Sympathetic ophthalmia: a review of literature

Oral beta-hydroxybutyrate alleviates COVID-19 related acute respiratory distress syndrome: A randomized, single-blind, placebo-controlled trial

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a lung complication of COVID-19 that requires intensive care and ventilation. Beta-hydroxybutyrate (BHB) is a ketone body that can modulate metabolism and inflammation in immune cells and lung tissues. We hypothesized that oral BHB could alleviate COVID-19 related ARDS by reducing pro-inflammatory cytokines and increasing anti-inflammatory cytokines.

METHODS

We randomized 75 patients with mild (as per Berlin criteria) ARDS symptoms to receive oral 25 g twice daily or placebo for five days. The primary outcome was the change in pro-inflammatory cytokines (Interleukin-1β, Interleukin-6, interleukin-18, tumour necrosis factor-alpha) and anti-inflammatory cytokine (interleukin-10) from baseline to day 5. The secondary outcomes were the change in BHB levels from baseline to day 5, the number of hospitalization days, and the occurrence of adverse events.

RESULTS

Treatment with formulated BHB resulted in a significant decrease in pro-inflammatory cytokines; Interleukin-1β (p = 0.0204), Interleukin-6 (p = 0.0309), interleukin-18 (p = 0.0116), tumour necrosis factor-alpha (p = 0.0489) and increase in interleukin-10 (p = 0.0246) compared treatment with placebo. Importantly, higher BHB levels (p = 0.0001) were observed after supplementation; additionally, patients who underwent this approach were hospitalized for fewer days. No serious adverse events were reported.

CONCLUSION

Beta-hydroxybutyrate, an oral adjunct therapy, has shown promising results in ameliorating symptoms of ARDS. This includes reduced inflammation, oxidative stress, and decreased patient fatigue levels. Further study with a large sample size is warranted to assess the potential of BHB therapy's effectiveness in reducing the development of severe illness.

CLINICAL TRIAL REGISTRATION

(http://ctri.nic.in/CTRI/2021/03/031790).

The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis

TOPIC

Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial.

CLINICAL RELEVANCE

This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat.

METHODS

Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR).

RESULTS

Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data.

DISCUSSION

Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Sympathetic ophthalmia following radiation-induced scleral necrosis in choroidal melanoma

Sympathetic ophthalmia (SO) is a bilateral granulomatous panuveitis. We report a rare case of SO presenting after scleral necrosis as a late complication of Gamma Knife radiotherapy for choroidal melanoma. A 55-year-old woman presented with primary choroidal melanoma in the right eye and has been treated with Gamma Knife radiotherapy with stable tumor size. Five years after radiotherapy, a pigmented protrusive uveal mass was visibly noted over the superior sclera of the same eye, corresponding to periocular soft tissue enhancement on computed tomography. Biopsies of the pigmented mass showed the absence of malignancy. One month later, acute blurred vision with signs of sympathetic ophthalmia developed in the left eye. The patient received high-dose systemic corticosteroids and immunomodulatory therapy. The intraocular inflammation in the left eye subsided with improving vision, and the uveal mass in the right eye flattened after the anti-inflammatory therapy. Scleral necrosis is a rare complication following radiotherapy for choroidal melanoma and may incite sympathetic ophthalmia, for which prompt and aggressive treatment is important to save vision, especially for the fellow eye.

An atypical presentation of sympathetic ophthalmia following chemical ocular burns

BACKGROUND

Sympathetic ophthalmia is a rare disease that can present as bilateral granulomatous uveitis after a penetrating trauma or surgery in one eye.

FINDINGS

We report a case of a 47-year-old male with history of decreased vision in the right eye, six months after sustaining severe chemical injury in the left eye. He was diagnosed with sympathetic ophthalmia and was treated with corticosteroids and long-term immunosuppressive therapy, leading to complete resolution of intraocular inflammation. Final visual acuity was 20/30 at one year of follow up.

CONCLUSIONS

Sympathetic Ophthalmia following chemical ocular burns is extremely uncommon. It can present as a diagnostic and therapeutic challenge. It warrants early diagnosis and management.

Sympathetic Ophthalmia - An Overview

INTRODUCTION

Sympathetic ophthalmia (SO) is rare, bilateral granulomatous panuveitis that typically occurs following penetrating or perforating ocular trauma or surgery. This review aims to provide an update on the etiopathogenesis, clinical presentations, diagnosis and treatment of SO.

METHODS

Reports cited in MEDLINE database, that analyzed SO in at least 5 patients, published prior to December 1st, 2021 were included.

