Pharmacotherapy of age-related macular degeneration.

BACKGROUND: Age-related macular degeneration is the leading cause of blindness in the developed world. The number of persons with vision loss from age-related macular degeneration is projected to increase dramatically over the next few decades. Therefore, effective therapeutic and prophylactic agents are greatly needed. OBJECTIVE: This article will discuss some of the newer treatment strategies that may help to reduce the incidence of visual loss from age-related macular degeneration. Some of these therapies and strategies can be implemented today, while many are hypothetical based on current laboratory data and ongoing clinical trials. METHODS: A review of the literature and ongoing clinical trials was undertaken. CONCLUSION: Current therapies using antioxidants for prevention of the progression of age-related macular degeneration and anti-vascular endothelial growth factor therapies for neovascular age-related macular degeneration have given us tools for tackling this disease better and reducing the number of patients with vision loss. Combinations of some of the existing treatments and new forms of therapy may yet further decrease the treatment burden in the future.

Sherrington innervational surgery in the treatment of chronic sixth nerve paresis.

INTRODUCTION AND PURPOSE: To describe a new operation to treat unilateral chronic sixth nerve paresis based on Sherrington's innervational law. A recession of the medial rectus (MR) in the good eye, yoke to the paretic lateral rectus (LR), will have the reciprocal innervational effect of relaxing the contracture of the contralateral MR and by doing so will enhance the effect of a weakening procedure performed on this muscle. The goal of this study was to eliminate diplopia in primary position by improving the function of the paretic LR and reducing the contracture of its antagonist MR. METHODS: The records of 14 consecutive patients with unilateral chronic sixth nerve paresis so treated were reviewed. Nine had bilateral medial rectus muscle retroplacement and postop' adjustable sutures. A non-adjustable resection of the paretic lateral rectus muscle was added to the other five. Average time from onset to surgery was 60 months (minimum 9 months). Average post-surgical followup was 22 months. RESULTS: The function of the paretic LR and the contracture of the ipsilateral MR were improved in all 14 cases. Patients with bilateral medial rectus recessions and postop' adjustable sutures had an average correction of 32 prism diopters in primary position. Patients with the added resection of the paretic LR had an average correction in primary position of 46 prism diopters. Two of the 14 patients failed our goals; one had residual diplopia in primary position and the other one had diplopia within 30 degrees on gaze to one side; for an 86% success rate. CONCLUSIONS: The 86% success rate in this study (ultimately we also achieved a 100% satisfaction rate) indicates that innervational surgery in the form of a recession of the MR in the good eye added to that of the MR in the involved eye in patients with unilateral chronic sixth nerve paresis is a safe and effective surgical procedure.

Patterns of regional and distant metastasis in patients with eyelid and periocular squamous cell carcinoma.

PURPOSE: To determine the frequency and location of regional lymph node metastasis in patients with squamous cell carcinoma (SCC) of the eyelid and periocular skin. Patterns of distant metastasis were also investigated. DESIGN: Retrospective case series. PATIENTS: One hundred eleven patients treated at The University of Texas M. D. Anderson Cancer Center for SCC of the eyelid and periocular skin between 1952 and 2000. METHODS: The clinical records of the 111 patients were retrospectively reviewed. The clinical characteristics analyzed included age, gender, location of lesion, treatment modalities, patterns of regional nodal and distant metastasis, and perineural invasion. Follow-up time ranged from 6 to 484 months (median, 76.6). MAIN OUTCOME MEASURE: Incidence of regional lymph node metastasis. RESULTS: The most common sites of SCC were the lower eyelid (54 patients [48.6%]), the medial canthus (40 patients [36.0%]), and the upper eyelid (25 patients [22.5%]). Local treatment of SCC consisted of wide local excision with frozen section analysis to ensure negative margins in 96 patients (86.4%), radiotherapy (without surgery) in 7 patients, and primary exenteration because of extensive tumor in 7 patients. Local recurrence occurred in 41 patients (36.9%). Twenty-seven patients (24.3%) had regional nodal metastasis during the study period. Sixteen of these patients had regional lymph node metastasis at the time of the initial presentation to M. D. Anderson Cancer Center. Eleven developed regional nodal disease later. Seven patients (6.2%) had distant metastasis during the study period. Nine patients (8.1%) had perineural invasion. CONCLUSION: This study indicates that the overall rate of regional lymph node metastasis in patients with SCC of the eyelid or periocular skin may be as high as 24%. Thus, careful surveillance of the regional lymph nodes is an important aspect of the initial management of eyelid or periocular skin SCC. Consideration could be given to studying sentinel lymph node biopsy as a technique to stage SCC of the eyelid or periocular skin more accurately, especially in patients with recurrent, large, or highly invasive lesions or with perineural invasion.

