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Patterson TJ, Kedzierski A, McKinney D, Ritson J, McLean C, Gu W, Colyer M, McClellan SF, Miller SC, Justin GA, Hoskin AK, Cavuoto K, Leong J, Rousselot Ascarza A, Woreta FA, Miller KE, Caldwell MC, Gensheimer WG, Williamson T, Dhawahir-Scala F, Shah P, Coombes A, Sundar G, Mazzoli RA, Woodcock M, Watson SL, Kuhn F, Halliday S, Gomes RSM, Agrawal R, Blanch RJ. The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis. Ophthalmology 2024; 131:557-567. [PMID: 38086434 DOI: 10.1016/j.ophtha.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 02/12/2024] Open
Abstract
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.
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Affiliation(s)
- Tim J Patterson
- Northern Ireland Medical and Dental Training Agency (NIMDTA), Beflast, United Kingdom
| | | | - David McKinney
- Northern Ireland Medical and Dental Training Agency (NIMDTA), Beflast, United Kingdom
| | - Jonathan Ritson
- Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom; Royal Centre for Defence Medicine, Birmingham, United Kingdom
| | - Chris McLean
- Epsom and St Helier University Hospitals NHS Trust, Epsom, United Kingdom
| | - Weidong Gu
- Vision Center of Excellence, Research & Development Directorate, J-9, Defence Health Agency, Silver Spring, Maryland
| | - Marcus Colyer
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Scott F McClellan
- Vision Center of Excellence, Research & Development Directorate, J-9, Defence Health Agency, Silver Spring, Maryland
| | - Sarah C Miller
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Grant A Justin
- Uniformed Services University of the Health Sciences, Bethesda, Maryland; Duke Eye Center, Duke University Hospitals, Durham, North Carolina
| | - Annette K Hoskin
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Kara Cavuoto
- Bascom Palmer Eye Institute, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - James Leong
- The University of Sydney, Save Sight Institute, Discipline of Ophthalmology, Sydney Medical School, Sydney, New South Wales, Australia; Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrés Rousselot Ascarza
- Consultorios Oftalmológicos Benisek-Ascarza, Ciudad Autónoma de Buenos Aires, Buenos Aires, Argentina
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kyle E Miller
- Uniformed Services University of the Health Sciences, Bethesda, Maryland; Department of Ophthalmology, Navy Medical Center Portsmouth, Portsmouth, Virginia
| | - Matthew C Caldwell
- Department of Ophthalmology, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas
| | - William G Gensheimer
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; White River Junction Veterans Administration Medical Center, White River Junction, Vermont
| | - Tom Williamson
- Department of Ophthalmology, St. Thomas Hospital, London, United Kingdom
| | | | - Peter Shah
- Birmingham Institute for Glaucoma Research, Birmingham, United Kingdom; Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrew Coombes
- Department of Ophthalmology, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Gangadhara Sundar
- Department of Ophthalmology, National University Hospital, Singapore, Republic of Singapore
| | - Robert A Mazzoli
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Malcolm Woodcock
- Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom
| | - Stephanie L Watson
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ferenc Kuhn
- Helen Keller Foundation for Research and Education, Birmingham, Alabama
| | | | - Renata S M Gomes
- Research & Innovation, BRAVO VICTOR, London, United Kingdom; Northern Hub for Veterans and Military Families Research, Northumbria University, Newcastle, United Kingdom
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Republic of Singapore; Singapore Eye Research Institute, Singapore, Republic of Singapore; Lee Kong Chian School of Medicine, Singapore, Republic of Singapore; Duke NUS Medical School, Singapore, Republic of Singapore
| | - Richard J Blanch
- Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Neuroscience & Ophthalmology, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, United Kingdom.