RESULTS

Initially, SO was associated with penetrating ocular trauma, however, various studies reported an increased incidence of SO after surgical procedures including vitreoretinal surgeries. Multimodal imaging including fluorescein and indocyanine green angiography, optical coherence tomography (OCT) and OCT angiography have added further insights into the understanding of SO. While pulse dose corticosteroids & immunosuppressive drugs are still the treatment of choice, TNF-α blockers & other biologic drugs represent new promising agents.

CONCLUSION

There is a growing pool of evidence in understanding the pathogenesis of SO. Novel treatment options have provided better prognosis for this potentially blinding condition.

Clinical and imaging features of sympathetic ophthalmia and efficacy of the current therapy

PURPOSE

The purpose of the study was to clarify the clinical and imaging features of sympathetic ophthalmia (SO) and evaluate the efficacy of the current therapy.

METHODS

The databases PubMed, EMBASE and Ovid up to January 2021 were searched to identify relevant studies. R software version 3.6.3 was used to perform the statistical analyses.

RESULTS

Thirty-two studies involving 1067 patients were finally included. Our study found SO was male-dominated, and more than half of SO patients aged 16 to 60 years old. Ocular trauma, surgical interventions and unknown events were estimated to be inciting events in 63%, 36% and 4% of SO patients. About 35% of the patients underwent baseline enucleation, and 45% took compelled enucleation during follow-up. The most common symptoms at the first presentation were decreased vision, followed by pain and redness. The most common signs were anterior chamber cells/flare, followed by vitritis, exudative retinal detachment and Dalen-Fuch nodules. Choroidal thickening was detected in 81% of SO patients by ocular ultrasound. The most common fluorescein fundus angiography signs were disc leakage. After corticosteroid therapy became the mainstay for SO, about 76% of SO patients could get inflammation well-controlled, while 24% of them might have recurrent inflammation. Around 72% of SO patients could achieve visual improvement, and more than half of them might have a best-corrected visual acuity of 20/50 or better.

CONCLUSION

SO is a complicated ocular disease with diverse clinical manifestations and imaging features. After proper anti-inflammation therapy, SO might not necessarily result in a poor prognosis.

Acute respiratory distress syndrome in COVID-19: possible mechanisms and therapeutic management

COVID-19 pandemic is a serious concern in the new era. Acute respiratory distress syndrome (ARDS), and lung failure are the main lung diseases in COVID-19 patients. Even though COVID-19 vaccinations are available now, there is still an urgent need to find potential treatments to ease the effects of COVID-19 on already sick patients. Multiple experimental drugs have been approved by the FDA with unknown efficacy and possible adverse effects. Probably the increasing number of studies worldwide examining the potential COVID-19 related therapies will help to identification of effective ARDS treatment. In this review article, we first provide a summary on immunopathology of ARDS next we will give an overview of management of patients with COVID-19 requiring intensive care unit (ICU), while focusing on the current treatment strategies being evaluated in the clinical trials in COVID-19-induced ARDS patients.

The Ruptured Globe, Sympathetic Ophthalmia, and the 14-Day Rule

PURPOSE

Prophylactic enucleation of a ruptured globe with no light perception within 14 days of injury to prevent sympathetic ophthalmia (SO) has been an established dictum in academic teaching for more than 100 years. This treatment strategy was originally based on observation, speculation, and careful thought, but there was never any scientific proof. This review summarizes and updates the current state of our knowledge about globe rupture and SO, examines the origin and validity of the 14-day rule, and emphasizes the importance of trying to save the traumatized eye whenever possible.

METHODS

A comprehensive literature review of SO and globe rupture was performed.

RESULTS

SO is a rare disorder that may potentially occur following traumatic globe rupture as well as following a variety of other intraocular surgeries. Vitreoretinal surgery may be a more common cause than trauma according to some studies. SO may still occur despite having the eye removed within 14 days of the trauma. A variety of new medications including biologic agents are now available to treat SO with improved efficacy in suppressing the associated ocular inflammation and allowing retention of some useful vision. Removing the traumatized, blind eye may have other important psychological consequences associated with it that require consideration before eye removal is carried out. Retaining the blind, phthisical, disfigured eye avoids phantom vision and phantom pain associated with enucleation as well as providing a good platform to support and move an overlying prosthetic eye. Data on the occurrence of SO following evisceration and enucleation with and without predisposing factors confirms the exceedingly low risk.

