Cataract Surgery in Ocular Graft-Versus-Host Disease

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Article initiated by:
Crystal Wen, Katherine Han, Alison Zhao, Isabell Guzchenko, Edward M. Nash, Rithika Sriram, Sachin Pathuri, Jainam Shah, Bruce Becker, MD, Andrew Go Lee, MD, Joshua Ong, John Berdahl
All contributors:
Crystal Wen, Katherine Han, Alison Zhao, Isabell Guzchenko, Edward M. Nash, Rithika Sriram, Sachin Pathuri, Jainam Shah, Andrew Go Lee, MD, Joshua Ong, John Berdahl, Bruce Becker, MD
Assigned editor:
Review:
Assigned status Update Pending
.


Cataract surgery in patients with ocular graft-versus-host disease (oGVHD) requires special consideration due to chronic ocular surface inflammation, tear-film instability, and impaired corneal epithelial integrity. Although cataract extraction can substantially improve visual acuity, these patients face increased risks of postoperative ocular surface deterioration and vision-threatening corneal complications. This article reviews preoperative evaluation and ocular surface optimization, biometry and intraocular lens selection, intraoperative surgical considerations, postoperative complications, and strategies to optimize visual outcomes.

Introduction

Cataracts are an important cause of visual impairment following allogeneic hematopoietic stem cell transplantation (HSCT), particularly among patients with ocular graft-versus-host disease (oGVHD). Cataract formation may be associated with total body irradiation, prolonged systemic corticosteroid exposure, and certain chemotherapy agents, with posterior subcapsular cataracts representing a common presentation.[1][2] Although phacoemulsification can provide meaningful visual improvement, cataract surgery in patients with oGVHD presents unique challenges due to preexisting ocular surface disease (OSD), tear-film instability, and impaired corneal epithelial integrity.

Successful cataract surgery in this population requires distinguishing cataract-related visual impairment from that attributable to ocular surface or corneal disease, as both may contribute to reduced visual acuity and visual disturbances.[3] Ocular surface instability may compromise the reliability of preoperative keratometry and biometry, while intraoperative exposure and postoperative inflammation can exacerbate epithelial disease and increase the risk of delayed healing and vision-threatening corneal complications.[3][4] Accordingly, surgical management requires careful assessment of disease activity, appropriate timing and ocular surface optimization, individualized biometry and intraocular lens planning, measures to minimize intraoperative surface injury, and continued postoperative surveillance. This article reviews these considerations, with an emphasis on optimizing visual outcomes while minimizing surgery-associated complications in patients with oGVHD.

Preoperative Evaluation and Ocular Surface Optimization

Since OSD drives most of the added risk of cataract surgery in oGVHD, the preoperative evaluation should pair the routine cataract work-up with a focused assessment of ocular surface health. Attention should be directed to findings that can compromise surgical timing, biometric accuracy, and epithelial healing, including corneal epithelial defects, significant punctate epithelial keratopathy, filamentary keratitis, tear-film instability or an irregular epithelial surface, and corneal thinning, ulceration, or cicatricial conjunctival/corneal changes. Disease severity and activity may influence outcomes, but the evidence is not uniform. Lower preoperative oGVHD severity has been associated with better postoperative corrected distance visual acuity (CDVA)[5], whereas a large multicenter cohort (104 eyes) found that best-corrected visual acuity (BCVA) improved significantly across all National Institutes of Health (NIH) severity grades and that this improvement was independent of oGVHD NIH severity.[3] Instead, visual outcome correlated with the preoperative degree of corneal staining (approximately 0.078 logMAR lost per one-grade increase in staining).[3] Taken together, these findings suggest that NIH severity grade alone may not reliably predict postoperative visual improvement, while the degree of preoperative corneal staining may provide additional prognostic information. These observations reinforce the importance of assessing ocular surface integrity alongside overall disease severity when evaluating surgical candidacy. Regardless of grade, aggravation of pre-existing surface disease after surgery is common, with vision-threatening corneal complications possible even with meticulous care.[6]

The ocular surface should be optimized before final surgical measurements are obtained, because tear-film instability and an irregular epithelium reduce the accuracy, reliability, and reproducibility of keratometry and biometry and can produce refractive surprises if not addressed.[4][7][8][9] Optimization generally involves continuing and, where needed, intensifying the patient’s existing oGVHD surface therapy before surgery. The specific therapies (e.g., autologous serum tears, topical immunomodulators, scleral/PROSE lenses) are reviewed in the Management of Ocular GVHD EyeWiki article and are considered here only as they pertain to surgical preparation. A collaborative subspecialty approach may improve results in active or severe disease: a preoperative immunomodulatory regimen delivered through combined dry-eye and cataract subspecialty care (pooled human immune globulin 1%, autologous serum 50%, and topical methylprednisolone 1%) achieved good visual outcomes (mean logMAR 0.17) with a low complication rate in oGVHD patients undergoing cataract surgery.[10] Coordination with the patient’s transplant/GVHD team is also reasonable when systemic disease is active.