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Lucchini S, Govetto A, Carini E, Casalino G, Donati S, Radice P. Presumed sympathetic ophthalmia following scleral buckling surgery: A case report and review of the literature. Eur J Ophthalmol 2023; 33:NP53-NP57. [PMID: 36517983 DOI: 10.1177/11206721221145212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
PURPOSE To report a case of presumed sympathetic ophthalmia (SO) following scleral buckling (SB) surgery and to discuss the possible pathogenesis of this condition by reviewing the current evidence on this subject. METHODS Case report and narrative review of the literature; our case was imaged with spectral-domain optical coherence tomography (SD-OCT) and optical coherence tomography angiography (OCTA), fundus autofluorescence (FAF), fluorescein angiography (FFA) and indocyanine green angiography (ICGA). RESULTS A 55-year-old man presented with a macula on rhegmatogenous retinal detachment which was treated with 360° SB surgery, subretinal fluid drain (SRFD), cryopexy and pneumoretinopexy. Due to failure of the primary surgery, a second procedure was performed the day after with the explant of the prior buckle and the implant of a wider circumferential element. At three months from surgery, the patient complained of severe bilateral vision loss. Multimodal imaging revealed bilateral, multi-focal exudative retinal detachments and choroidal swelling. A diagnosis of presumed SO was made and the patient was treated with a combination of steroid and immunosuppressive drugs. The clinical picture completely resolved at postoperative month 12. CONCLUSION SO may be a rare complication of SB surgery. In our case, early recognition and prompt immunosuppressive treatment achieved good long-term clinical results.
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Affiliation(s)
- Sara Lucchini
- Ophthalmology Department, Circolo and Fondazione Macchi Hospital, ASST Sette Laghi, Varese, Italy
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Andrea Govetto
- Ophthalmology Department, Circolo and Fondazione Macchi Hospital, ASST Sette Laghi, Varese, Italy
| | - Elisa Carini
- Ophthalmology Department, Circolo and Fondazione Macchi Hospital, ASST Sette Laghi, Varese, Italy
| | - Giuseppe Casalino
- Eye Clinic, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Simone Donati
- Ophthalmology Department, Circolo and Fondazione Macchi Hospital, ASST Sette Laghi, Varese, Italy
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Paolo Radice
- Ophthalmology Department, Circolo and Fondazione Macchi Hospital, ASST Sette Laghi, Varese, Italy
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Zhou Y, Zhou A, Philip AM, Margolis M, Babiker F, Chang PY, Anesi SD, Foster CS. Vision Outcomes of Long-Term Immunomodulatory and Steroid Therapy in Sympathetic Ophthalmia. Am J Ophthalmol 2023; 253:152-159. [PMID: 37150338 DOI: 10.1016/j.ajo.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE To compare vision acuity outcomes of long-term steroid therapy compared with immunomodulatory therapy for treatment of sympathetic ophthalmia. DESIGN Single-center, retrospective, comparative clinical study. METHODS Patients with sympathetic ophthalmia treated from March 2005 to October 2022 with at least 1 year of follow-up were included. Visual acuity outcomes were compared by steroid and immunomodulatory treatment modality. RESULTS Thirty-five patients with sympathetic ophthalmia were included in the study, with follow-up ranging from 1 to 17 years. Higher rates of vision loss correlated with longer periods of active uveitis and steroid treatment. Lower rates of vision loss correlated with longer periods of uveitis remission on immunomodulatory therapy alone and drug-free remission. Treatment with alkylating agents or combination therapy with an antimetabolite, a biologic-response modifier, and cyclosporine are more likely to result in sympathetic ophthalmia remission. CONCLUSION Immunomodulatory therapy leads to superior vision outcomes in cases of steroid-resistant or recurrent sympathetic ophthalmia. Steroid therapy may be useful for acute or recalcitrant sympathetic uveitis but is insufficient for long-term inflammatory control. PRéCIS: This manuscript describes a retrospective analysis of vision outcomes in patients with sympathetic ophthalmia. Results indicate that long-term immunomodulatory therapy is associated with better vision outcomes than long-term steroid therapy for sympathetic ophthalmia treatment.
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Affiliation(s)
- Yujia Zhou
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Avery Zhou
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Andrew M Philip
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Michael Margolis
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Fatima Babiker
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Peter Y Chang
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - Stephen D Anesi
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F)
| | - C Stephen Foster
- From Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA (Y.Z, A.Z, A.M.P, M.M, F.B, P.Y.C, S.D.A, C.S.F); Department of Ophthalmology, Harvard Medical School, Boston, MA, USA (C.S.F).