CONCLUSION

Most civilian open globe injuries can be successfully repaired with modern, advanced microsurgical techniques currently available. Because of the exceedingly low risk of SO, even with the severity of open globe trauma during military conflicts being more devastating as a result of the blast and explosive injuries, today every attempt is made to primarily close the eye rather than primarily enucleate it, providing there is enough viable tissue to repair. The 14-day rule for eye removal after severe globe ruptures is not scientifically supported and does not always protect against SO, but the safe time period for prophylactic eye removal is not definitively known. In the exceptional cases where SO does occur, several new medications are now available that may help treat SO. We advocate saving the ruptured globe whenever possible and avoiding prophylactic enucleation to prevent the rare occurrence of SO. When an eye requires removal, evisceration is an acceptable alternative to enucleation in cases that do not harbor intraocular malignancy.

A review of diseases of the retina for neurologists

Diseases of the retina are common and numerous, with causes ranging over inherited, inflammatory, vascular, infectious, neoplastic, traumatic, toxic, and idiopathic etiologies. A key issue in the diagnosis of retinal disease is the duration of symptoms, which can be acute, chronic, or acute presentations of chronic disease. Clinical examination with direct ophthalmoscopy or, even better, biomicroscopy with a slit lamp and condensing lens, is a key component of diagnosis, which can be enhanced through investigational methods such as fluorescein angiography, optical coherence tomography, or electroretinography. Consideration of the history, visual acuity and visual field, and fundoscopic findings is usually sufficient to determine whether patients need referral on an emergency, urgent, or routine basis. Emphasis is given to vascular disease, age-related macular degeneration, diabetic retinopathy, genetic eye disease, and retinal detachment.

Celastrol Regulates the Secretion of Interleukin-17 in Patients with Sympathetic Ophthalmia Through Signal Transducer and Activator of Transcription 3

Purpose: The excessive secretion of interleukin (IL)-17 contributes to the pathological process of sympathetic ophthalmia (SO). Celastrol is a naturally active product and exhibits an immunosuppressive effect. However, whether the supplementation of celastrol relieves SO remains unclear. Methods: The peripheral blood mononuclear cells (PBMCs) were extracted from the venous blood samples of 20 SO patients and 20 healthy controls, followed by stimulating with various concentrations of celastrol. The levels of IL-23 and IL-17 were measured by enzyme-linked immunosorbent assay and real-time polymerase chain reaction assay. The activation of the signal transducer and activator of transcription 3 (STAT3) in PBMCs of SO patients was detected by Western blot. Results: The levels of IL-23 and IL-17 in PBMCs isolated from SO patients were significantly increased compared with those in PBMCs isolated from healthy controls. Celastrol treatment inhibited the production of both IL-23 and IL-17 in PBMCs of SO patients in a dose-dependent manner. In PBMCs isolated from SO patients and healthy controls, the administration of recombinant human IL-23 (rIL-23) enhanced the production of IL-17, which was then suppressed by co-stimulation with celastrol. Also, celastrol treatment reduced rIL-23-induced phosphorylation of STAT3 in PBMCs isolated from SO patients. Conclusions: Celastrol can reduce the production of IL-17 in PBMCs of SO patients. The mechanism may be related to the reduction of IL-23 secretion, which in turn inhibits the phosphorylation of STAT3.

Sympathetic ophthalmia: Report of a case series and comprehensive review of the literature

PURPOSE

To evaluate the factors related to sympathetic ophthalmia (SO) in a series of patients in our ophthalmology center and previously published cases.

METHODS

A retrospective and noncomparative review was performed on 16 patients with SO attending our ophthalmology center from 2013 to 2019. A total of 87 previously published cases of SO were identified by searching the Medline database from 2009 to 2019.

RESULTS

Sixteen patients were included in the analysis, and six cases were induced by transscleral cyclophotocoagulation (TCP). All patients had achieved controlled inflammation at their last follow-up visit. Thirteen patients (81.3%) had improved best-corrected visual acuity (BCVA). A review of the literature revealed 87 previously reported cases of SO. Shared clinical features and treatment outcomes were summarized.

CONCLUSION

Ocular therapies, including both penetrating ocular therapy and non-penetrating ocular intervention, have become increasingly prevalent risk factors for SO, and the latent period has increased compared to past reports. Visual prognosis with appropriate medical management is relatively good.

Exudative Retinal Detachment in Ocular Inflammatory Diseases: Risk and Predictive Factors

PURPOSE

This study evaluated the risk and risk factors for exudative retinal detachment (ERD) in ocular inflammatory diseases.

