• Silicone punctum plugs

• Systemic therapy– Doxycyline– Prednisolone– Immunosuppressive

therapy (mycofenolate and cyclosporine )

– Photopheresis

Clinical Findings• Bacterial ulcer with

hypopyon in the left eye

• Conjunctival and corneal cultures negative

• Response to topical fortified vancomycine and ceftazidime therapy

Bacterial keratitis with hypopyon

Clinical Findings

One months later • Multiple corneal

infiltrates, OD• Cultures were positive

for candida albicans • Response to topical

amphotericin B and topical voriconazole 1% therapy Candida keratitis with multiple infiltrates

Clinical Findings

• Infectious crystalline keratopathy and satellite infiltrates caused by candida albicans in the right eye

Satellite infiltrates

After Treatment

Clinical Findings

• Response to topical amphotericin B and topical voriconazole 1% therapy

After Treatment

Conclusions• Patients with chronic GVHD may develop

severe inflammatory changes in the ocular surface– Severe dry eye –Persistent trophic ulcers – Infectious keratitis • Bacterial keratitis• Fungal keratitis

Conclusions

• Crystalline keratopathy may develop due to corneal infections

• Microbial causes include not only bacteria but fungi as well

• GVHD patients should be carefully evaluated for such severe complications in order to start the appropriate treatment timely