Timing relative to surface activity appears important. In a multicenter federated electronic health record analysis, postoperative vision-threatening corneal event (VTCE) risk rose as preoperative ocular surface activity occurred closer to surgery, and was highest when activity occurred within 30 days before surgery (HR 3.78). Preoperative ocular surface optimization was associated with lower VTCE risk (HR 0.56).[11] These associations derive from an exploratory observational analysis and should not be interpreted as establishing causality or a specific minimum interval between active disease and surgery. Nevertheless, they support controlling ocular surface inflammation and deferring elective surgery until the ocular surface is sufficiently stable when feasible.

Biometry, Intraocular Lens Selection, and Surgical Planning

Accurate biometry and intraocular lens (IOL) power calculation are particularly challenging in patients with oGVHD because tear-film instability, epithelial irregularity, and corneal scarring can compromise the reliability of corneal measurements. Although preoperative ocular surface optimization is essential, residual irregularity may persist despite treatment, making measurement reproducibility particularly important. An oGVHD-specific review recommends obtaining both optical biometry and corneal topography, with repeated measurements to assess consistency in corneal curvature and astigmatism. When measurements remain discrepant, cataract surgery should generally be deferred until further ocular surface stabilization and reassessment can be performed.[12] Corneal topography may also help distinguish regular astigmatism from irregular astigmatism associated with epithelial abnormalities or stromal scarring. In patients with advanced keratopathy, reliable keratometry may remain difficult to obtain, necessitating individualized IOL calculations and counseling regarding greater refractive uncertainty.[13]

IOL selection should account for the optical limitations of the ocular surface and the potential for ongoing disease activity after surgery. Monofocal IOLs are generally a reasonable choice in patients with significant oGVHD, particularly when corneal irregularity or scarring may limit postoperative visual quality. Multifocal IOLs should be approached cautiously and avoided in patients with unstable tear films, irregular astigmatism, or significant corneal higher-order aberrations because these abnormalities may further compromise contrast sensitivity and contribute to glare or halos.[14][15] Toric IOLs may be considered in selected patients with regular astigmatism when its magnitude and axis remain reproducible across measurements. However, unstable keratometry, irregular astigmatism, and progressive ocular surface changes may limit the predictability of toric correction.[13][15] Direct comparative evidence evaluating different IOL designs in oGVHD remains limited, and these recommendations are largely extrapolated from broader OSD literature.

Special consideration is warranted in patients who depend on therapeutic scleral lenses for visual rehabilitation and ocular surface protection. In these patients, postoperative refractive planning should account for the existing scleral lens prescription and the anticipated need for continued lens wear. A retrospective series of six eyes from three patients with oGVHD described an individualized method of selecting the refractive target using the effective scleral lens system power, calculated from the existing lens power, base curve, and corneal curvature. All six eyes achieved corrected visual acuity of 20/30 or better while wearing their preexisting scleral lenses one week after surgery, without requiring lens replacement.[16] Although limited by its small sample size, this approach highlights the potential value of coordinating IOL calculations with the patient’s scleral lens provider to preserve postoperative visual function and minimize the need for refitting.

Surgical planning should also account for anatomical changes associated with chronic oGVHD, including corneal thinning, scarring, vascularization, and conjunctival cicatrization. An oGVHD-specific review describes clear corneal, anterior limbal, and scleral tunnel incisions as potential approaches, with clear corneal incisions generally suitable when the ocular surface is adequately controlled and scleral incisions considered in severe disease refractory to treatment.[12] In patients with advanced corneal or conjunctival disease, coordination with a cornea specialist may assist in selecting an appropriate surgical approach.