Experience with sentinel lymph node biopsy for eyelid and conjunctival malignancies at a cancer center.

PURPOSE: To describe one center's experience with sentinel lymph node (SLN) biopsy in patients with eyelid and conjunctival malignancies performed with a smaller volume of technetium than was initially used and a small incision directly overlying the sentinel node(s). METHODS: A noncomparative interventional case series of 13 patients with clinically negative regional lymph nodes who underwent SLN biopsy for eyelid or conjunctival malignancies at The University of Texas M. D. Anderson Cancer Center between May 2002 and July 2003. Preoperative lymphoscintigraphy was performed with an injection of 0.3 mCi of technetium Tc-99m sulfur colloid in a volume of 0.2 mL. Images were taken as soon as the first SLN was detected through the gamma camera. Intraoperative mapping was performed with the same volume and concentration of technetium Tc-99m sulfur colloid along with an injection of isosulfan blue dye. RESULTS: Five patients had conjunctival melanoma, 6 had sebaceous cell carcinoma of the eyelid, and 2 had eyelid melanoma. SLN(s) were identified in all patients. In 12 patients, more than 1 SLN was identified. During surgery, no SLNs were blue. One patient with conjunctival melanoma had an SLN that was positive on histologic examination. There were no ocular or extraocular complications from the procedure except for mild temporary weakness of the marginal mandibular branch of the facial nerve in 2 patients that resolved completely within 4 to 6 weeks and without any further intervention. None of the patients had permanent blue tattooing of the conjunctival surface or eyelid skin. CONCLUSIONS: Our experience suggests that lymphoscintigraphy and SLN biopsy with a small volume of technetium Tc-99m sulfur colloid and small incisions, even without the use of the blue dye, can identify SLNs in patients with conjunctival and eyelid malignancies, and can be performed safely.

Outcomes in patients with adenoid cystic carcinoma of the lacrimal gland.

PURPOSE: To evaluate the outcomes among patients with adenoid cystic carcinoma of the lacrimal gland treated at various stages of their disease at a tertiary care cancer center. METHODS: A retrospective case series of 20 patients with adenoid cystic carcinoma of the lacrimal gland treated at a single institution between 1952 and 2002. Clinical records were available for all 20 patients; histologic sections from 12 of the 20 patients were available for review. Disease-free survival was measured from the completion of treatment; overall survival was measured from the date of initial diagnosis. RESULTS: The study included 6 men and 14 women. The mean age at diagnosis was 39.5 years. The median follow-up time was 34 months (range, 6 to 264 months). The local/regional treatment modalities included exenteration with bone removal and radiation therapy (RT) in 5 patients, exenteration with RT (no bone removal) in 8 patients, exenteration (no RT or bone removal) in 1 patient, exenteration with bone removal (no RT) in 1 patient, local resection with RT in 3 patients, and local resection without RT in 2 patients. Overall, 16 patients had RT as part of their treatment regimen. Seven patients (35%) had local recurrence. Sixteen patients (80%) had distant metastasis during the study period. At the time of this report, 13 (65%) of the patients had died of disease. The median disease-free survival for the entire group was 18 months. Eight patients had a predominantly basaloid histologic pattern. Ten patients had verifiable histologic evidence of perineural invasion. CONCLUSIONS: This study underscores the generally grave prognosis for patients with adenoid cystic carcinoma of the lacrimal gland and the difficulty in making any conclusive recommendations for local therapy for this disease.

Nasolacrimal duct obstruction associated with radioactive iodine therapy for thyroid carcinoma.

