Ocular Graft-Versus-Host-Disease After Allogeneic Haematopoietic Stem Cell Transplantation: A Territory-Wide Prospective Cohort
Conditions: Graft Vs Host Disease, Haematological Malignancy, Cancer
Sponsor: The University of Hong Kong

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Study Protocol 
 
Title: Ocular Graft-Versus-Host-Disease Following Allogeneic Haematopoietic 
Stem Cell Transplantation: a Territory-wide Prospective Cohort  
 
Principle Investigator 
Dr Allie Lee 
Clinical Assistant Professor 
Department of Ophthalmology, LKS Faculty of Medicine, University of Hong Kong 
Address: Room 301, Block B, Cyberport 4 
Tel: 3962 1405 
Email: aleeni@hku.hk 
 
Co-investigator 
1. Dr Singh Gill Harinder Harry 
Clinical Assistant Professor 
Department of Medicine, LKS Faculty of Medicine, University of Hong Kong 
Email: gillhsh@hku.hk 
 
 

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Background 
 
Allogeneic haematopoietic stem cell transplantation (HSCT) is an effective treatment 
for all array of haematological disorders. Graft-versus-host-disease (GVHD) occurs as 
a result of an overactive systemic immunological response against normal host tissues, 
in particular the liver, skin, mucosal surface of the eye, gastrointestinal tract and 
genitalia.  
 
Ocular graft-versus-host-disease (oGVHD) occurs in 30-70% patients after allogeneic 
HSCT [1][2]. It mainly affects the ocular surface, and pathologically it is characterized 
by decreased conjunctival goblet cell density, increased conjunctival squamous 
metaplasia and infiltration of tissues with inflammatory cells [3]. Common clinical 
manifestations include keratoconjunctivitis sicca, marginal keratitis, conjunctivitis and 
conjunctival scarring, and anterior uveitis [4]. In severe cases, these can lead to painful 
non-healing corneal ulcers, secondary infections and visual loss. Risk factors for 
oGVHD reported in the literature included non-Caucasian race, male recipient from 
female donor, more extensive and severe systemic involvement, pre-existing diabetes 
mellitus and use of anti-thymocyte globulin [5][6][7][8].  
 
oGVHD can be debilitating and severely impact patients' quality of life. Although 
common and significant, currently there are no widely accepted guidelines available 
for prophylaxis and management. 
 
The Haemopoietic Stem Cell Transplantation Centre at Queen Mary Hospital is the 
only quaternary referral centre for adults in Hong Kong since 1990 and now it serves 
over 100 patients per year [9]. In collaboration with the Department of Haematology of 
QMH, we set out to establish a territory-wide cohort of patients receiving allogeneic 
HSCT to fill the current knowledge gaps. 
 
 
References 
1. Global and organ-specific chronic graft-versus-host disease severity according 
to the 2005 NIH Consensus Criteria. Blood 2011;118:4242–4249 

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2.  Zeiser R, Blazar BR. Pathophysiology of Chronic Graft-versus-Host Disease 
and Therapeutic Targets. N Engl J Med 2017;377:2565-79. 
3. Aronni S, Cortes M, Sacchetti M, et al. Upregulation of ICAM-1 expression in 
the conjunctiva of patients with chronic graft-versus-host disease. Eur J 
Ophthalmol 2006; 16:17–23. 
4. Kim SK. Ocular Graft vs. Host Disease. Ocular Surface 2011;3:S–177–S–179. 
5. Wang, J. C., Teichman, J. C., Mustafa, M., O'Donnell, H., Broady, R., & 
Yeung, S. N. (2015). Risk factors for the development of ocular graft-versus-
host disease (GVHD) dry eye syndrome in patients with chronic GVHD. Br J 
Ophthalmol, 99(11), 1514-1518. doi:10.1136/bjophthalmol-2014-306438 
6. Ogawa, Y., Kim, S. K., Dana, R., Clayton, J., Jain, S., Rosenblatt, M. I., . . . 
Tsubota, K. (2013). International Chronic Ocular Graft-vs-Host-Disease 
(GVHD) Consensus Group: proposed diagnostic criteria for chronic GVHD 
(Part I). Sci Rep, 3, 3419. doi:10.1038/srep03419 
7. Na, K. S., Yoo, Y. S., Mok, J. W., Lee, J. W., & Joo, C. K. (2015). Incidence 
and risk factors for ocular GVHD after allogeneic hematopoietic stem cell 
transplantation. Bone Marrow Transplantation, 50(11), 1459-1464. 
doi:10.1038/bmt.2015.187 
8. Tabbara, K. F., Al-Ghamdi, A., Al-Mohareb, F., Ayas, M., Chaudhri, N., Al-
Sharif, F., . . . Aljurf, M. (2009). Ocular findings after allogeneic 
hematopoietic stem cell transplantation. Ophthalmology, 116(9), 1624-1629. 
doi:10.1016/j.ophtha.2009.04.054 
9. https://www3.ha.org.hk/hkwc/transplantservice/HSCT-Adult.html 
 