Overall, refractive planning in oGVHD should prioritize reliable measurements, preservation of ocular surface integrity, and compatibility with the patient’s long-term visual rehabilitation needs. Even after technically successful cataract extraction, persistent ocular surface abnormalities may limit refractive predictability and visual quality. Individualized IOL selection and surgical planning are therefore essential to achieving meaningful visual improvement while minimizing avoidable ocular surface complications.

Intraoperative Considerations

The main goal of intraoperative management in oGVHD is to minimize additional injury to an already vulnerable ocular surface, ideally after optimizing the surface preoperatively to prevent surgery in the setting of active surface disease. Minimal literature describes intraocular techniques specific to oGVHD, but extensive work in other OSDs, such as iatrogenic dry eye disease, which shares much of its symptomatology with oGVHD, offers potentially translatable strategies. These include avoiding large incisions, limiting microscopy light intensity and exposure to protect against phototoxic and desiccating effects of prolonged illumination, and avoiding an aspirating speculum or preserved topical agents intraoperatively.[17]

The use of dispersive ophthalmic viscosurgical devices (OVDs) to protect the corneal endothelium, as well as topical viscoelastic agents to coat the corneal epithelium and minimize intraoperative desiccation, may provide additional protection during cataract surgery.[18][19] Corneal coating strategies developed to reduce postoperative discomfort in dry eye patients undergoing cataract surgery may also translate to oGVHD. One study found that compared to a balanced salt solution (BSS), the use of EyeDRO, a tripolymeric gel of hydroxypropyl methylcellulose, xanthan gum, and carrageenan, allowed postoperative tear break-up time and OSD index scores to return to baseline quicker.[20] Another study found that using hydroxypropyl methylcellulose (HPMC 2%) improved clinical outcomes of tear films and ocular surface health, especially in dry eye patients, compared to those who received BSS.[19]

In oGVHD, surgical visualization can be challenged due to severe epithelial irregularity and corneal disease. In addition to keeping the cornea lubricated throughout surgery, chandelier endoillumination through the pars plana has been shown to enhance visualization in patients with corneal opacities.[21] Another method is to stain the anterior capsule with trypan blue in order to improve capsulorhexis visualization.[14] In all oGVHD patients, and specifically in those with symblepharon, forniceal shortening, or lid cicatrization, aspirating speculum insertion can cause conjunctival tearing. Instead, a gentler non-aspirating speculum can be used in order to minimize surface manipulation and prevent aggravated dry eye symptoms postoperatively.[22] Further, shortening the operative time and reducing surface exposure has been explicitly recommended in patients with OSD and oGVHD, as well as restricting phacoemulsification in these patients to experienced anterior segment or cornea surgeons.[3]

Because patients with oGVHD are at risk of stromal thinning and melt, surgeons should avoid placing incisions in areas of thinning or vascularized scarring, and consider the location of any existing conjunctival disease.[12][14] However, this may create tension with surgical planning, as the safest location for a patient with oGVHD may not align with the steepest corneal meridian needed to reduce the eye’s overall astigmatism.[23] Taken altogether, these strategies reflect the importance of minimizing surface trauma and exposure while maximizing lubrication and visualization intraoperatively, and while largely extrapolated from other OSDs, remain a reasonable foundation for surgical planning.

Postoperative Surveillance and Surgery-Associated Complications

Patients with oGVHD warrant early and continued ocular-surface surveillance after cataract surgery, because the epithelial instability of oGVHD can be precipitated or amplified by post-operative inflammation and because serious corneal complications may evolve rapidly. The NIH Chronic GVHD Consensus Project published recommendations following a consensus in 2020 suggesting a comprehensive eye exam within the first 3 months after allo-HSCT with follow up based on development of ocular symptoms.[24] At each postoperative visit, visual acuity, symptoms, and the ocular surface should be reassessed with slit-lamp examination and fluorescein staining. Clinicians should evaluate for new or worsening punctate epithelial keratopathy, filamentary keratitis, epithelial defects, corneal infiltrate or ulceration, stromal thinning or melt, worsening ocular-surface inflammation, and signs of infection. A nonhealing epithelial defect should prompt assessment for a neurotrophic component, including corneal sensation testing. Chronic oGVHD is associated with neurotrophic keratitis, and a history of cataract surgery was independently associated with neurotrophic keratopathy in one retrospective oGVHD cohort (OR 5.03); neurotrophic disease may contribute to persistent epithelial defects, ulceration, and perforation.[25] New decrease in vision, corneal infiltrate, progressive thinning, or epithelial breakdown warrants prompt evaluation and a low threshold for cornea/ocular-surface specialist involvement.[11][25]