A 50-year-old woman presented with a 5-year history of unilateral epiphora that began shortly after 131I therapy for thyroid carcinoma. A recent recombinant human thyroid-stimulating hormone (Thyrogen) scan had shown a focus of uptake adjacent to the right eye that was initially thought to be a possible metastasis. Probing and irrigation revealed complete blockage of the right nasolacrimal duct. The patient underwent a right dacryocystorhinostomy (DCR) and biopsy of the lacrimal sac. Histopathologic examination of the lacrimal sac and nasal mucosa revealed foreign-body reaction and fibrosis with no malignant cells. A repeat Thyrogen scan after DCR showed no residual focus of activity in the nose or near the lacrimal sac and confirmed reestablishment of lacrimal drainage on the right side. This case demonstrates that 131I therapy for thyroid carcinoma can be associated with nasolacrimal duct obstruction. The appearance of a focus of uptake near the lacrimal sac on Thyrogen scanning in a patient with a history of thyroid carcinoma may not be due to a new focus of metastasis and may indeed be due to pooling of 131I in the lacrimal sac due to nasolacrimal duct blockage.

The role of supraorbital nerve biopsy in cutaneous malignancies of the periocular region.

PURPOSE: To describe clinical situations in which a biopsy or resection of the supraorbital nerve may play a role in patients in whom perineural invasion secondary to cutaneous head and neck malignancies is suspected. METHODS: The clinical records of 230 patients with squamous cell carcinoma (SCCA) of the skin of the head and neck who were treated at the University of Texas M.D. Anderson Cancer Center between April 1994 and March 2001 were reviewed. Thirty-five patients were identified as having primary lesions on the forehead skin. Of these, 8 patients had microscopic or clinical evidence of perineural invasion. Four of these 8 patients had undergone a supraorbital nerve biopsy or resection in the course of their treatment. Although all 4 patients were classified as having had SCCA, 1 patient had a variant of undifferentiated SCCA that more appropriately should have been classified as lymphoepithelioma-like carcinoma. The clinical history was reviewed in each case. The median follow-up time for this cohort was 47 months (range, 24 to 72 months). RESULTS: The 4 cases reported here illustrate that a supraorbital nerve biopsy can help confirm the diagnosis of perineural invasion, identify the extent of tumor infiltration, and help in staging of particularly aggressive cutaneous malignancies of the periocular region. Access to the proximal (orbital) portion of the nerve can be accomplished through an anterior orbitotomy. CONCLUSIONS: A biopsy of the peripheral branches of the trigeminal nerve may be indicated as part of the staging or to confirm the diagnosis of perineural invasion in patients with SCCA or other locally aggressive cutaneous malignancies of the head and neck.

Docetaxel-induced histologic changes in the lacrimal sac and the nasal mucosa.

PURPOSE: To identify histopathologic changes in the lacrimal sac and the nasal mucosa caused by docetaxel in 3 patients with canalicular narrowing and nasolacrimal duct obstruction. METHODS: Small case series. Lacrimal sac and nasal mucosal specimens were obtained at the time of dacryocystorhinostomy or during silicone intubation to correct epiphora in 3 patients receiving docetaxel. Histologic evaluation was performed. RESULTS: Extensive fibrotic changes in the stroma of the lacrimal sac and the nasal mucosa were the prominent histologic features in all 3 patients. A biopsy specimen was taken from the lower portion of the nasal mucosa (near the inferior turbinate) in one patient at the time of silicone intubation and showed both clinical and histologic evidence of keratinization with marked epidermalization of the surface epithelium, thickening, and parakeratosis of the squamous epithelium. CONCLUSIONS: Nasolacrimal duct obstruction secondary to treatment with docetaxel may be in part due to stromal fibrosis in the mucosal lining of the lacrimal drainage apparatus.

Blockage of the lacrimal drainage apparatus as a side effect of docetaxel therapy.