DESIGN

Retrospective cohort study.

METHODS

Patients with noninfectious ocular inflammation had been followed longitudinally between 1978 and 2007 at 4 US subspecialty uveitis centers. The main outcome measurements were occurrences of ERD and predictive factors.

RESULTS

A total of 176 of 14,612 eyes with ocular inflammation presented with ERD. Among uveitis cases, Vogt-Koyanagi-Harada syndrome (VKH) (odds ratio [OR] = 109), undifferentiated choroiditis (OR = 9.18), sympathetic ophthalmia (OR = 8.43), primary or secondary panuveitis (OR = 7.09), multifocal choroiditis with panuveitis (OR = 4.51), and "other" forms of posterior uveitis (OR = 16.9) were associated with a higher prevalence of ERD. Among the 9,209 uveitic or scleritic eyes initially free of ERD and followed, 137 incident ERD cases were observed over 28,949 eye-years at risk (incidence rate = 0.47% [0.40%-0.56%/eye-year]). VKH (HR = 13.2), sympathetic ophthalmia (HR = 5.82), undifferentiated choroiditis (HR = 6.03), primary or secondary panuveitis (HR = 4.21), and rheumatoid arthritis (HR = 3.30) were significantly associated with incident ERD. A significant dose-response relationship with the prevalence and incidence of ERD were observed for AC cells and vitreous cell activity. African Americans had significantly higher prevalence and incidence of ERD.

CONCLUSIONS

Other ocular inflammatory conditions in addition to VKH syndrome and posterior scleritis were associated with increased risk of ERD, indicating that ERD does not necessarily dictate a diagnosis of VKH or posterior scleritis. In addition, the relationship between ERD and inflammatory severity factors implies that inflammation is a key predictive factor associated with developing ERD and requires early and vigorous control.

Sympathetic Ophthalmia - a Contribution to Immunology, Clinic and Current Imaging

BACKGROUND

Sympathetic ophthalmia (SO) is a rare inflammation of an operated or injured eye that spreads to the fellow eye. It is typically a bilateral granulomatous panuveitis. The traumatized eye is referred to as inciting eye and the fellow eye as sympathizing eye. The pathophysiology of the disease is not entirely understood, but there is strong evidence of an autoimmune genesis.

PATIENTS/MATERIAL AND METHODS

A selective literature search on epidemiology, immunology, clinical features and risk factors of SO was carried out. In addition, our own experience using multimodal imaging for this clinical entity was introduced.

RESULTS

In the literature, the incidence after traumatic eye injuries is 0.1 - 3% and approximately 0.01% after intraocular surgery. Among the iatrogenic causes, vitreoretinal surgery has the highest rate of SO, presumably due to disruption of the blood-retinal barrier and involvement of retinal and choroidal tissue, which are susceptible to anterior traction, phthisis and chronic inflammation. In 90% of patients, the disease develops within a year following the eliciting event and is associated with a potentially bilateral risk of blindness. Typical symptoms include bilateral visual impairment with photophobia, dull pain and photopsia. The spectrum of clinical manifestations ranges from granulomatous anterior uveitis and vitritis, to choroiditis, serous retinal detachment and Dalen-Fuchs nodules in the context of posterior involvement. The diagnosis of SO is generally based on clinical presentation and is supported by imaging methods. These primarily comprise fluorescein and indocyanine green angiography, which are increasingly being supplemented by non-invasive methods such as optical coherence tomography. They can provide important information for assessment of severity, differential diagnosis as well as for disease monitoring. The differential diagnosis includes i. a. Vogt-Koyanagi-Harada syndrome, ocular sarcoidosis and the rare phacoanaphylactic endophthalmitis. Immediate systemic high-dose steroid therapy is used as initial treatment. The course of the disease is often relapsing to chronic progressive. Immunomodulators such as ciclosporine A, azathioprine, cyclophosphamide, mycophenolate mofetil, and biologics are increasingly being used and contribute to the significantly better prognosis of the disease. Generally, SO can be triggered by any kind of intraocular intervention.

CONCLUSION

SO remains a threatening clinical diagnosis that poses diagnostic and therapeutic challenges. It can be triggered post-traumatic, but also any intraocular surgery. This should be taken into account when assessing the indication for intraocular eye surgery, especially in eyes with reduced visual outcome.

Bilateral Sterile Pyogranulomatous Keratitis in a Dog

Purpose

To describe the clinicopathologic features of bilateral sterile pyogranulomatous keratitis in a 16-year-old spayed female rat terrier dog.

