A historical review of sympathetic ophthalmia and its epidemiology

Sympathetic ophthalmia

BACKGROUND

Sympathetic ophthalmia (SO) is a rare, bilateral, non-necrotizing, granulomatous uveitis that occurs after ocular trauma or surgical procedures to one eye threatening sight in the fellow eye. The pathophysiology is not clearly understood, but it appears that the disrupted integrity of the inciting eye leads to an autoimmune hypersensitivity reaction against the exposed ocular antigens in the injured eye as well as in the sympathizing eye. More recently, vitreoretinal surgery has been noted to be a risk factor for the development of SO.

METHODS

Medline search for case reports of sympathetic ophthalmia with links to full text in English yielded articles for review of patient demographics, clinical presentation and examination, therapies and final visual acuity.

RESULTS

Eighty-six patients with SO were included in this review. Sixty-two patients were male and 24 were female with an average age of 46 years. Injuries accounted for 47% of patients while ocular surgery was reported in 44% of patients with pars plana vitrectomy occurring in 21%. Most patients reported reduced vision and presented with uveitis. Ninety-five percent of them received systemic corticosteroid therapy and 75% of patients also received immunomodulators. About 70% of patients had improved visual acuity in their sympathizing eye at their last reported evaluation.

CONCLUSIONS

Sympathetic ophthalmia warrants prompt evaluation and treatment to maintain a favorable visual outcome. Ocular surgeries including vitreoretinal surgery and cyclodestructive procedures have been noted to be risk factors for the development of sympathetic ophthalmia. With current medical management including corticosteroids and immunomodulators visual prognosis is relatively good.

The importance of 'Mechnikov's thorn' for an improved understanding of 21st century medicine and immunology: a view from the eye

In 1908, Ehrlich and Mechnikov shared the Nobel Prize in Medicine for their independent studies that set the scene for the modern understanding of innate and adaptive immunity. However, 20th century immunology thinking was dominated by aberrant adaptive immunity but this never adequately explained the full spectrum of inflammatory disease. This article draws on medical observations, from where immunology originated, and uses the example of the eye to illustrate how the integration of medicine and immunology leads to an improved understanding of inflammation against self. The spectrum of ocular inflammation can be viewed as either predominantly adaptive immune mediated (mostly the realm of immunology), or predominantly due to ocular tissues factors that lead to regional innate immune activation (the realm of medicine), or a variable interaction between the two. Just as the thorns that Mechnikov inserted into molluscs lead to localized innate immune activation; ocular inflammation can likewise be driven by non-immune factors that include tissue degeneration or microdamage. The present article emphasizes the importance of such factors in the initiation or phenotypic expression of ocular immunopathology allowing different immunological dogmas including self-non-self discrimination, immunological tolerance and immunoprivilege to be viewed in a different light. This scheme also leads to an appreciation of how the innate immune system may be the sole perpetuator of some ocular immunopathologies. We propose that this integrated view of medicine and immunology is crucial for understanding immunology from a translational angle and has implications far beyond ocular disease.

Posterior sympathetic ophthalmia: a single centre long-term study of 40 patients from North India

OBJECTIVE

To report 'posterior sympathetic ophthalmia' in North Indian population as an early manifestation of sympathetic ophthalmia.

METHODS

Forty consecutive patients with a diagnosis of sympathetic ophthalmia seen between 1989 and 2004 at our centre were studied for their clinical presentation and disease course. All received systemic corticosteroids and 12 patients, in addition, also received immunosuppressive agents.

RESULTS

There were 28 male and 12 female patients with a median age of 29.4 years. In 22 of the 40 sympathizing eyes, the only presenting sign was the fundus lesions without any associated anterior segment inflammation. Only four eyes showed classically described granulomatous anterior uveitis at presentation. The fundus lesions predominately included exudative retinal detachment (29 eyes), yellowish-white mid-peripheral lesions (10 eyes), optic disc oedema (15 eyes), vasculitis (three eyes), and peripapillary choroidal neovascular membrane (two eyes). Over a median follow-up of 5.2 years, recurrences were seen in 12 of 40 (30%) eyes and were mainly in the anterior segment. Over a median follow-up of 5.2 years, a final visual acuity of 20/40 or better could be achieved in 29/36 (80.5%) eyes.

