Brazilian Guidelines for Ocular Graft-versus-Host Disease After Hematopoietic Stem Cell Transplantation: Recommendations from the Brazilian Society of Bone Marrow Transplantation
DOI:
https://doi.org/10.46765/2675-374X.2025v7n1e365Keywords:
Graft vs host disease, Dry eye syndromes, Hematopoietic stem cell transplantation, Meibomian gland dysfunctionAbstract
Chronic graft-versus-host disease (GVHD) is the most significant long-term complication of allogeneic hematopoietic stem cell transplantation (HSCT), with ocular involvement, predominantly dry eye disease (DED), affecting 40–60% of patients and causing substantial morbidity. This consensus document, developed by the Ophthalmology Group of the Brazilian Society of Bone Marrow Transplantation, provides evidence-based recommendations for the diagnosis and management of ocular GVHD, graded according to GRADE methodology. Ocular GVHD results from donor-derived T-lymphocyte-mediated injury to the lacrimal gland, meibomian glands, and conjunctiva, producing a mixed aqueous deficient and evaporative dry eye phenotype. Baseline ophthalmologic evaluation before HSCT is recommended to stratify risk and guide follow-up. Diagnosis integrates the 2015 National Institutes of Health (NIH) Consensus criteria for systemic chronic GVHD, the organ-specific scoring system proposed by the International Chronic Ocular GVHD Consensus Group (ICOGCG), and the Tear Film & Ocular Surface Society Dry Eye Workshop III framework for tear film homeostasis, combining symptom questionnaires (6-question version of the ocular surface disease index), Schirmer testing, tear break-up time, ocular surface staining, and osmolarity. Comparative and multicenter validation studies indicate that ICOGCG criteria outperform isolated NIH-based ocular assessment in diagnostic accuracy. Management follows a stepwise approach, beginning with preservative-free lubrication and progressing to topical anti-inflammatory agents, autologous serum, and meibomian gland dysfunction therapies. Systemic immunosuppression and surgical interventions, including scleral lenses, amniotic membrane transplantation, and tarsorrhaphy, are reserved for moderate to severe or refractory disease, requiring coordination with the hematology team. This guideline emphasizes a multidimensional, evidence-graded approach to ocular GVHD, integrating validated diagnostic tools with individualized, severity-based treatment strategies to preserve ocular surface integrity and quality of life in HSCT survivors.
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