Methods

The dog presented one year prior due to ulceration of the right and left corneas. The ulcers healed but plaques developed on both eyes which progressed, during the course of one year, to cover both the left and the right corneas. Due to the animal's loss of sight and its painful condition, bilateral enucleation was performed with submission of the eyes for histopathology.

Results

Microscopic examination revealed bilateral pyogranulomatous keratitis absent of etiological organisms.

Conclusions

To the authors' knowledge, this is the first documented case of bilateral sterile pyogranulomatous keratitis in a dog.

Sympathetic Ophthalmia after Vitreoretinal Surgeries: Incidence, Clinical Presentations and Outcomes of a Rare Disease

Aim: To evaluate clinical presentation, course and outcomes in patients without a history of penetrating ocular trauma who developed Sympathetic Ophthalmia (SO) following vitreoretinal surgeries Methods: Retrospective review of clinical records of all patients diagnosed and treated as S.O was done . All cases without a previous history of trauma were included and were analyzed with respect to clinical presentations, anatomic and visual outcomes. Results: 175 cases of sympathetic ophthalmia were diagnosed and treated till June 2017. 16 of these cases had undergone a pars plana vitrecomy (PPV) in the past and had no history of prior ocular trauma. SO after vitreoetinal surgeries accounted for 9.14 percent of all cases of SO .In the same duration, till 2017,a total 41365 PPV were done. Thus 0.038 percent of PPV cases developed a SO . 10 patients were males and 6 were females. The median age at presentation was 45.7 years. The time interval from surgery to diagnosis of sympathetic ophthalmia ranged from 22 days to 4 years after undergoing a surgery. The mean visual acuity in the sympathizing eye was 1.26 logMAR (snellens equivalent of 20/320) which improved to 0.62 logMAR(snellens equivalent of 20/80) after treatment. The most common anterior segment finding was non granulomatous anterior uveitis, seen in 8 cases (50%) while neurosensory detachments were the most common posterior segment presentation (10 cases, 62.5%).12 patients had undergone more than 1 surgery (mean number of surgeries was 1.88). 10 patients had undergone a sutureless PPV (6 cases of 23 gauge and 4 cases of 25 gauge vitrectomy) while 4 patients had undergone a 20 gauge vitrectomy where all sclerotomies were sutured after surgery All patients were treated with systemic steroids and immunosuppresants and 15 out of 16 patients showed significant improvement in the final visual acuity in the sympathizing eye Conclusions: Sympathetic ophthalmia after vitreoretinal surgeries is a rare but potentially sight threatening disease occurring in 0.038 percent of all cases of Pars Plana Vitrectomy. Presence of inflammation in the fellow eye after a vitreoretinal surgery in the other eye should alert the surgeon to possibility of sympathetic ophthalmia.

Comparison of Clinical Features and Visual Outcome between Sympathetic Ophthalmia and Vogt-Koyanagi-Harada Disease in Chinese Patients

PURPOSE

To characterize the clinical features of sympathetic ophthalmia (SO) and compare SO and Vogt-Koyanagi-Harada (VKH) disease in Chinese patients.

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 131 consecutive SO and 500 VKH disease patients randomly selected from among those referred to our uveitis center from April 2008 through June 2018.

METHODS

History, extraocular and ocular findings, best-corrected visual acuity (BCVA), auxiliary examination findings, complications, and therapeutic effects were analyzed retrospectively in SO and VKH disease patients.

MAIN OUTCOME MEASURES

Visual outcome, extraocular and ocular findings, and therapeutic effects.

RESULTS

Sympathetic ophthalmia manifested as posterior uveitis (68.8%) within 2 weeks and equal involvement of anterior and posterior segment (44.4%), respectively, was observed between 2 weeks and 2 months after disease onset. Two months after disease onset, SO patients showed sunset glow fundus (51.2%) and granulomatous anterior uveitis (27.3%). Vogt-Koyanagi-Harada disease patients mainly showed posterior uveitis (100%), anterior segment involvement (92.4%) associated with posterior uveitis (84.9%), and granulomatous anterior uveitis (97.4%) accompanying sunset glow fundus (91.5%) in the 3 periods mentioned above. The frequencies of extraocular manifestations were lower in SO patients (24.4%) as compared with VKH disease patients (84.8%; P < 0.001). Best-corrected visual acuity of SO patients improved from 0.68±0.86 logarithm of the minimum angle of resolution (logMAR) to 0.47±0.78 logMAR (P = 0.01), and BCVA of VKH disease patients improved from 0.67±0.79 logMAR to 0.24±0.53 logMAR (P < 0.001) at 12 months of follow-up. A worse BCVA was noted in SO patients compared with VKH disease patients after treatment (P = 0.003). Kaplan-Meier survival analysis showed that the risk of loss of useful vision in SO patients was significantly higher than that of VKH disease patients (P < 0.001).