BACKGROUND: The current study was conducted to report the severity and management of canalicular and nasolacrimal duct stenosis as a side effect of docetaxel therapy and to report the outcomes of surgical intervention for this condition. METHODS: The records of 148 patients with epiphora associated with docetaxel therapy who were evaluated at the Ophthalmology Service at The University of Texas M. D. Anderson Cancer Center were reviewed. The frequency of docetaxel administration, the dose intensity, the cumulative dose of docetaxel, and any concomitant chemotherapeutic agents were recorded. Each patient underwent an ophthalmologic examination and in-office probing and irrigation. The patients either were treated with topical steroids or offered a surgical procedure for canalicular stenosis- (silicone intubation, dacryocystorhinostomy [DCR] with the placement of silicone tubes, or DCR with the placement of Pyrex glass tubes), depending on the severity of the canalicular stenosis. RESULTS: Docetaxel was given weekly in 71 patients, every 2 weeks in 5 patients, and every 3 weeks in 72 patients. Thirty patients (59 eyes) who received weekly docetaxel underwent surgery to correct epiphora. Twenty-three patients (39 eyes) were treated with temporary silicone tube placement, 9 patients (13 eyes) were treated with DCR with temporary silicone tube placement, and 4 patients (7 eyes) were treated with DCR with permanent Pyrex glass tube placement. Twenty-nine of the 30 patients who underwent surgery reported improvement or total resolution of epiphora after the procedure. Ten additional patients (20 eyes) who received weekly docetaxel had complete closure of their canaliculi but elected not to undergo surgery. Of special note were two patients who received weekly docetaxel in the neoadjuvant setting and developed complete closure of the canaliculi. Of the patients who received docetaxel every 2 or 3 weeks, only 3 required a surgical intervention to correct epiphora; none required Pyrex glass tube placement. CONCLUSIONS: Canalicular and nasolacrimal duct obstruction is a common side effect of weekly docetaxel therapy and can occur even when this drug is used in the neoadjuvant setting. The results of the current study indicate that early temporary silicone intubation in symptomatic patients receiving weekly docetaxel can prevent further closure of the lacrimal drainage apparatus and obviate more involved surgical interventions and permanent Pyrex glass tube placement. Cancer 2003;98:504-7.

Margins of excision for cutaneous melanoma of the eyelid skin: the Collaborative Eyelid Skin Melanoma Group Report.

PURPOSE: To evaluate the practice patterns among surgeons who treat melanomas of the eyelid skin with respect to margins of excision and to look for possible correlation between margins of excision and the incidence of local and regional recurrence and distant metastasis. METHODS: A retrospective survey of the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the European Society of Ophthalmic Plastic and Reconstructive Surgery yielded 44 cases. The patients' age, sex, date of diagnosis, histologic classification of melanoma, Breslow thickness, Clark level, location of melanoma, size of margins of excision, and findings of local or regional recurrence or distant metastasis were recorded in each case. Patients were stratified on the basis of margins of excision: 5 mm but <10 mm; and >/=10 mm. Patients were also stratified by Breslow thickness. A Cox regression model was used to evaluate the predictive value of each factor for recurrence. Main outcome measures were the incidences of local and regional recurrence and distant metastasis as a function of margins of excision and Breslow thickness. RESULTS: The majority of patients for whom reliable information was available had excision margins of /=10 mm, but this difference was not statistically significant because very few patients had melanomas at least 2 mm thick. Breslow thickness was the only statistically significant predictor of local, regional, and distant metastasis. Margins of excision did not have a statistically significant effect on local, regional, or distant recurrence. CONCLUSIONS: Breslow thickness is an important prognostic indicator for eyelid skin melanomas. A 5-mm margin of excision may be adequate for thin melanomas of the periocular skin, but because of the small number of patients in this series who had >5-mm margins, a definitive comparison of outcome with larger margins of excision cannot be made. For melanomas >/=2 mm, wider margins of excision may be prudent, and careful surveillance for local and regional recurrence is indicated.

Feasibility of preoperative lymphoscintigraphy for identification of sentinel lymph nodes in patients with conjunctival and periocular skin malignancies.

PURPOSE: To determine the feasibility of preoperative lymphoscintigraphy for identification of sentinel lymph nodes (SLNs) in patients with conjunctival and periocular skin tumors and to determine the patterns of lymphatic drainage from such tumors. METHODS: We retrospectively reviewed the records of all patients with biopsy-confirmed conjunctival and periocular skin malignancies who underwent lymphoscintigraphy with or without SLN biopsy between January 1999 and June 2000. Patients underwent lymphoscintigraphy with 0.3 to 1 mCi of technetium Tc-99m sulfur colloid in a volume of either 0.2 mL or 1 mL. Images were taken as soon as the first SLNs were detected through the camera and every 15 minutes thereafter. Intraoperative mapping and SLN biopsy was performed 1 to 2 days after lymphoscintigraphy unless the patient refused or there were medical contraindications to the procedure. RESULTS: The study included 7 patients with malignant melanoma of the conjunctiva or periocular skin and 1 patient with Merkel cell carcinoma of the eyelid. On lymphoscintigraphy, at least 1 SLN was identified in 7 of the 8 patients. Although all lesions located in the lateral half of the ocular adnexa drained to at least one SLN in the parotid (preauricular) area, there was some variability in the drainage patterns of lesions located in the medial half of the ocular adnexa. A smaller injection volume (0.2 mL) was adequate for detecting the nodes draining the area of injection and led to less spread of technetium to the surrounding areas. Six patients underwent SLN biopsy. In all but one, the nodes identified during surgery corresponded with those visualized on lymphoscintigraphy. CONCLUSIONS: Preoperative lymphoscintigraphy successfully identifies SLNs in most patients with conjunctival and periocular skin malignancies. Smaller injection volumes (0.2 mL) appear to be adequate for identification of the sentinel nodes and lead to less spread to surrounding tissues.