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Ripa M, Panos GD, Rejdak R, Empeslidis T, Toro MD, Costagliola C, Ferrara A, Gotzaridis S, Frisina R, Motta L. Sympathetic Ophthalmia after Vitreoretinal Surgery without Antecedent History of Trauma: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12062316. [PMID: 36983316 PMCID: PMC10057773 DOI: 10.3390/jcm12062316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Background: To evaluate the morbidity frequency measures in terms of the cumulative incidence of sympathetic ophthalmia (SO) triggered by single or multiple vitreoretinal (VR) surgery procedures in eyes without an antecedent history of trauma and previous ocular surgery, except for previous or concomitant uneventful lens extraction, and to further investigate the relationship between VR surgery and SO. Methods: A literature search was conducted using PubMed, Embase, and Scopus from inception until 11 November 2022. The Joanna Briggs Institute (JBI) critical appraisal checklist for the case series and the Newcastle–Ottawa Scale were used to assess the risk of bias. The research was registered with the PROSPERO database (identifier, CRD42023397792). Meta-analyses were conducted using the measurement of risk and a 95% confidence interval (CI) for each study. Results: A random-effect meta-analysis demonstrated that the pooled cumulative incidence of SO triggered by single or multiple VR surgery procedures in eyes without an antecedent history of trauma and previous ocular surgery, except for previous or concomitant uneventful lens extraction among patients who developed SO regardless of the main trigger, was equal to 0.14 with a CI between 0.08 and 0.21 (I2 = 78.25, z: 7.24, p < 0.01). The pooled cumulative incidence of SO triggered by single or multiple VR surgery procedures in eyes without an antecedent history of trauma and previous ocular surgery, except for previous or concomitant uneventful lens extraction among patients who underwent VR surgery, was equal to 0.03 for every 100 people, with a confidence interval (CI) between 0.02% and 0.004% (I2 = 27.77, z: 9.11, p = 0.25). Conclusions: Despite postsurgical SO being a rare entity, it is a sight-threatening disease. VR surgery should be viewed as a possible inciting event for SO and considered when counseling patients undergoing VR surgery.
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Affiliation(s)
- Matteo Ripa
- Department of Ophthalmology, William Harvey Hospital, East Kent Hospitals University NHS Foundation Trust, Ashford TN24 0LZ, UK; (M.R.)
| | - Georgios D. Panos
- Department of Ophthalmology, Queen’s Medical Centre Campus, Nottingham University Hospitals, Nottingham NG7 2UH, UK
| | - Robert Rejdak
- Department of General and Pediatric Ophthalmology, Medical University of Lublin, Ul. Chmielna 1, 20079 Lublin, Poland
| | | | - Mario Damiano Toro
- Department of General and Pediatric Ophthalmology, Medical University of Lublin, Ul. Chmielna 1, 20079 Lublin, Poland
- Eye Clinic, Public Health Department, University of Naples Federico II, 80133 Naples, Italy
- Correspondence:
| | - Ciro Costagliola
- Eye Clinic, Department of Neurosciences, Reproductive and Dentistry Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Andrea Ferrara
- Department of Ophthalmology and Neuroscience, Medical School, University of Bari “Aldo Moro”, 70121 Bari, Italy
| | | | - Rino Frisina
- Ophthalmology Unit of Surgery, Department of Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Lorenzo Motta
- Department of Ophthalmology, William Harvey Hospital, East Kent Hospitals University NHS Foundation Trust, Ashford TN24 0LZ, UK; (M.R.)