CONCLUSION

In the early stage, sympathetic ophthalmia may present only in the posterior segment without any associated anterior segment inflammation and carries a good visual prognosis. Anterior segment inflammation, however, maybe seen during recurrences.

Sympathetic ophthalmia following postoperative bacterial endophthalmitis: a clinicopathologic study

PURPOSE

Clinical and histopathologic documentation of sympathetic ophthalmia (SO) development in eyes with postoperative bacterial endophthalmitis.

DESIGN

Observational case series; retrospective clinicopathologic study.

METHODS

All patients who presented with a clinical diagnosis of SO during 2002 to 2004 were included in the study. The diagnosis of SO was made on the basis of history of penetrating ocular injury, followed by development of bilateral intraocular inflammation, ultrasonographic detection of bilateral diffuse thickening of the choroid, or both. Patients presenting with the additional finding of hypopyon underwent an anterior chamber tap and vitreous aspirate for microbiologic detection of bacteria and fungi. Eight exciting eyes were enucleated and submitted for histologic examination.

RESULTS

Of a total of 26 patients with a clinical diagnosis of SO, four also had bacterial endophthalmitis. Of these, histologic examination of three exciting eyes revealed vitreous abscess and typical features of SO. Of the five remaining enucleated globes, histologic examination showed that two eyes had phacoanaphylactic endophthalmitis, and two others revealed features of SO; the one remaining eye had nongranulomatous diffuse choroiditis.

CONCLUSIONS

Bacterial endophthalmitis cannot prevent the development of SO. Early diagnosis of coexistent mixed infectious and inflammatory processes, and initiation of antimicrobial treatment directed at the infection followed by immunomodulatory agents to address the autoimmune component may improve the prognosis in such cases.

Sympathetic Ophthalmia After Injury in the Iraq War

A 21-year-old US soldier received a penetrating eye injury while fighting in Iraq and was treated with evisceration. Sympathetic ophthalmia developed, which responded well to steroid treatment. This is the first case of sympathetic ophthalmia after a war injury reported since World War II.

Sympathetic ophthalmia

Sympathetic ophthalmia is a rare, bilateral granulomatous uveitis that occurs after either surgical or accidental trauma to one eye. The ocular inflammation in the fellow eye becomes apparent usually within 3 months after injury. Clinical presentation is an insidious or acute anterior uveitis with mutton-fat keratic precipitates. The posterior segment manifests moderate to severe vitritis, usually accompanied by multiple yellowish-white choroidal lesions. Evidence suggests that sympathetic ophthalmia represents an autoimmune inflammatory response against choroidal melanocytes mediated by T cells. Diagnosis is based on clinical findings and a history of previous ocular trauma or surgery. Other causes of granulomatous uveitis, such as Vogt-Koyanagi-Harada disease, sarcoidosis, tuberculosis, and syphilis should be considered. Treatment of sympathetic ophthalmia consists of systemic anti-inflammatory agents with high dose oral corticosteroid as the drug of choice. However, if the inflammation cannot be controlled, cyclosporine is then used. Other immunosuppressive agents, such as chlorambucil, cyclophosphamide or azathioprine, may be necessary for the control of inflammation. The role of enucleation after the diagnosis of sympathetic ophthalmia remains controversial. Visual prognosis is reasonably good with prompt wound repair and appropriate immunomodulatory therapy.

Sympathetic ophthalmia following evisceration: a rare case

We describe a case of sympathetic ophthalmia following evisceration of a blind, painful, posttraumatic, glaucomatous eye. Although rare, this complication has been reported previously in the literature. We provide a brief review of sympathetic ophthalmia following evisceration and discuss the importance of a high degree of clinical suspicion and prompt treatment with high-dose systemic corticosteroids or other immunomodulators.

