Ocular Manifestations

Stella K. Kim, M.D.

MD Anderson Cancer Center
Houston, TX

Michael R. Robinson, M.D.

National Eye Institute
National Institutes of Health
Bethesda, MD
 Ocular Chronic GVHD:
Response Criteria
Background: Staging/grading systems for
ocular GVHD
Current applications of chronic GVHD
response criteria
Subjective symptom scale
Objective measure: Schirmers test
Considerations for pediatric patients
 Cicatricial Conjunctivitis
Grading (Robinson 2004)
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More relevant to CHRONIC manifestations, though it can occur prior to day

100 transplantation, de novo or post-pseudomembrane conjunctivitis
 Assessing Ocular GVHD:
Ophthalmic Evaluation Required
Conjunctival staging/grading systems
Corneal and conjunctival stainings
Others (ocular surface disease tools,
biopsy, etc.)
 Chronic GVHD Activity
Assessment: Ocular
Symptom measurement: Main eye symptom
reporting (severity rating 010)
Objective measurement: Schirmers test
(measurement of aqueous tear production
surrogate of lacrimal gland function)
 Main Eye Symptom
What is your main complaint with regard to
your eyes?
Please rate how severe is this eye
symptom, between 0 (not at all severe) to
10 (most severe)
What is your main complaint with regard to your eyes?
Please rate how severe is this eye symptom, between 0
(not at all severe) and 10 (most severe):
0 1 2 3 4 5 6 7 8 9 10
 Schirmers Test
Measurement of tear function (record mm of wetting for left and right
eye separately)
Without anesthetic: measures both reflex and basal tear function
With anesthetic: measures basal tear function
For evaluation of chronic GVHD response, Schirmers is obtained
without anesthesia.1
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1. Vitali, C., Bombardieri, S., Jonsson, R. et al (2002). Classification criteria for Sjogrens syndrome: A revised version of the
Photos Courtesy of Dr. M. Robinson European criteria proposed by the American-European Consensus Group. Annals of Rheumatologic Disease, 61, 554-558.
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Bend at the 0 mm line

Important to place the strip at the very corner of the
eye (avoids possible corneal abrasion)
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Have patient keep his/her eyes closed for 5 minutes.

No talking (or chewing/eating).
Schirmers score should be recorded as mm of
wetting for left and right eye separately.
 Schirmers Test
Results may be influenced by other factors
(e.g., medications and hydration level).
Recommendation based on consensus is to
defer Schirmers testing for patients less
than 9 years old.
Evaluation by an ophthalmologist may be
needed for objective scoring in younger
children.