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Wilkins CS, Chen M, Chandra G, Muldoon TO, Sidoti PA, Samson CM, Rosen RB. “Persistence of Memory” – Multimodal imaging of delayed sympathetic ophthalmia. Am J Ophthalmol Case Rep 2022; 27:101572. [PMID: 35845745 PMCID: PMC9284322 DOI: 10.1016/j.ajoc.2022.101572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 04/13/2022] [Accepted: 05/01/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose To describe a case of late post-surgical sympathetic ophthalmia documented with multimodal imaging. Observations A 74-year-old male presented to the urgent care of the New York Eye and Ear Infirmary with blurry vision and discomfort in his left eye for three weeks. His vision was 20/50, with intraocular pressure of 13 mmHg, and slit lamp examination was significant for conjunctival congestion, 1+ anterior segment cell and flare, and diffuse keratic precipitates. His right eye was no light perception with a condensed hyphema, intraocular lens and inferonasal tube. His medical history included coronary artery bypass, prostate cancer, hyperlipidemia, and hypertension. His ocular history included blunt trauma to the right eye at age 11 with development of a traumatic macular hole and later rhegmatogenous retinal detachment at age 53, repaired with multiple vitreoretinal procedures. He developed glaucoma in the right eye and was treated with a tube shunt and ultimately transscleral cyclophotocoagulation (TSCPC) 7 years later, 13 years prior to his presentation of the left eye. Dilated fundus examination of his left eye revealed diffuse chorioretinal folds in the macula without any discrete chorioretinal lesions. Ultrasound of the right showed serous macular detachments with scleral thickening. Presumptive diagnosis of sympathetic ophthalmia was made and oral corticosteroid therapy was initiated. Subsequent SD-OCT and en-face OCT-A demonstrated Dalen-Fuchs nodules within the macula underlying areas of resolved serous detachment, after 6 weeks of oral steroids and initiation of immunomodulatory therapy (IMT). Conclusions Sympathetic ophthalmia may rarely present with very delayed onset, and TSCPC is an uncommon inciting event. These patients may develop serous detachment, choroidal folds and inflammatory nodules identifiable on exam and multimodal imaging, which can resolve when treated appropriately. OCT-A may provide utility in monitoring response to immunosuppressive treatment in these patients.
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Affiliation(s)
- Carl S. Wilkins
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 East 14th Street, New York, NY, 10003, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Masako Chen
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 East 14th Street, New York, NY, 10003, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Gaurav Chandra
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 East 14th Street, New York, NY, 10003, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - Thomas O. Muldoon
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 East 14th Street, New York, NY, 10003, USA
| | - Paul A. Sidoti
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 East 14th Street, New York, NY, 10003, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
| | - C. Michael Samson
- Department of Ophthalmology, Manhattan Eye, Ear, and Throat Hospital, Zucker School of Medicine at Hofstra/Northwell Health, 210 East 64 Street, New York, NY, 10021, USA
| | - Richard B. Rosen
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, 310 East 14th Street, New York, NY, 10003, USA
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029, USA
- Corresponding author. New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th Street, New York, NY, 10003, USA.
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Parchand S, Agrawal D, Ayyadurai N, Agarwal A, Gangwe A, Behera S, Bhatia P, Mulkutkar S, Barwar G, Singh R, Sen A, Agarwal M. Sympathetic ophthalmia: A comprehensive update. Indian J Ophthalmol 2022; 70:1931-1944. [PMID: 35647958 PMCID: PMC9359263 DOI: 10.4103/ijo.ijo_2363_21] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/05/2021] [Accepted: 12/07/2021] [Indexed: 11/17/2022] Open
Abstract
Sympathetic ophthalmia is a rare, bilateral, granulomatous, panuveitis following penetrating trauma or surgery to one eye. Clinical presentation commonly occurs within the first year of trauma occurrence but can be delayed by several years. It manifests as acute/chronic granulomatous uveitis with yellowish-white choroidal lesions or Dalen-Fuchs nodules. Initially, patients respond rapidly to corticosteroid therapy, but a majority require long-term use of corticosteroid-sparing agents to prevent recurrences. The purpose of this review is to elaborate on the current understanding of the pathophysiology, the importance of multimodal imaging in early diagnosis, and the role of newer immunomodulatory and biological agents in recalcitrant cases.