Stumpfes Augentrauma

This review presents typical patterns of posterior segment injuries as well as diagnostic and therapeutic considerations after ocular contusion or rupture of the globe. Vitreal prolapse is associated with retinal detachment (20%), iridodialysis or ciliary body cleft (43%), and contusion cataract (41%). Berlin's edema (35%) and retinal detachment (5-7%) are frequent after ocular contusion. In cases of central Berlin's edema, choroidal infarction (Hutchinson-Siegrist-Neubauer syndrome) or choroidal rupture, macular hole or choroidal neovascularization should be ruled out. A central choroidal rupture is often associated with choroidal neovascularization (14-20%). Globe ruptures (5% of blunt injuries) are associated with hyphema grades III and IV (58 vs 5% in ocular contusions). The prognosis of globe ruptures to develop a visual function <20/200 is 51 times more frequent than in eyes with contusion. The risk of trauma-induced globe ruptures is higher in eyes after cataract surgery (27 x) (in females 5 x).

Clinical Case Notes. Changing trends in sympathetic ophthalmia

Sympathetic ophthalmia is a rare and potentially visually devastating bilateral panuveitis, typically following non-surgical penetrating injury to one eye. Three patients are presented where sympathetic ophthalmia developed after repeated vitreoretinal surgery. Prompt and effective management with systemic immunosuppressive agents permitted control of their disease and retention of good visual acuity in their remaining eye. Vitreoretinal surgery is an important risk factor in sympathetic ophthalmia. Informed consent for vitreoretinal surgery (especially in the re-operation setting) should now include the risk of sympathetic ophthalmia (approximately 1 in 800). Diverse clinical presentations are possible in sympathetic ophthalmia and any bilateral uveitis following vitreoretinal surgery should alert the surgeon to the possibility of sympathetic ophthalmia. Modern immunosuppressive therapy with systemic steroids and steroid-sparing agents such as cyclosporin A and azathioprine have improved the prognosis. This is particularly so in cases where early diagnosis is made and prompt and suitable immunotherapy is commenced.

PENETRATING TRAUMA ASSOCIATED WITH FINDINGS OF MULTIPLE EVANESCENT WHITE DOT SYNDROME IN THE SECOND EYE

PURPOSE

To report a case of sympathetic ophthalmia (SO) resembling multiple evanescent white dot syndrome (MEWDS).

METHODS

Retrospective chart review.

RESULTS

A 17-year-old girl with a ruptured globe in the right eye underwent prompt primary repair and vitrectomy, scleral buckling, and silicone oil infusion 3 weeks later. Eight weeks after injury, she presented with visual loss in the left eye. Fundus examination in the left eye disclosed optic disk swelling and well-circumscribed, 100 to 500 microm diameter gray-white lesions at the level of the retinal pigment epithelium (RPE) posterior to the equator, sparing the fovea. On fluorescein angiography, the lesions appeared as areas of blocked choroidal fluorescence in the arterial phase and were associated with dye leakage in a wreathlike pattern during venous filling. Dye leakage occurred at the optic disk. Visual field testing showed depressed central sensitivity and an enlarged blind spot in the left eye. The patient was treated with prednisone and underwent diagnostic enucleation of the right eye. Histopathology showed rare choroidal granulomata and pigment phagocytosis. Vision improved to 20/20 in the left eye, and the window defects persisted. Visual field testing 6 months later was normal. One month after discontinuing prednisone, new areas of RPE hypopigmentation developed. Two weeks later, choroidal inflammation recurred and periphlebitis developed.

CONCLUSION

This case indicates that SO can mimic MEWDS.

Traumatic eye injuries due to large unusual foreign bodies: a Singapore case series

PURPOSE

Traumatic eye injuries due to large foreign bodies (FB) are rare. The visual prognosis is often poor in these cases because of severe ocular damage. Staged surgical procedures with eventual enucleation or evisceration are often indicated.

METHODS

Case series.

RESULTS

The authors describe two patients with eye injury due to large FB with visual acuity of no light perception at presentation. Both had initial repair of the ocular injuries and removal of the FB. One patient with an intraocular FB eventually underwent enucleation; the other, with intraorbital FB, had evisceration as a secondary procedure. Orbital implantations were done in both. Neither of the patients had developed sympathetic ophthalmia at the last review.

