1. 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

2. Ocular Chronic GVHD: Response Criteria Background: Staging/grading systems for ocular GVHD Current applications of chronic GVHD response criteria –Subjective symptom scale –Objective measure: Schirmer’s test Considerations for pediatric patients

3. Cicatricial Conjunctivitis Grading (Robinson 2004) More relevant to CHRONIC manifestations, though it can occur prior to day 100 transplantation, de novo or post-pseudomembrane conjunctivitis All Images Are Copyright Protected

4. Assessing Ocular GVHD: Ophthalmic Evaluation Required Conjunctival staging/grading systems Corneal and conjunctival stainings Others (ocular surface disease tools, biopsy, etc.)

5. Chronic GVHD Activity Assessment: Ocular Symptom measurement: Main eye symptom reporting (severity rating 0–10) Objective measurement: Schirmer’s test (measurement of aqueous tear production— surrogate of lacrimal gland function)

6. 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

7. Schirmer’s 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, Schirmer’s is obtained without anesthesia. 1 Photos Courtesy of Dr. M. Robinson 1. Vitali, C., Bombardieri, S., Jonsson, R. et al (2002). Classification criteria for Sjogren’s syndrome: A revised version of the European criteria proposed by the American-European Consensus Group. Annals of Rheumatologic Disease, 61, 554-558. All Images Are Copyright Protected

8. Bend at the 0 mm line Important to place the strip at the very corner of the eye (avoids possible corneal abrasion) All Images Are Copyright Protected

9. Have patient keep his/her eyes closed for 5 minutes. No talking (or chewing/eating). Schirmer’s score should be recorded as mm of wetting for left and right eye separately. All Images Are Copyright Protected

10. Schirmer’s Test Results may be influenced by other factors (e.g., medications and hydration level). Recommendation based on consensus is to defer Schirmer’s testing for patients less than 9 years old. Evaluation by an ophthalmologist may be needed for objective scoring in younger children.