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Affiliation(s)
- Swapnil Parchand
- Department of Vitreo-retina and Uvea Services, MGM Eye Institute, Raipur, Chandigarh, India
| | - Deepshikha Agrawal
- Department of Cornea and Anterior segment Services, MGM Eye Institute, Raipur, Chandigarh, India
| | - Nikitha Ayyadurai
- Department of Ophthalmology, Advanced Eye Center, PGIMER, Chandigarh, India
| | - Aniruddha Agarwal
- The Eye Institute, Cleveland Clinic, Abu Dhabi (CCAD), Abu Dhabi, United Arab Emirates (UAE)
| | - Anil Gangwe
- Department of Vitreo-retina and Uvea Services, MGM Eye Institute, Raipur, Chandigarh, India
| | - Shashwat Behera
- Department of Vitreo-retina and Uvea Services, MGM Eye Institute, Raipur, Chandigarh, India
| | - Priyavat Bhatia
- Department of Retina and Uvea Services, Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India
| | - Samyak Mulkutkar
- Department of Ophthalmology, PD Hinduja Hospital, Mumbai, Maharashtra, India
| | - Gulshan Barwar
- Department of Vitreo-retina and Uvea Services, MGM Eye Institute, Raipur, Chandigarh, India
| | - Ramandeep Singh
- Department of Ophthalmology, Advanced Eye Center, PGIMER, Chandigarh, India
| | - Alok Sen
- Department of Retina and Uvea Services, Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India
| | - Manisha Agarwal
- Department of Uvea Services, Dr Shroff’s Charity Eye Hospital, New Delhi, India
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Agarwal M, Radosavljevic A, Tyagi M, Pichi F, Al Dhanhani AA, Agarwal A, Cunningham ET. Sympathetic Ophthalmia - An Overview. Ocul Immunol Inflamm 2022; 31:793-809. [PMID: 35579612 DOI: 10.1080/09273948.2022.2058554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Mamta Agarwal
- Medical Research Foundation, Sankara Nethralaya, Uveitis & Cornea Services, Chennai, India
| | | | | | - Francesco Pichi
- Eye Institute, Cleveland Clinic, Abu Dhabi, UAE.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University Cleveland, Cleveland, Ohio, USA
| | | | - Aditi Agarwal
- Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Emmett T Cunningham
- The Department of Ophthalmology, California Pacific Medical Center, San Francisco, California, USA.,West Coast Retina Medical Group, San Francisco, California, USA.,The Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA.,Proctor Foundation, UCSF School of MedicineThe Francis I., San Francisco, California, USA
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Anikina E, Wagner S, Liyanage S, Sullivan P, Pavesio C, Okhravi N. The Risk of Sympathetic Ophthalmia Following Vitreoretinal Surgery. Ophthalmol Retina 2022; 6:347-360. [PMID: 35093583 DOI: 10.1016/j.oret.2022.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE To investigate the clinical course and the outcomes of sympathetic ophthalmia and correlate these with the nature of the inciting event and the number of vitreoretinal procedures undergone by patients. DESIGN A retrospective case review. SUBJECTS All patients diagnosed with sympathetic ophthalmia who have been treated or monitored at a single centre over a 15 year period. METHODS A search of the electronic patient record system at Moorfields Eye Hospital, Londo over a 15 year period (between January 2000 and December 2015) was carried out, using the search terms "sympathetic", "ophthalmia" and "ophthalmitis". 61 patients with available records were identified and data collected from their complete electronic and paper records. MAIN OUTCOME MEASURES The main outcome measures looked at were the best-corrected visual acuity (BCVA) at 1 year and at the end of follow up and the number of vitreoretinal surgical procedures preceding the diagnosis. Data was also collected to report on patient age, gender, disease duration, ocular and systemic manifestations, ocular complications, retinal angiography and treatment. RESULTS There was a wide age range at presentation (2-84) and the length of follow up ranged 1-75 years. The first ocular event was trauma in 40 patients and surgery in 21. Vitreoretinal (VR) surgery accounted for 13 of the 21 surgical first event triggers (62%). 23/61 patients (38%) underwent VR surgery (1-7 operations) at some point prior to diagnosis. Surgical details were available for 15 patients, who had a total of 25 VR procedures carried out. Based on the surgical activity of the unit, the risk of developing SO following a single VR procedure is estimated at 0.008%, rising to 6.67% with 7 procedures. A total of 23 patients (38%) experienced a decrease in acuity at the end of the follow up period, versus 9 patients (15%) experiencing an improvement and 18 (30%) remaining unchanged. CONCLUSIONS We feel that the most significant finding in this study is the calculated risk of SO development following a single VR procedure, which is significantly lower in our cohort than previously reported in the literature. This is seen to rise exponentially with additional procedures.