Published cataract series describe a spectrum ranging from transient epithelial worsening to vision-threatening corneal disease. In two single-center cohorts, epithelial defects occurred in 8% and 9.1% of eyes, filamentary keratitis in 6% and 6.5%, and worsening epitheliopathy or superficial punctate keratopathy in 16% and 24.7%, respectively.[5][26] In a seven-center retrospective series of 104 eyes, corneal epitheliopathy worsened in 42% of eyes; corneal perforation occurred in 6% and endophthalmitis in 1%.[3] A small series limited to patients with severe oGVHD also reported postoperative corneal melt in two patients.[27]

Recent comparative evidence further supports surveillance beyond the immediate postoperative period. In a multicenter national electronic-health-record analysis, oGVHD was associated with a higher 90-day risk of vision-threatening corneal events, defined as corneal ulceration, stromal melt, or perforation, than both cataract controls (HR 1.87) and HSCT recipients with GVHD but no documented ocular involvement (HR 1.36); patients with oGVHD also demonstrated a more severe distribution of events, with stromal melt and perforation comprising a greater proportion, and postoperative ocular-surface treatment escalation was more frequent.[11] The between-group excess risk was evident as early as 30 days and remained evident through one year of follow-up.[11] As this was an observational study, these findings support risk stratification and close monitoring. Postoperative worsening may require reintensification of the patient's ocular-surface regimen and, in severe cases, interventions such as amniotic membrane transplantation or tarsorrhaphy. Persistent epithelial defects, progressive melt or perforation, and suspected infectious keratitis or endophthalmitis require urgent management.

Visual Outcomes, Risk Factors, and Patient Counseling

Despite the additional ocular surface risks associated with oGVHD, cataract surgery can provide meaningful improvements in visual acuity and visual function. In a multicenter retrospective study, Gehlsen et al. reported a significant improvement in BCVA from 0.7 ± 0.5 to 0.4 ± 0.4 logMAR following cataract surgery, with improvements observed across all NIH oGVHD severity grades.[3] Other studies have similarly demonstrated favorable visual outcomes following cataract extraction in patients with chronic oGVHD.[5][26] These findings suggest that the presence of oGVHD should not independently preclude cataract surgery when visually significant lens opacity contributes substantially to visual impairment. Rather, surgical candidacy should reflect the anticipated visual benefit relative to the degree of coexisting ocular surface compromise.

Importantly, improvement in postoperative visual acuity does not necessarily correspond to complete resolution of visual symptoms. Although cataract extraction addresses the lenticular component of visual impairment, persistent tear-film instability, corneal epithelial irregularity, and ocular surface inflammation may continue to affect visual quality and contribute to fluctuating vision. Consequently, patients may experience substantial improvements in measured visual acuity while continuing to report dryness, irritation, or intermittent visual disturbances. This distinction is particularly relevant when establishing realistic expectations, as postoperative satisfaction may depend not only on the degree of visual acuity improvement but also on the stability of vision and persistence of ocular surface symptoms.

The available evidence also suggests that postoperative outcomes are influenced by the underlying condition of the ocular surface, although the prognostic significance of individual measures of oGVHD severity remains variable.[3][26] While patients across different severity grades may achieve meaningful visual improvement, those with greater corneal surface compromise or recent inflammatory activity may face a less predictable postoperative course and increased risk of complications.[3][11] These considerations underscore the importance of distinguishing between factors that may limit the magnitude of visual recovery and those that increase the likelihood of postoperative ocular surface deterioration. Accordingly, the decision to proceed with cataract surgery should be individualized, weighing the anticipated improvement in visual function against the patient’s baseline ocular surface condition and potential for postoperative complications.

Preoperative counseling should therefore emphasize both the potential benefits and limitations of cataract surgery in the setting of oGVHD. Patients should understand that ocular surface irregularity may contribute to less predictable refractive outcomes and that postoperative visual recovery may be prolonged or fluctuate as the ocular surface heals. They should also be informed of the possibility of worsening ocular surface symptoms, delayed epithelial healing, and the need for additional medical or surgical interventions.[26] Although uncommon, vision-threatening complications such as corneal ulceration, stromal melt, and perforation should be discussed, particularly in patients with advanced or recently active ocular surface disease.[11] Importantly, cataract surgery does not treat the underlying oGVHD, and patients should anticipate continued ocular surface management even after successful cataract extraction.