CONCLUSIONS

Chinese SO and VKH disease patients have a different evolutionary process. The frequency of extraocular manifestations in SO patients is much lower as compared with VKH disease patients. Visual outcome is worse in SO as compared with VKH disease.

CNS inflammation and neurodegeneration: sequelae of peripheral inoculation with spinal cord tissue in rat

OBJECTIVE

Recent research demonstrates that victims of spinal cord injury (SCI) are at increased risk for dementia and that encephalitis can occur as a consequence of isolated SCI. We theorize that autoimmunity to the central nervous system (CNS) could explain these phenomena and undertook this study to determine whether peripheral inoculation with spinal cord homogenate on 1 or 2 occasions is associated with CNS-directed autoimmunity and neurodegeneration in a rat model.

METHODS

Rats were subcutaneously inoculated with saline or 75 mg of allogeneic spinal cord tissue on 1 or 2 occasions. Animals underwent Morris Water Maze testing, and serial serum samples were collected. Animals were sacrificed 8 weeks following the first inoculation. Autoantibody titers to myelin antigens MAG and GM1 were measured in serum. Immunohistochemistry was used to identify autoantibodies targeting NeuN-labeled neurons and CC1-labeled oligodendrocytes. Quantitative real-time polymerase chain reaction (qPCR) and western blotting were performed for pro-inflammatory cytokines TNF-α, IL-1β, and IL-6 and the cell death marker caspase 3 as well as the neurodegenerative proteins tau and β-amyloid in both brain and spinal cord. Fluoro-Jade B was used to stain degenerating neurons, facilitating counting.

RESULTS

Animals inoculated with spinal cord homogenate exhibited increased titers of autoantibodies to MAG and GM1 and autoantibodies binding to neurons and oligodendrocytes. Double-inoculated animals demonstrated a significant increase in the expression of pro-inflammatory cytokines in the brain (TNF-α, p = 0.016; IL-6, p = 0.009) as well as the spinal cord (TNF-α, p = 0.024; IL-6, p = 0.002). The number of degenerating neurons was significantly increased in the brain and spinal cord of inoculated animals (p < 0.0001 and p = 0.028, respectively). Elevated expression of tau and β-amyloid was seen in brain of double-inoculated animals (p = 0.003 and p = 0.009, respectively). Inflammatory marker expression in the brain was positively correlated with anti-myelin autoimmune antibody titers and with tau expression in the brain. Inoculated animals showed impaired memory function in Morris Water Maze testing (p = 0.043).

CONCLUSIONS

The results of these experiments demonstrate that peripheral exposure to spinal cord antigens is associated with CNS-directed autoimmunity and inflammation in the brain and spinal cord as well as degeneration of CNS cells, memory impairment, and production of neurodegenerative proteins particularly when this exposure is repeated. These data support CNS autoimmunity as a candidate mechanism for the dementia that can follow SCI and perhaps other posttraumatic dementias such as chronic traumatic encephalopathy.

Sympathetic Ophthalmia in a 22-Month-Old Infant With Sturge-Weber Syndrome With Atypical Histopathological Correlation

Purpose

Sturge-Weber syndrome (SWS) and sympathetic ophthalmia (SO) are unusual pathologies. Their association has not been previously reported. This unusual diagnosis can be elucidated by clinical suspicion.

Methods

Case report of a 22-month-old female with SO.

Results

SWS with a unilateral diffuse choroidal hemangioma. The exciting eye had multiple surgeries for glaucoma that required enucleation. Clinical picture of SO was found on the sympathizing eye. Atypical histopathology (nongranulomatous choroidal infiltrate and perivascular mononuclear cells) is found in the enucleated eye.

Conclusions

To the best of the authors' knowledge, this is the first description of an association of SWS, diffuse choroidal hemangioma, infantile glaucoma, and SO. Many confounding factors are present (ie, multiple surgeries, risk of infectious endophthalmitis). Therefore, a high index of suspicion must be kept in mind to make the diagnosis. We aim to raise awareness of such a devastating condition in a pediatric patient with many comorbidities.