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Affiliation(s)
- Evgenia Anikina
- Vitreoretinal Service, Moorfields Eye Hospital NHSFT, London, EC1V 2PD United Kingdom; NIHR Biomedical Research Centre at Moorfields Eye Hospital NHSFT,; UCL Institute of Ophthalmology, London, EC1V 2PD United Kingdom
| | - Siegfried Wagner
- Vitreoretinal Service, Moorfields Eye Hospital NHSFT, London, EC1V 2PD United Kingdom; NIHR Biomedical Research Centre at Moorfields Eye Hospital NHSFT,; UCL Institute of Ophthalmology, London, EC1V 2PD United Kingdom
| | - Sidath Liyanage
- Vitreoretinal Service, Moorfields Eye Hospital NHSFT, London, EC1V 2PD United Kingdom; NIHR Biomedical Research Centre at Moorfields Eye Hospital NHSFT,; UCL Institute of Ophthalmology, London, EC1V 2PD United Kingdom
| | - Paul Sullivan
- Vitreoretinal Service, Moorfields Eye Hospital NHSFT, London, EC1V 2PD United Kingdom
| | - Carlos Pavesio
- Uveitis Service, Moorfields Eye Hospital NHSFT, London, EC1V 2PD United Kingdom; NIHR Biomedical Research Centre at Moorfields Eye Hospital NHSFT,; UCL Institute of Ophthalmology, London, EC1V 2PD United Kingdom
| | - Narciss Okhravi
- Uveitis Service, Moorfields Eye Hospital NHSFT, London, EC1V 2PD United Kingdom; NIHR Biomedical Research Centre at Moorfields Eye Hospital NHSFT,; UCL Institute of Ophthalmology, London, EC1V 2PD United Kingdom.
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Fromal OV, Swaminathan V, Soares RR, Ho AC. Recent advances in diagnosis and management of sympathetic ophthalmia. Curr Opin Ophthalmol 2021; 32:555-560. [PMID: 34494974 DOI: 10.1097/icu.0000000000000803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Sympathetic ophthalmia is a bilateral granulomatous uveitis that occurs following unilateral trauma or surgery and is sight-threatening in the contralateral eye. Despite significant potential morbidity, disease remains poorly understood. Variable presentations and clinical courses, as well as a lack of definitive diagnostic laboratory tests can complicate the diagnosis and result in delayed treatment, which can beget permanent vision loss. This review focuses on recent advances in areas of pathophysiology, classification, diagnosis and treatment. RECENT FINDINGS Sympathetic ophthalmia is thought to involve a cell-mediated immune response to retinal and uveal antigens exposed through trauma or surgery. Multiple mechanisms have been implicated, including activation of the interleukin-23/IL-17 pathway. Ongoing emphasis is placed on early disease recognition and prompt treatment with multimodal imaging. Multiple authors advocate for the routine use of optical coherence tomography (OCT) for screening and disease monitoring. Systemic steroids and steroids sparing-immunosuppressive agents remain the mainstay of treatment. SUMMARY Understanding pathophysiology may provide useful targets for drug development, as well as allow for identification of patients at risk. OCT is a useful tool in early diagnosis and management of sympathetic ophthalmia, as OCT changes may precede clinical symptoms and signs, allowing for early disease detection and better visual outcomes.