Ultimately, successful cataract surgery in patients with oGVHD requires balancing the potential for meaningful visual improvement against the challenges imposed by chronic ocular surface disease. While the available evidence supports favorable visual outcomes in appropriately selected patients, surgical success should be considered in the broader context of postoperative visual quality, ocular surface stability, and patient expectations. Individualized assessment of visual potential, appropriate surgical timing, careful perioperative management, and realistic counseling are essential to maximizing the benefits of cataract surgery while minimizing the risk of adverse outcomes in this complex patient population.

References

  1. ↑ Singh RB, Cho W, Liu C, et al. Immunopathological mechanisms and clinical manifestations of ocular graft-versus-host disease following hematopoietic stem cell transplantation. Bone Marrow Transplant. 2024;59(8):1049-1056. doi:10.1038/s41409-024-02321-3
  2. ↑ Inamoto Y, Petriček I, Burns L, et al. Non-GVHD ocular complications after hematopoietic cell transplantation: expert review from the Late Effects and Quality of Life Working Committee of the CIBMTR and Transplant Complications Working Party of the EBMT. Bone Marrow Transplant. 2019;54(5):648-661. doi:10.1038/s41409-018-0339-6
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Gehlsen U, Faust C, Blecha C, et al. Outcomes and complications of cataract surgery in patients with chronic ocular graft-versus-host-disease-a multicenter, retrospective analysis. Graefes Arch Clin Exp Ophthalmol. 2022;260(8):2613-2622. doi:10.1007/s00417-022-05613-w
  4. ↑ 4.0 4.1 Ahn S, Eom Y, Song JS, Kim DH. Short-term variability in ocular biometry and the impact of preoperative dry eye. Sci Rep. 2024;14(1):26762. Published 2024 Nov 5. doi:10.1038/s41598-024-77572-7
  5. ↑ 5.0 5.1 5.2 Bae SS, Iovieno A, Yeung SN. Long-term Outcomes of Cataract Surgery in Patients With Chronic Ocular Graft-Versus-Host Disease. Cornea. 2022;41(5):587-592. doi:10.1097/ICO.0000000000002779
  6. ↑ de Melo Franco R, et al. Outcomes of cataract surgery in graft-versus-host disease. Cornea. 2015. doi:10.1097/ICO.0000000000000395
  7. ↑ Nibandhe AS, Donthineni PR. Understanding and Optimizing Ocular Biometry for Cataract Surgery in Dry Eye Disease. Semin Ophthalmol. 2022. doi:10.1080/08820538.2022.2112699
  8. ↑ Venkateswaran N, Luna RD, Gupta PK. Ocular surface optimization before cataract surgery. Saudi J Ophthalmol. 2022. doi:10.4103/sjopt.sjopt_190_21
  9. ↑ Biela K, Winiarczyk M, Gumieniak-Goch B, Mackiewicz J. The Effect of Dry Eye Disease Treatment Prior to Cataract Surgery on Refractive Error Reduction. J Clin Med. 2026. doi:10.3390/jcm15041640
  10. ↑ Roca D, et al. Novel Management of Ocular Surface Inflammation in oGVHD in the Setting of Cataract Surgery. Eye Contact Lens. 2024. doi:10.1097/ICL.0000000000001076
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 Shah J, Pathuri S, Golnik K, Berdahl JP, Ong J, Pandit R. The Ocular Surface Following Cataract Surgery in Ocular Graft-Versus-Host Disease: A Multicenter National Analysis. Cornea. 2026. doi:10.1097/ICO.0000000000004227.
  12. ↑ 12.0 12.1 12.2 Nair S, Vanathi M, Mukhija R, Tandon R, Jain S, Ogawa Y. Update on ocular graft-versus-host disease. Indian J Ophthalmol. 2021;69(5):1038-1050. doi:10.4103/ijo.IJO_2016_20
  13. ↑ 13.0 13.1 Donthineni PR, Deshmukh R, Ramamurthy C, Sangwan VS, Mehta JS, Basu S. Management of cataract in dry eye disease: Preferred practice pattern guidelines. Indian J Ophthalmol. 2023;71(4):1364-1372. doi:10.4103/IJO.IJO_2807_22