CONCLUSIONS

The visual outcome of eye injuries due to large FB is poor. Both enucleation and evisceration can be performed with low risk of sympathetic ophthalmia. Prevention remains the best approach to such devastating injuries.

Incidence of sympathetic ophthalmia after penetrating eye injury and choice of treatment

INTRODUCTION

Sympathetic ophthalmia, a diffuse bilateral granulomatous panuveitis, is a serious potential complication after penetrating eye injury. Many surgeons recommend enucleation within two weeks of trauma to prevent this condition. We retrospectively reviewed the medical records of patients with penetrating ocular injuries who had either evisceration or enucleation to determine the incidence of sympathetic ophthalmia and to evaluate the surgical interventions and their complications. Age at surgery, time after penetrating trauma, surgery technique, follow-up period, ophthalmic examination of the fellow eye, and surgical complications were evaluated.

RESULTS

In total, 217 patients were included in the study with a mean follow-up period of 10.3 +/- 6.6 years. The longest time between the trauma and time of surgery was 43 years. Postoperative uveitis was observed in only one patient (0.5%) who had primary repair after injury. Histopathological review did not reveal typical sympathetic ophthalmia. Complications after enucleation were significantly higher than after evisceration.

CONCLUSION

There was no histopathologically supported sympathetic ophthalmia in our series. Sympathetic ophthalmia is very rare even when the injured eye is retained. With this in mind, the first choice of treatment may not be enucleation. Furthermore, evisceration may be the procedure of choice if primary repair cannot be performed or for patients who have panophthalmitis.

Presumed trematode-induced granulomatous anterior uveitis: a newly recognized cause of intraocular inflammation in children from south India

PURPOSE

To describe the epidemiologic, clinical, and histopathologic features of a presumed trematode granulomatous anterior uveitis, primarily in children from south India.

DESIGN

Prospective, noncomparative, case series.

METHODS

Children with clinical evidence of granulomatous anterior uveitis were selected for the study. Those who presented with distinct anterior chamber nodules were evaluated. Demographic details, such as clinical findings and course of illness, were noted. Patients underwent either medical treatment or surgical aspiration of the lesion based on the size of the lesion. Aspirated materials were subjected to histopathologic analysis and cultures for bacteria and fungi. Response to treatment and final visual status were evaluated.

RESULTS

One hundred thirteen patients with anterior chamber nodules were seen between 1998 and 2000. Ninety-three (82.4%) were males and 20 (17.7%) were females. The median age was 11.0 years. All patients were from south India and all gave a history of bathing or swimming in the local pond or river. All had normal systemic work ups. Of the 113 patients, 110 had anterior chamber nodules and three had both anterior chamber and subconjunctival nodules. Aspirates of the anterior chamber lesions revealed lymphocytes, intact and necrotic neutrophils, and eosinophils admixed with histiocytes. One subconjunctival nodule showed necrotizing granuloma, displaying the tegument of a trematode. Those patients who were followed had good visual recovery after medical or surgical intervention or both.

CONCLUSION

The present study shows a newly recognized granulomatous anterior uveitis caused by a presumed water-borne trematode infection. This infection appears to be a common cause of pediatric granulomatous anterior uveitis in south India.

Sympathetic ophthalmia after complicated cataract surgery and intraocular lens implantation

PURPOSE

To report a case of sympathetic ophthalmia (SO) associated with cataract surgery and intraocular lens (IOL) implantation.

METHODS

Case report.

RESULTS

A 50-year-old man developed SO two months after complicated cataract surgery and IOL implantation. Adequate and prompt use of immunosuppressive medications and removal of the IOL by pars plana vitrectomy techniques resulted in control of the uveitis with significant visual improvement.

CONCLUSIONS

Sympathetic ophthalmia should be included as one of the devastating complications of IOL insertion. A high index of suspicion must be maintained whenever inflammation occurs in the fellow eye of an eye that has undergone intraocular surgery.