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Affiliation(s)
- Ollya V Fromal
- Mid Atlantic Retina, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Paulbuddhe V, Addya S, Gurnani B, Singh D, Tripathy K, Chawla R. Sympathetic Ophthalmia: Where Do We Currently Stand on Treatment Strategies? Clin Ophthalmol 2021; 15:4201-4218. [PMID: 34707340 PMCID: PMC8542579 DOI: 10.2147/opth.s289688] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/30/2021] [Indexed: 01/05/2023] Open
Abstract
Sympathetic ophthalmia is a rare bilateral diffuse granulomatous panuveitis that usually results from surgical or penetrating trauma to one eye. The symptoms range from impaired near vision to pain, photophobia, and loss of visual acuity. Anterior segment manifestations include bilateral acute uveitis with mutton-fat keratic precipitates and posterior segment findings include vitritis, multifocal neurosensory retinal detachment, choroiditis, optic nerve edema, and Dalen-Fuchs nodules. The diagnosis is clinical. Ancillary investigations include fundus fluorescein angiography, indocyanine green angiography, optical coherence tomography (OCT), ultrasound B scan, and autofluorescence imaging. The management options include corticosteroids (topical and systemic) as the first line along with immunomodulatory therapy started at the presentation of the disease. Recent advances include imaging with OCT-angiography, enhanced depth imaging-OCT (EDI-OCT, choroidal vascular index/CVI), targeting IL-23/IL-17 pathway, and use of biologics for the management of this rare entity. Recent advances in early diagnosis and prompt treatment has led to improved final visual outcomes in both the sympathizing and exciting eye. This review is aimed at giving a comprehensive overview of sympathetic ophthalmia along with a special emphasis on current treatment strategies and recent advances.
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Affiliation(s)
- Vivek Paulbuddhe
- Department of Vitreoretina, ASG Eye Hospital, Guwahati, 781006, Assam, India
| | - Sujit Addya
- Department of Vitreoretina, ASG Eye Hospital, Guwahati, 781006, Assam, India
| | - Bharat Gurnani
- Department of Cornea, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, 605007, Puducherry, India
| | - Dheerendra Singh
- Department of Retina, ASG Eye Hospital, Bhopal, 462016, Madhya Pradesh, India
| | - Koushik Tripathy
- Department of Vitreoretina, ASG Eye Hospital, Kolkata, 700058, West Bengal, India
| | - Rohan Chawla
- Department of Ophthalmology, All India Institute of Medical Sciences, New Delhi, 110029, India
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Abstract
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.
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Shen J, Zhang Z, Ye D, Wen Z, Shu X, Chen Z. Sympathetic ophthalmia after vitreoretinal surgery: a report of two cases. J Int Med Res 2021; 49:3000605211032782. [PMID: 34382463 PMCID: PMC8366150 DOI: 10.1177/03000605211032782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Sympathetic ophthalmia (SO) is a panuveitis that usually occurs after trauma to one eye. We describe two cases of SO occurring after 23-gauge vitrectomy. Case 1 involved a 66-year-old woman who underwent pars plana vitrectomy (PPV) for a rhegmatogenous retinal detachment. Two months later, she presented with decreased visual acuity (VA) and bilateral uveitis. Case 2 involved a 43-year-old woman who underwent a second PPV for recurrent retinal detachment. Two months later, she presented with bilateral panuveitis. Both patients were diagnosed with SO and were treated with methylprednisolone and cyclosporine. The first patient was further treated with a dexamethasone intravitreal implant (Ozurdex®) owing to the side effects of methylprednisolone. The VA and symptoms improved significantly after treatment in both patients. Bilateral granulomatous panuveitis following PPV should alert surgeons to consider SO. Appropriate interventions for SO can produce positive outcomes.
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Affiliation(s)
- Junhui Shen
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Ophthalmology of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Zheng Zhang
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Ophthalmology of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Dian Ye
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Ophthalmology of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Zuohui Wen
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Ophthalmology of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Xupeng Shu
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Ophthalmology of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Zhiqing Chen
- Eye Center, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.,Key Laboratory of Ophthalmology of Zhejiang Province, Hangzhou, Zhejiang, China
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Orbital Blowout Fracture With Globe Displacement Into the Maxillary Sinus: A Case Report and Literature Review. J Oral Maxillofac Surg 2020; 79:204.e1-204.e12. [PMID: 33080207 DOI: 10.1016/j.joms.2020.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 11/23/2022]
Abstract
Blunt trauma in the orbital region often results in fracture of 1 or more bone walls resulting in alteration of the orbital volume with the potential for visual sequelae. This study reports a rare case of displacement of the eyeball into the maxillary sinus after blunt trauma as well as its initial management, treatment, and clinical follow-up. Victims of eyeball displacement have a poor visual prognosis. Even if the patient has already been diagnosed with amaurosis on arrival to the hospital, all measures for rapid eye repositioning and reconstruction of the orbital cavity must be instituted, as well as appropriate clinical and pharmacologic management to avoid further complications.