 

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Objectives 
1. To establish the population-based epidemiology of oGVHD after allogeneic 
HSCT 
2. To understand the natural history and long-term ophthalmic outcomes in 
chronic oGVHD 
3. To perform quantitative analysis of ocular surface changes in oGVHD 
4. To identify biomarkers in blood and tear samples in oGVHD 
5. To investigate the change in the ophthalmic microbiome in oGVHD over 
time 
6. To recruit patients for future clinical trials on prophylactic and therapeutic 
regiments 
 
Plan of Investigation: 
 
Study Design 
We proposed a prospective cohort study with up to five years of follow-up. Enrolled 
patients will be seen at baseline before HSCT, and at months 3, 6, 9, 12; and optional 
at months 18, 24 and annually up to 5 years. 
 
The following examinations will be performed at some of the visits where appropriate: 
 
(1) Clinical examination 
This includes visual acuity, intraocular pressure, slit-lamp and fundus examination. 
 
(2) Tear assessment 
This includes tear breakup time (TBUT), fluorescein staining pattern, Schirmer's test 
(no anaesthetics), tear osmolarity and tear matrix metalloproteinase-9 (MMP-9). 
 
(3) Ocular surface imaging 
Meibography and quantitative tear film parameters by Keratography 5M and LipiView, 
pachymetry, specular microscopy and pentacam will be used.  
 
(4) Fundus imaging 
Optical coherence tomography (OCT) of the retinal nerve fibre layer (RNFL) and 

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macula will be taken. Fundus structure will be captured by a wide-field fundus camera. 
 
(5) Questionnaires 
Several dry eye questionnaires for symptom severity and burden on quality of life will 
be administered 
 
(6) Collection of a tear sample 
Tear from the conjunctival sac will be collected by the following tools: 
i. 
InflammaDry
® test kit (Quidel, San Diego, California, USA) 
ii. 
TearLabTM Osmolarity System (TearLab Corp., Escondido, California, 
USA)  
iii. 
Capillary glass tube 
iv. 
Schirmer’s test paper 
 
(7) Collection of conjunctival swabs 
Conjunctival samples will be collected by using swabs for laboratory investigation of 
the ocular microbiome.  
 
(8) Collection of a blood sample 
Blood samples will be collected during regular blood taking at the Department of 
Haematology, Queen Mary Hospital. 
 
 
 
 
Subjects 
In a two-year recruitment period, all patients attending the pre-HSCT assessment clinic 
in the Bone Marrow Transplant Centre (BMTC) at Queen Mary Hospital (QMH) will 
be invited to join the cohort. The sample size is estimated to be 250. This is based on 
the calculation that, each year, approximately 120-130 patients underwent allogeneic 
HSCT at the BMTC of QMH. 
 
Inclusion Criteria 
 Patient aged 18 or above 

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 Underwent allogeneic HSCT in QMH in the two-year recruitment period 
 
Exclusion Criteria 
 Underwent autologous HSCT 
 Patient unable to attend follow-up visits 
 
Family Control Subjects 
The research team will invite an accompanying family member to be the family control. 
Microbiome and tear samples will be collected for comparison. The sample collection 
schedule is the same as the corresponding post-HSCT case. 
 
Outcomes 
Primary outcome: 
 The population-based epidemiology, natural history and long-term ophthalmic 
outcomes of oGVHD after allogeneic HSCT 
Secondary outcomes: 
 A quantitative description of ocular surface changes in oGVHD 
 The change in the ophthalmic microbiome in oGVHD over time 
 
 
Data Processing and Statistics 
The proportion of detectable ocular microbiome in tear samples between patients will 
be compared using Fisher's exact test. Factors affecting the change of ocular 
microbiome in oGVHD, for example age, gender, days from onset of symptoms, 
intraocular pressure, and central corneal thickness, will be studied using logistic and 
linear regression models. All statistical analyses will be performed using software 
packages STATA (Statacorp LLC, USA) and R (The R Foundation, Austria). 
 
 
Data Handling and Record Keeping 
Each participant will be assigned a study number at time of enrollment. Data collected 
will be stored in a password-protected computer and processed without any patient 
identifying number. Patient confidentiality and data security will be strictly observed in 
accordance with the University’s and Department data security guidelines and data 

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management plans. Personal data will be discarded within 5 years after the completion 
of the study. 
 
 
Ethics 
All study procedures will be explained to participants and written informed consent 
obtained. There are no additional interventions and particular risks induced. 
 
 
Financial Interest 
There is no financial or conflict of interest to declare.