Enucleation, evisceration, and sympathetic ophthalmia

This year's review of enucleation, evisceration, and sympathetic ophthalmia yielded a multitude of studies and data. Articles ranged from single case reports to large clinical series and in-depth subject overviews. With regard to enucleation, several new HA implant variations were described, along with limited clinical experience. Various techniques for management of postenucleation and evisceration complications also were described, including management of infection, implant exposure, and postenucleation socket syndrome. The risk of sympathetic ophthalmia after evisceration, as compared with enucleation, remains a highly polarized and inconclusive subject.

Prospective surveillance of sympathetic ophthalmia in the UK and Republic of Ireland

AIMS

To establish current epidemiological data, risks, and interventional outcomes of newly diagnosed sympathetic ophthalmia (SO).

METHODS

Prospective surveillance took place of all permanently employed ophthalmologists in the UK and Republic of Ireland by a monthly reporting card through the British Ophthalmological Surveillance Unit. Case ascertainment was made of newly diagnosed SO from July 1997 and questionnaire data were returned at baseline, 6 months, and 1 year after diagnosis.

RESULTS

23 patients with newly diagnosed SO were recruited over 15 months, corresponding to a minimum estimated incidence of 0.03/100 000. Baseline data were available on 18 patients, in whom SO occurred after surgery in 11 patients, after retinal surgery alone in six patients, and after accidental trauma in seven patients. 12 of the 16 patients with 1 year follow up had a visual acuity of 6/12 or better. Good visual outcome was related to prompt and adequate systemic immunosuppressive therapy.

CONCLUSIONS

The incidence of sympathetic ophthalmia is very low. The main current risk is surgery, particularly retinal surgery, but visual prognosis is good if early diagnosis is made and rapid, adequate immunotherapy is commenced.

Enucleation

The three most common indications for enucleation are intraocular malignancy, trauma, and a blind, painful eye. Recommending enucleation is one of the most difficult therapeutic decisions in ophthalmology. In some cases of malignancy, cryotherapy, laser photocoagulation, diathermy, chemotherapy, and radiation therapy may be viable alternatives to surgery. When surgery is chosen, evisceration or exenteration may be alternatives to enucleation. Once the decision is made to perform enucleation or evisceration, the surgeon must choose from several types of implants and wrapping materials. These devices can be synthetic, autologous, or eye-banked tissues. With certain implants, the surgeon must decide when and if to drill for subsequent peg placement. In this review, the authors discuss choices, techniques, complications, and patient consent and follow-up before, during, and after enucleation. Controversies and results of the Controlled Ocular Melanoma Study are summarized.

Endophthalmitis

Endophthalmitis is an inflammatory reaction of intraocular fluids or tissues. Infectious endophthalmitis is one of the most serious complications of ophthalmic surgery. Occasionally, infectious endophthalmitis is the presenting feature of an underlying systemic infection. Successful management of infectious endophthalmitis depends on timely diagnosis and institution of appropriate therapy. Recognition of the different clinical settings in which endophthalmitis occurs and awareness of the highly variable presentation it may have facilitate timely diagnosis. Biopsy of intraocular fluid/tissue is the only method that permits reliable diagnosis and treatment. The different presenting clinical settings, a rational approach to diagnosis (i.e., when, what, and how to biopsy), and the treatment of infectious endophthalmitis are reviewed.

Eye injuries in twentieth century warfare: a historical perspective

With successive wars in the twentieth century, there has been a relative increase in injuries to the eye compared to injuries of other parts of the body. The main causes of eye injury have changed with advances in techniques and weaponry of warfare, with blast fragmentation injuries accounting for 50-80% of cases. Penetrating and perforating injuries are most common, and injuries associated with intraocular foreign bodies pose special diagnostic and management problems. Injuries are bilateral in 15-25% of cases. Injuries associated with chemical, nuclear, and laser weapons have distinct characteristics and epidemiology. Enucleation was commonly performed at the turn of the century, but incidence has declined with better understanding of the pathophysiology of ocular trauma, improved surgical techniques and sepsis control with antibiotics. Sympathetic ophthalmia appears to be uncommon and earlier fears of this complication seem to have been exaggerated. Timely evacuation to a surgical facility is important for a good visual prognosis and preservation of the globe. However, prevention of injuries with eye armor is ultimately the best management, and the need for a comprehensive eye protection program in the military cannot be overemphasized, especially since eye injuries pose important socioeconomic, as well as medical, problems.