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Rua D, Pohlmann D, Pleyer U. Sympathetic Ophthalmia - a Contribution to Immunology, Clinic and Current Imaging. Klin Monbl Augenheilkd 2020; 237:1060-1069. [PMID: 32967030 DOI: 10.1055/a-1245-4373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- David Rua
- Universitäts-Augenklinik, Charité Campus Virchow-Klinik, Berlin
| | | | - Uwe Pleyer
- Universitäts-Augenklinik, Charité Campus Virchow-Klinik, Berlin
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Dutta Majumder P. Commentary: Optical coherence tomography in sympathetic ophthalmia. Indian J Ophthalmol 2020; 68:2023-2024. [PMID: 32823466 PMCID: PMC7690494 DOI: 10.4103/ijo.ijo_886_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Krásný J, Eckchlager T, Smetana K, Šach J, Šubrtová H. The long-term monitoring of sympathetic ophthalmia in the diagnostic and terapeutic view. Review Department of Ophthalmology. ACTA ACUST UNITED AC 2019; 75:235-248. [PMID: 32397725 DOI: 10.31348/2019/5/1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM To evaluate options of diagnostic and therapeutic procedures of sympathetic ophthalmia (SO) compared with literature data. Backgroud: SO is an ocular autoimmune disease. It is characterized by disbalance in the imunoregulatory T-subsets within cell mediated immune response. METHODS File examination of SO by evaluation humoral and cellular immunity was ranked nukleolar test (NT). It evaulates the current status of lymphocyte activation based on the nucleolar morphology and RNA transcription aktivity. The classical histological examination was supported by immunohistochemical analysis of lymphocytic subpopulations in the eyeball enucleated for. SO in one case. MATERIAL Five boys and men overall were monitored and treated in two studies from 1979 to 1994 and from 1999 to 2017 with SO In four cases it was subsequent after penetrating injuries and once after lensectomy with vitrectomy. The age of patients in the time of onset of SO was between 4 and 24 years (average 12 years). The time interval between insult and onset of SO varied between 10 days and 3 months (average 1.7 months). The relaps of disease appeared in the all cases in the time interval from 3 months to 38 years (average 15 years). Another two patients with SO were examined only in consultation: 16 years old boy with relaps of SO after cataract extraction and 71 years old women with SO subsequent after lensectomy and vitrectomy. There was examined and compared group of 19 patients with other types of uveitis in the same time. The lens-associated uveitis were caused after ocular contusion and penetrating eye injury in 16 patients (13 male patients). In another three cases (young women) with uveitid underlined by II. or III. type of hypersenzitivity the enucleation of dolorous eyeball calmed down the secondary uveitis on their second eye without any change of immunosupressive treatment and without change in NT. RESULTS There were changes in the complex immunological laboratory tests results in the SO cases in the counts of activated lymphocytes in the peripheral blood. The count of activated lymphocytes was increased in SO cases unlike in lens-associated uveitis. There was detected in NT statistically significant difference (p = 0,0134) between the two groups of uveitis. The histological examination (5 eyes with SO and 7 eyes without sympathetic uveitis) confirmed the diagnoses, supporting basically the clinical diagnosis. The immunohistochemical examination corfirmed the presence of populations of T-lymphocytes, macrophages and also B-lymphocytes. A basis of immunosuppressive therapy was the combination of prednisone and azathioprin at the first time. Effective therapy featured cyklosporine later. CONCLUSION The nucleolar test of lymphocytes draws attention of their up-to-day increased activity without the diferentiation of subpopulations and their absolute number increase related to the current activation of type IV. hypersensitivity (cell-mediated) in uveitis mechanism. The immunosupressive therapy calmes down this activation predominantly in SO, but also in other case sof uveitis with different types of hypersensivity. The immunohistochemical examination illustrates different presence of lymphocytic types according to the stage of SO.
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