Early Recovery of Sympathetic Ophthalmia with Hearing Loss in a Young Man

Hearing loss is rarely associated with sympathetic ophthalmia. We describe a young man who presented with sympathetic ophthalmia and concurrent hearing loss one month post globe rupture. The presentation was very subtle and atypical. However, the patient recovered fully after two weeks of prompt oral corticosteroid therapy which resulted in good visual and hearing outcomes. This patient demonstrated that the acute phase of sympathetic ophthalmia is reversible with early recognition of features, timely diagnosis, and rapid initiation of corticosteroid therapy.

Pneumonia, Acute Respiratory Distress Syndrome, and Early Immune-Modulator Therapy

Acute respiratory distress syndrome (ARDS) is caused by infectious insults, such as pneumonia from various pathogens or related to other noninfectious events. Clinical and histopathologic characteristics are similar across severely affected patients, suggesting that a common mode of immune reaction may be involved in the immunopathogenesis of ARDS. There may be etiologic substances that have an affinity for respiratory cells and induce lung cell injury in cases of ARDS. These substances originate not only from pathogens, but also from injured host cells. At the molecular level, these substances have various sizes and biochemical characteristics, classifying them as protein substances and non-protein substances. Immune cells and immune proteins may recognize and act on these substances, including pathogenic proteins and peptides, depending upon the size and biochemical properties of the substances (this theory is known as the protein-homeostasis-system hypothesis). The severity or chronicity of ARDS depends on the amount of etiologic substances with corresponding immune reactions, the duration of the appearance of specific immune cells, or the repertoire of specific immune cells that control the substances. Therefore, treatment with early systemic immune modulators (corticosteroids and/or intravenous immunoglobulin) as soon as possible may reduce aberrant immune responses in the potential stage of ARDS.

A common immunopathogenesis mechanism for infectious diseases: the protein-homeostasis-system hypothesis

It was once believed that host cell injury in various infectious diseases is caused solely by pathogens themselves; however, it is now known that host immune reactions to the substances from the infectious agents and/or from the injured host cells by infectious insults are also involved. All biological phenomena in living organisms, including biochemical, physiological and pathological processes, are performed by the proteins that have various sizes and shapes, which in turn are controlled by an interacting network within the living organisms. The author proposes that this network is controlled by the protein homeostasis system (PHS), and that the immune system is one part of the PHS of the host. Each immune cell in the host may recognize and respond to substances, including pathogenic proteins (PPs) that are toxic to target cells of the host, in ways that depend on the size and property of the PPs. Every infectious disease has its own set of toxic substances, including PPs, associated with disease onset, and the PPs and the corresponding immune cells may be responsible for the inflammatory processes that develop in those infectious diseases.

Classical pathology of sympathetic ophthalmia presented in a unique case

The ocular pathology of sympathetic ophthalmia is demonstrated in a 10 year-old boy who sustained a penetrating left globe injury and subsequently developed sympathetic ophthalmia in the right eye two months later. Two and a half weeks following extensive surgical repair of the left ruptured globe, he developed endophthalmitis and was treated with oral and topical fortified antibiotics. One month after the initial injury, a progressive corneal ulcer of the left eye led to perforation and the need for emergent corneal transplantation. The surgical specimen revealed fungus, Scedosporium dehoogii. The boy received systemic and topical anti-fungal therapy. Two months following the penetrating globe injury of the left eye, a granulomatous uveitis developed in the right eye. Sympathetic ophthalmia was suspected and the patient began treatment with topical and oral corticosteroids. Given the concern of vision loss secondary to sympathetic ophthalmia in the right eye, as well as poor vision and hypotony in the injured eye, the left eye was enucleated. Microscopically, granulomatous inflammation with giant cells was noted within a cyclitic membrane which filled the anterior and posterior chamber of the left globe. Other classic features including Dalen-Fuchs nodules were identified. Small, choroidal, ill-defined granulomas and relative sparing of the choriocapillaris were present. Molecular analysis did not identify evidence of remaining fungal infection. The pathology findings were consistent with previously described features of sympathetic ophthalmia. The present case is unique in that co-existing fungal infection may have potentiated the risk for developing sympathetic ophthalmia in the fellow eye.

