Analyses and Correlation of Pathologic and Ocular Cutaneous Changes in Murine Graft versus Host Disease

Graft versus host disease (GVHD) is initiated by donor allo-reactive T cells activated against recipient antigens. Chronic GVHD (cGVHD) is characterized by immune responses that may resemble autoimmune features present in the scleroderma and Sjogren's syndrome. Unfortunately, ocular involvement occurs in approximately 60-90% of patients with cGVHD following allo-hematopoietic stem cell transplants (aHSCT). Ocular GVHD (oGVHD) may affect vision due to ocular adnexa damage leading to dry eye and keratopathy. Several other compartments including the skin are major targets of GVHD effector pathways. Using mouse aHSCT models, the objective was to characterize cGVHD associated alterations in the eye and skin to assess for correlations between these two organs. The examination of multiple models of MHC-matched and MHC-mismatched aHSCT identified a correlation between ocular and cutaneous involvement accompanying cGVHD. Studies detected a "positive" correlation, i.e., when cGVHD-induced ocular alterations were observed, cutaneous compartment alterations were also observed. When no or minimal ocular signs were detected, no or minimal skin changes were observed. In total, these findings suggest underlying cGVHD-inducing pathological immune mechanisms may be shared between the eye and skin. Based on the present observations, we posit that when skin involvement is present in aHSCT patients with cGVHD, the evaluation of the ocular surface by an ophthalmologist could potentially be of value.

Assessment of Corneal Fluorescein Staining in Different Dry Eye Subtypes Using Digital Image Analysis

Purpose

To describe a new objective technique of digital image analysis for the quantification and the morphological characterization of corneal staining in the setting of dry eye disease (DED), and to apply it to distinguish Sjögren syndrome (SS) from ocular graft versus-host disease (oGVHD).

Methods

Slit-lamp photographs of corneal staining obtained from 40 patients with DED (20 with SS and 20 with oGVHD; mean age 60.7 ± 12.3 years) were evaluated. Images were subjectively graded using Oxford and National Eye Institute (NEI) scales, the staining pattern was classified as micropunctate, macropunctate, coalescent, or patch. The corneal staining index (CSI) was calculated automatically using the software ImageJ 1.51s. Particles analysis was used to calculate mean area, circularity, and roundness of staining spots.

Results

CSI was significantly correlated with Oxford and NEI scales (respectively Rs = 0.823 and Rs = 0.773; both P < 0.001), and showed a good interobserver reliability (intraclass correlation coefficient [ICC] = 0.988 [95% confidence interval [CI]: 0.978–0.994]). The mean area of staining spots calculated with particles analysis was significantly correlated with the subjective classification of the staining pattern (Rs = 0.550, P < 0.001). The circularity and roundness of staining spots were significantly higher in oGVHD patients compared with SS (respectively, 0.51 ± 0.11 vs. 0.44 ± 0.10, P = 0.040; 0.61 ± 0.03 vs. 0.59 ± 0.02, P = 0.004). Sensitivity and specificity to distinguish oGVHD from SS were respectively 65.0% and 60% for circularity and 80.0% and 70.0% for roundness.

Conclusions

The new algorithm showed good reliability and was well correlated with the traditional subjective grading scales. Particles analysis for the objective assessment of the staining pattern may help to differentiate patients with oGVHD from those with SS.

Translational Relevance

The digital image analysis technique may be a reliable alternative to evaluate corneal staining objectively in the clinic and in clinical trials.