Docetaxel secretion in tears: association with lacrimal drainage obstruction.

OBJECTIVE: To test the hypothesis that docetaxel may be secreted in tears after intravenous infusion. DESIGN: Prospective pilot trial. PATIENTS AND METHODS: Tear fluid was collected from 4 patients receiving docetaxel weekly and 2 patients receiving docetaxel every 3 weeks as a single agent for the treatment of metastatic breast cancer. Tear samples were collected once prior to and again within 30 minutes following the end of the 1-hour docetaxel infusion. A blood sample was also obtained after infusion. The tear and plasma samples were analyzed for drug content using high-performance liquid chromatography and tandem mass spectrometry. RESULTS: Docetaxel was found in the tear samples collected from all 6 patients. CONCLUSION: The secretion of docetaxel in tears may be a mechanism for canalicular inflammation and tear drainage obstruction, which are known to occur as an adverse effect of the drug.

Severe periorbital edema secondary to STI571 (Gleevec).

STI571 (imatinib mesylate; Gleevec) is a selective inhibitor of the bcr-abl, c-kit, and platelet-derived growth factor receptor tyrosine kinases. Mild periorbital edema has been noted as a common side effect in Phase I and II trials of this drug for the treatment of patients with chronic myelogenous leukemia and gastrointestinal stromal tumors. The authors report the case of male patient age 63 years who developed severe periorbital edema after treatment with STI571 for chronic myelogenous leukemia. His edema was severe enough to cause visual obstruction due to lower eyelid festoons that ultimately required surgical debulking. Histopathologic analysis of specimens of the excised upper and lower eyelid tissue revealed dermal dendrocytes that expressed the platelet-derived growth factor receptor and c-kit tyrosine kinases, suggesting a possible role for dermal dendrocytes in the development of this toxic effect.

Clinical presentation and treatment of secondary orbital lymphoma.

PURPOSE: To describe the clinical features and histologic classification of orbital lymphoma secondary to systemic non-Hodgkin lymphoma, to evaluate the efficacy of various treatment modalities for controlling the orbital component of disease, and to analyze vision-related outcomes. METHODS: In this retrospective case series, the clinical records of patients diagnosed with orbital lymphoma who were treated between January 1999 and May 2001 at the University of Texas M.D. Anderson Cancer Center were reviewed. Demographic data, histologic classification of lymphoma, immunophenotype, stage of disease, treatment outcomes, vision-related outcomes, and duration of follow-up after the diagnosis of orbital lymphoma were recorded in each case. RESULTS: At the time of diagnosis, all 15 patients identified either had a previous history of non-Hodgkin lymphoma or had simultaneous involvement of lymph node or other sites. Ten patients (67%) had intermediate-grade or high-grade lymphoma. All 15 patients had a B-cell phenotype. Systemic chemotherapy or immunotherapy was the initial treatment modality in 13 patients; the other 2 patients were treated with radiation as the initial mode of therapy. Eleven patients (73%) achieved complete regression of the orbital tumor; one patient had partial regression of the orbital lymphoma. Loss of vision secondary to compressive optic neuropathy was seen in 5 patients (33%); in 3 of these patients, the orbital lymphoma was diagnosed early and treatment was successful in reversing the loss of vision. One patient had irreversible vision loss secondary to compressive optic neuropathy; in this case, therapy had not been initiated until several months after onset of symptoms. Another patient died of lymphoma before the orbital disease could have responded to therapy. CONCLUSIONS: Because of often widespread systemic involvement and a usually more aggressive histologic classification than primary orbital lymphomas, secondary orbital lymphomas warrant treatment with systemic chemotherapy or systemic immunotherapy. In some cases, combining such systemic therapy with local radiation treatment is beneficial. Loss of vision as the result of compressive optic neuropathy in this setting can be reversed if systemic therapy is initiated soon after the onset of progressive signs and symptoms of orbital disease.