Repositioning of a traumatically displaced globe with maxillary antrostomy: review of the literature and treatment recommendations

Complete dislocation of the globe, inferiorly into the maxillary sinus, medially into the ethmoid sinus, or superiorly into the anterior cranial fossa, can occur with significant blunt facial trauma. The degree of injury to the globe, its adnexal structures, and the optic nerve is dependent on the extent of the dislocation. Complete traumatic subluxation of the globe into the maxillary sinus is associated with severe injury to the periocular structures and represents a challenging and unique reconstructive process rarely encountered in published studies. The present case report represents only the 15th reported case of complete orbital prolapse into the maxillary sinus. Controversy exists regarding the definitive treatment of traumatic globe dislocations, the risk of sympathetic ophthalmia (SO), the sequela of postenucleation socket syndrome, and prophylactic steroid treatment to decrease the incidence of SO and traumatic optic neuropathy.

Sympathetic ophthalmia: to the twenty-first century and beyond

Sympathetic ophthalmia is a rare bilateral granulomatous inflammation that follows accidental or surgical insult to the uvea of one eye. Onset of sympathetic ophthalmia can be insidious or acute, with recurrent periods of exacerbation. Clinical presentation shows mutton-fat keratic precipitates, choroidal infiltrations, and Dalen-Fuchs nodules. Histopathology reveals diffuse or nodular granulomatous inflammation of the uvea. Prevention and treatment strategies for sympathetic ophthalmia are currently limited to two modalities, enucleation of the injured eye and immunosuppressive therapy, aimed at controlling inflammation. The etiology and pathophysiology of the disease is still unclear but is largely thought to be autoimmune in nature. Recent insight on the molecular pathology of the disease as well as developments in imaging technology have furthered both the understanding on the autoimmune process in sympathetic ophthalmia and the targeting of prevention and treatment strategies for the future.

Barriers of the Human Organism and Their Achilles’ Heels

The human body is covered by barriers separating it from the external and internal surroundings. The “milieu enterieur” has to be stabilised in spite of the variable external and internal conditions of toxic, osmotic, microbial and climatic environmental circumstances. This first line of barriers is composed of skin and mucous membranes of complicated structures.

A second line of barrier system is present in our organisms. Certain organs have to be separated from the immune system and other parts of the body because of evolutionary reasons (eye-bulb and testicles) because of unique proteins “unknown” for the acquired immune system. The blood-brain barrier (BBB) is providing enhanced safety circumstances for the central nervous system. The second line of barriers is represented by the special properties of the capillary endothelial system.

The maternal-fetal barrier is the most complex. At the maternal fetal interface two individuals of two different haplotypes has to be live 9 months separated by a very complicated dynamic barrier.

The placenta is the organ, which is separating the maternal and fetal tissues. Similar to others the bidirectional transport of gasses, metabolites, cells, proteins, regulatory substances, are transported by active or passive transcellular and intercellular mechanisms.

The fetal immune system develops immunotolerance to all maternal cells and antigens transferred transplacentally. The problem is to mitigate the maternal immune system to tolerate the paternal haplotype of the fetus. In the case of normal pregnancy a complex series of physiological modifications can solve the problem without harmful consequences to the mother and fetus.

The outermost contact cells of trophoblasts express instead of HLA-class Ia and class II antigens non-variable HLA-C, HLA-E, HLA-F and HLA-G antigens. The first consequence of this is reduction of the activity of maternal natural killer cells and maternal dendritic cells;

Progesteron, micro-RNA and mediators influence the development of T effector-cells. The production of soluble HLA-G(5 and 6) and IL-10 supports the differentiation of Th-2 CD4⁺ helper cells, reducing the ability of maternal cells to kill fetal cells.

Series of receptors and costimulators are expressed by the different lines of semi-allogenic trophoblast cells to bind HLA-G and mitigate maternal immune response;

The maternal immunotolerance is further facilitated by the activation of CD4⁺CD25^brightFoxp3⁺ regulatory T (T_REG) cells.

Infections have to be prevented during pregnancy. The cells of placenta express 10 Toll-like receptors a group of pattern recognition receptors responsible for innate immunity. The interferon level is also higher in the placental tissues than in the somatic fetal or maternal cells.

The complement system is also adapted to the requirements of the pregnancy and fetal damage is inhibited by the production of “assymmetric IgG antibodies” under hormonal and placental-regulation. These modifications prevent the activation of complement, cytotoxic activity, opsonising ability, antigen clearance and precipitating activity of the molecules.

The Achilles’ heels of the different barriers are regularly found by virus infections. Lamina cribrosa of the blood-brain barrier, optical nerve of the eyes, etc. the risk factors of the maternal-fetal barrier has been summarised in Table 1.1.