Focal posttraumatic choroidal granulomatous inflammation

PURPOSE

This study was performed to describe the clinicopathologic features of a group of patients with posttraumatic unilateral focal choroidal granulomatous inflammation.

METHODS

Enucleated eyes with focal choroidal granulomatous inflammation without clinical signs of contralateral ocular inflammation were identified. Clinical and pathologic features were recorded.

RESULTS

Six enucleated eyes that had been injured by projectiles had focal uveal granulomatous inflammation of the posterior choroid. Four eyes had uvea attached to or incarcerated into the wound. Two eyes had foreign material associated with the granulomatous inflammation, and two eyes had a disrupted lens with lens-induced inflammation. Two eyes exhibited the focal granulomatous inflammation at the site of a choroidal rupture. None of the six enucleated eyes contained Dalen-Fuchs' nodules.

CONCLUSIONS

Focal choroidal granulomatous inflammation may occur as a result of penetrating ocular trauma. The origin of this condition is unknown, although it likely represents a reaction to a foreign body.

The eye and the eosinophil

Recent work has highlighted the eosinophil's role as an effector cell in a wide array of disease entities, including parasitic infections and allergic and nonallergic diseases. The eosinophil is filled with granules containing toxic cationic proteins, capable of harming tissue when released to the extracellular space. In the eye, toxic eosinophil cationic granule proteins have been encountered in conjunctiva, cornea, tears, and contact lenses of patients suffering from ocular allergy, suggesting an effector role for the eosinophil in the ophthalmic manifestations of atopy. Laboratory investigations indicate that eosinophil granule major basic protein, the principal eosinophil granule protein, may adversely influence corneal epithelium, and promote corneal ulceration in the severest forms of ocular allergy. Further, the eosinophil may play a contributory pathophysiologic role in some nonallergic ophthalmic diseases such as Wegener's granulomatosis, orbital pseudo-tumor, and histiocytosis X. The eosinophil's morphologic, immunologic, and biochemical characteristics will be reviewed and its role in certain ophthalmic diseases thoroughly examined.

Sympathetic ophthalmia: visual results with modern immunosuppressive therapy

Sympathetic ophthalmia is a rare bilateral panuveitis that follows penetrating injury to one eye. The use of systemic corticosteroids has transformed the prognosis, and good acuity in the sympathizing eye can now be achieved. The use of immunosuppressive drugs, such as cyclosporin and azathioprine, in combination with the steroids, allows control of the intraocular inflammation at a much lower steroid dose, with concomitant reduction in the systemic side effects that accompany the use of systemic steroids.

Embolization of the ophthalmic artery for control of epistaxis: report of two cases

Embolization of the internal maxillary artery, an accepted method for control of severe or recurrent posterior epistaxis, usually involves the ipsilateral artery, but occasionally the contralateral vessel and the facial arteries as well. Such endovascular treatment may fail if the vascular supply to the bleeding vessels originates in derivative branches of the ophthalmic artery. We report two unusual cases in which embolization of the ophthalmic artery was performed to control epistaxis. The first patient had a prosthetic eye. In the second, sight in one eye was sacrificed after careful consideration in order to prolong life.

Cyclo-oxygenase inhibitors in ophthalmology

Cyclo-oxygenase inhibitors, which are formulated as ophthalmic eyedrop preparations, have recently become commercially available for use by ophthalmologists in the United States to inhibit intraoperative miosis during cataract surgery and to prevent postoperative inflammation. In addition, they are available worldwide as ocular antiinflammatory drugs and are used in the prevention and treatment of pseudophakic and aphakic cystoid macular edema. Understanding the rationale behind the use of these agents requires an understanding of the pathophysiology of the cyclo-oxygenase inhibitors. In this review recent advances in laboratory and clinical science are emphasized. The role of COIs during and following surgery is examined.