Insight, The Journal of ASORN ASORN Insight 2018 Q3 - Page 17

15 Susan Goldstein, MA, RN, BSN, CCRN f o c u s Ophthalmic Issues in the Hematopoietic Stem Cell Transplant Recipient Hematopoietic stem cell transplantation (HSCT) is used to treat The transplant process brought with it many side effects, includ- a number of malignant / premalignant (i.e., leukemias, lym- ing ophthalmic effects. His first ocular complaint was dry eye, phoma) and nonmalignant disorders (i.e., inherited metabolic which began with commencement of the chemotherapeutic disorders; inherited or acquired immune disorders, including regimen and worsened at the time of engraftment. He also expe- HIV; and inherited red cell disorders, such as sickle cell). Trans- rienced transient visual acuity changes. With a baseline myopia plants may be autologous, in which the patient’s own blood- of −2.75, he was unable to read the signs posted in his hospital producing stem cells are harvested and stored, then reinfused room without corrective lenses. After transplant, he was startled following chemotherapy and/ or radiation treatment, or alloge- to wake up one day and find himself able to read the smallest neic, in which the patient receives chemotherapy and/or radia- print on these signs effortlessly. This passed within a few days tion that destroys the patient’s own stem cells, which are then and he returned to baseline. A few days later he developed a new replaced by those of a donor. When donor cells are used, donor presbyopia and required reading glasses for the first time in his and recipient tissue types are matched as closely as possible; life. however, these transplants bring the risk of complications due to the possibility of antigen reactions between the donor cells and recipient. These reactions can result in the development of graft-versus-host disease (GVHD). GVHD may affect many areas, including the skin, liver, lungs, GI tract, and eyes, and can present significant challenges for post-allogeneic HSCT patients. With the growing population of patients undergoing HSCTs and living longer after transplant, ophthalmic nurses can expect to care for patients who have experienced HSCT. My husband was discharged from the hospital in mid-September. He was on multiple medications, including strong immunosup- pressive drugs to prevent the donor immune cells from attacking his body’s own tissues. These drugs were tapered off gradually throughout the fall and winter. His dry eye worsened significantly during this time. Notably, his new-onset presbyopia simultane- ously improved to a point of complete resolution. To address the dry eye, he was seen by a local ophthalmologist, who developed a treatment plan of artificial tears and lubricant Case Study eye drops, followed by cyclosporine drops if necessary. If these My husband underwent an allogeneic bone marrow transplant measures did not resolve the condition, he would be a candidate from a matched, unrelated donor in August of 2016 for myelo- for punctal plugs. dysplastic syndrome. He received a full-strength chemothera- peutic regimen of busulfan and fludarabine prior to transplant, which completely destroyed his own bone marrow, permanently eliminating his immune system and capacity to produce blood cells. After receiving the infusion of donated stem cells, he was hospitalized for three weeks and confined to a germ-free isola- tion room while the donor cells established themselves in his Fortunately, at the same time we realized that with the cold, dry winter, the relative humidity in our house had become extremely low, less than 12%. Using a whole-house humidification system to bring the house to a healthy 45% humidity level helped improve my husband’s ocular symptoms until he only occasionally used artificial tears and lubricants. body. This period of establishment, known as “engraftment,” A multitude of factors may have contributed to his ocular condi- replaced his destroyed marrow with the healthy stem cells of the tions. The chemotherapy regimen had included fludarabine, an donor. agent with known ocular toxicity (Ding, Herzlich, Bishop, Tuo & continued on the next page ASORN INSIGHT Summer 2018