  14. ↑ 14.0 14.1 14.2 Agarwal S, Srinivasan B, Harwani AA, Fogla R, Iyer G. Perioperative nuances of cataract surgery in ocular surface disorders. Indian J Ophthalmol. 2022;70(10):3455-3464. doi:10.4103/ijo.IJO_624_22
  15. ↑ 15.0 15.1 Goto S, Maeda N. Corneal Topography for Intraocular Lens Selection in Refractive Cataract Surgery. Ophthalmology. 2021;128(11):e142-e152. doi:10.1016/j.ophtha.2020.11.016
  16. ↑ Ma KK, Luo ZK. Novel Method to Determine Target Refraction in Cataract Surgery for Patients Dependent on Therapeutic Scleral Lenses. Eye Contact Lens. 2021;47(6):352-355. doi:10.1097/ICL.0000000000000747
  17. ↑ Giannaccare, G., Barabino, S., Di Zazzo, A., & Villani, E. (2024). Preventing and Managing Iatrogenic Dry Eye Disease during the Entire Surgical Pathway: A Study Focusing on Patients Undergoing Cataract Surgery. Journal of clinical medicine, 13(3), 748. https://doi.org/10.3390/jcm13030748
  18. ↑ Yildirim TM, Auffarth GU, Son H, Khoramnia R, Munro DJ, Merz PR. Dispersive viscosurgical devices demonstrate greater efficacy in protecting corneal endothelium in vitro. BMJ Open Ophthalmology. 2019;4:e000227. https://doi.org/10.1136/bmjophth-2018-000227
  19. ↑ 19.0 19.1 He, Y., Li, J., Zhu, J., Jie, Y., Wang, N., & Wang, J. (2017). The improvement of dry eye after cataract surgery by intraoperative using ophthalmic viscosurgical devices on the surface of cornea: The results of a consort-compliant randomized controlled trial. Medicine, 96(50), e8940. https://doi.org/10.1097/MD.0000000000008940
  20. ↑ Mencucci, R., Cennamo, M., Favuzza, E., Rechichi, M., & Rizzo, S. (2019). Triphasic polymeric corneal coating gel versus a balanced salt solution irrigation during cataract surgery: A postoperative anterior segment optical coherence tomography analysis and confocal microscopy evaluation. Journal of cataract and refractive surgery, 45(8), 1148–1155. https://doi.org/10.1016/j.jcrs.2019.03.002
  21. ↑ Parameshwarappa, D. C., Nanda, S., Kavya, N., Matada, R., Murthy, G. J., & Murthy, P. R. (2022). Endoilluminator-aided cataract surgery in eyes with corneal opacity - A modified surgical approach. Indian journal of ophthalmology, 70(5), 1868. https://doi.org/10.4103/ijo.IJO_1014_22
  22. ↑ Moon, H., Yoon, J. H., Hyun, S. H., & Kim, K. H. (2014). Short-term influence of aspirating speculum use on dry eye after cataract surgery: a prospective study. Cornea, 33(4), 373–375. https://doi.org/10.1097/ICO.0000000000000072
  23. ↑ Li, P. P., Huang, Y. M., Cai, Q., Huang, L. L., Song, Y., & Guan, H. J. (2019). Effects of steep-axis incision on corneal curvature in one-handed phacoemulsification. International journal of ophthalmology, 12(8), 1277–1282. https://doi.org/10.18240/ijo.2019.08.07
  24. ↑ Kitko CL, Pidala J, Schoemans HM, et al. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IIa. The 2020 Clinical Implementation and Early Diagnosis Working Group Report. Transplant Cell Ther. 2021;27(7):545-557. doi:10.1016/j.jtct.2021.03.033
  25. ↑ 25.0 25.1 Singh, R. B. et al. Prevalence of neurotrophic keratopathy in patients with chronic ocular graft-versus-host disease. The Ocular Surface 26, 13–18 (2022). https://doi.org/10.1016/j.jtos.2022.07.001
  26. ↑ 26.0 26.1 26.2 26.3 Saboo, U. S., Amparo, F., Shikari, H., Jurkunas, U. V. & Dana, R. Outcomes of phacoemulsification in patients with chronic ocular graft-versus-host disease. Graefe's Archive for Clinical and Experimental Ophthalmology 253, 901–907 (2015). https://doi.org/10.1007/s00417-015-2940-3
  27. ↑ Shah, A., Santhiago, M. R. & Espana, E. M. Cataract surgery in patients with chronic severe graft-versus-host disease. Journal of Cataract and Refractive Surgery 42, 833–839 (2016). https://doi.org/10.1016/j.jcrs.2016.02.046
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