Marginal keratitis associated with administration of filgrastim and sargramostim in a healthy peripheral blood progenitor cell donor.

PURPOSE: To describe a 61-year-old healthy peripheral blood progenitor cell (PBPC) donor who developed marginal keratitis and mild uveitis on the third day after receiving daily recombinant human granulocyte colony-stimulating factor (rhG-CSF; filgrastim) and recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF; sargramostim) to mobilize PBPCs for allogeneic transplantation. METHODS: Interventional case report. RESULTS: The keratitis was treated with topical administration of 1% prednisolone acetate solution and resolved within 24 hours. The topical steroid dose was tapered and ultimately discontinued without recurrence of keratitis. CONCLUSION: Healthy PBPC donors receiving rhG-CSF or rhGM-CSF should be monitored for ocular complications, particularly marginal keratitis and uveitis.

Canalicular stenosis secondary to weekly versus every-3-weeks docetaxel in patients with metastatic breast cancer.

PURPOSE: To compare the frequency of canalicular stenosis as a side effect of weekly versus every-3-weeks docetaxel in patients with metastatic breast cancer. DESIGN: Retrospective nonrandomized comparative trial. PATIENTS AND METHODS: Eighteen patients enrolled in a phase II study of weekly docetaxel plus trastuzumab and 18 patients enrolled in a phase II study of every-3-weeks docetaxel plus doxorubicin were evaluated. Each patient underwent a comprehensive ophthalmologic examination, probing and irrigation of the nasolacrimal duct, and, in some instances, a nuclear lacrimal scan. MAIN OUTCOME MEASURES: If epiphora (excessive tearing) was reported by the patient, its time of onset was documented. In patients with epiphora, presence or absence of canalicular stenosis was evaluated on the basis of the findings on probing and irrigation. The duration of treatment with docetaxel, the dose frequency, and the cumulative dose of docetaxel were recorded in each case. RESULTS: Fourteen patients (77%) receiving weekly docetaxel plus trastuzumab had epiphora. Nine of these patients had significant anatomic narrowing of the canaliculi. Bicanalicular silicone intubation or dacryocystorhinostomy was recommended in all nine patients. Eight patients underwent surgery and experienced complete or near complete resolution of epiphora. Although two patients (11%) receiving every-3-weeks docetaxel plus doxorubicin reported transient symptoms of epiphora, neither patient was found to have narrowing of the canaliculi, and the epiphora was not severe enough to justify surgical intervention. The mean duration of docetaxel therapy for the patients in this study was 19 weeks. The mean cumulative dose of docetaxel was higher in patients with canalicular stenosis than in patients without this side effect. CONCLUSIONS: Canalicular stenosis was more common in patients receiving weekly docetaxel than in those receiving every-3-weeks docetaxel for metastatic breast cancer. Bicanalicular silicone intubation early in the course of weekly docetaxel therapy should be considered, because this intervention can prevent complete closure of the canaliculi. Once complete or near complete stenosis of the canaliculi occurs, placement of a permanent Pyrex glass tube may become necessary to overcome the blockage of tear outflow.

Scleritis as the initial clinical manifestation of graft-versus-host disease after allogenic bone marrow transplantation.

PURPOSE: To describe a case of scleritis with choroidal detachment as the initial clinical manifestation of graft-versus-host disease after allogenic bone marrow transplantation. DESIGN: Interventional case report. METHODS: Review of clinical records. RESULTS: A 50-year-old man developed symptoms of mild dry eye syndrome 20 days after receiving a one-antigen-mismatched allogenic bone marrow transplant. Five days later, he developed orbital pain, moderate visual loss, and a sterile orbital abscess on the left side. The orbital inflammatory collection was drained, and symptoms improved. On day 41 after bone marrow transplantation, the patient developed severe ocular pain and scleral thickening with secondary choroidal detachment and glaucoma in the right eye. The patient had no systemic signs of graft-versus-host disease at this time. The ocular symptoms and signs responded remarkably well to intravenous corticosteroids. Six months after bone marrow transplantation, while receiving low-dose oral methylprednisolone, the patient developed a skin rash. A biopsy of the involved skin confirmed the diagnosis of graft-versus-host disease. CONCLUSION: Scleritis can be the initial clinical manifestation of graft-versus-host disease after allogenic bone marrow transplantation.