Visual prognosis and sympathetic ophthalmia

Sympathetic ophthalmia: A comprehensive update

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.

Leopard retinopathy: An unusual presentation of sympathetic ophthalmia

We report an unusual case of sympathetic ophthalmia (SO) in an elderly gentleman following multiple eye surgeries. He presented with diffuse granulomatous panuveitis resembling leopard retinopathy in the left eye. There was a delay in the initiation of effective treatment of his intraocular inflammation, but he responded to corticosteroid and azathioprine. The pigmentary changes in his fundus were highly unusual, and he was investigated extensively to rule out other possible causes including a search for occult malignancy. The delay in initiation of effective treatment or suboptimal therapy in SO, can lead to variable clinical picture in elderly patients. A proper screening to exclude any malignancy along with aggressive immunosuppressive therapy can achieve optimum results.

The Risk of Sympathetic Ophthalmia Following Vitreoretinal Surgery

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.

[Sympathetic ophthalmia : Therapy with steroid-free immunosuppressant azathioprine]

This article describes the case of a 48-year-old male patient who presented with persistent inflammation and deterioration of vision to a best corrected visual acuity (BCVA) of 0.6 in the only functioning left eye. The right eye had suffered a severe penetrating ocular trauma 6 months prior to presentation. After diagnosis of a sympathetic ophthalmia a high dosage corticosteroid therapy was initiated. Due to intolerance with decompensating diabetes an immunosuppressive therapy with azathioprine was initiated. This therapy resulted in stable clinical findings with an increase in BCVA to 0.9.

Photoreceptor oxidative damage in sympathetic ophthalmia

PURPOSE

To determine photoreceptor oxidative stress and damage in sympathetic ophthalmia (SO).

DESIGN

Immunohistologic study.

METHODS

Eight formalin-fixed and paraffin-embedded human globes with typical histologic features of SO and five age-matched globes without intraocular inflammation (controls) were retrieved from the Doheny Eye Institute ophthalmic pathology files. Deparaffinized sections of the globes were processed to localize tumor necrosis factor-alpha (TNF-alpha), tumor necrosis factor receptor-1 (TNF-R1), acrolein, inducible nitric oxide synthase (iNOS), and nitrotyrosine by immunolocalization method. The latter two were localized to photoreceptor mitochondria using anti-cytochrome C antibody. Apoptotic cells were detected by Terminal deoxynucleotidyl transferase biotin-dUTP Nick End Labeling (TUNEL) assay and were localized to the site of oxidative stress using antinitrotyrosine antibody.

RESULTS

Increased expression of TNF-alpha can be seen in the photoreceptor nuclear layer in all SO globes, whereas no such expression was observed in control globes. TNF-R1, iNOS, acrolein, and nitrotyrosine were immunolocalized to the inner segments of the photoreceptors in all SO globes, but only mild focal staining was observed in the control retinas. Both nitrotyrosine and iNOS immunolocalization revealed positive staining restricted primarily to mitochondria at the inner segments of the photoreceptors. Most of the TUNEL-positive cells were detected in the photoreceptors at the site of nitrotyrosine staining. In contrast, the age-matched control globes showed negative results.

CONCLUSIONS

In SO, photoreceptor mitochondrial oxidative stress occurs in the absence of leukocytic infiltration of the retina and may lead to photoreceptor apoptosis and subsequent vision loss. The oxidative stress seems to be mediated by iNOS and TNF-alpha. The current anti-inflammatory therapy combined with agents that could prevent oxidative stress may prevent photoreceptor damage in SO and may preserve vision.

Sympathetic ophthalmia after surgical resection of iridociliary melanoma. A case report

BACKGROUND

We report a case of sympathetic ophthalmia with systemic findings following resection of a malignant melanoma of the iris and ciliary body, and describe the treatment and clinical outcome.

METHODS

A 49-year-old man underwent sector iridocyclectomy of a malignant iridociliary melanoma of the right eye. Five weeks later, he was diagnosed with sympathetic ophthalmia. Snellen's best-corrected visual acuity, fluorescein angiography, electroretinography, cerebrospinal fluid analysis and audiometry were performed. High-dose systemic steroid and immunosuppressive (cyclosporine and azathioprine) therapy was prescribed. Two months later chorioretinitis and macular edema persisted, and intravitreous triamcinolone was injected into the right eye.

RESULTS

Five weeks after resection of an iridociliary melanoma, our patient had reported acute bilateral vision loss. Visual acuity was hand motion in both eyes. Examination showed bilateral granulomatous uveitis, diffuse choroiditis with Dalen-Fuchs nodules, papillitis and vitritis. On fluorescein angiography multiple hyperfluorescent dots, which coalesced in areas of exudative retinal detachment, were evident. The patient presented meningismus with pleocytosis on cerebrospinal fluid analysis, and sensorineural deafness. Sympathetic ophthalmia was diagnosed. High-dose intravenous steroids followed by oral prednisone at a tapering dose and immunosuppressive agents (cyclosporine and azathioprine), topical steroids in both eyes and intravitreal steroids in the right eye were administered. Phacoemulsification and intraocular lens implantation were performed to treat a dense cataract of the right eye. After 24 months of follow-up, best-corrected visual acuity was 20/200 in the right eye and 20/25 in the left; no signs of intraocular inflammation were observed and neurological signs had resolved. Low maintenance doses of systemic steroids and immunosuppressive agents were administered up to month 18 of follow-up to avoid recurrence.

CONCLUSIONS

Sympathetic ophthalmia is a rare, but severe disease that can occur after resection of iridociliary melanoma. High-dose steroid therapy and supplementation with immunosuppressive agents early in the course of the disease was effective in resolving the condition.

Sympathetic ophthalmia following evisceration: a rare case

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

Clinical Case Notes. Changing trends in sympathetic ophthalmia

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

Peripapillary choroidal atrophy in sympathetic ophthalmia and management with triple-agent immunosuppression

PURPOSE

To describe the occurrence of peripapillary choroidal atrophy and experience with triple-agent immunosuppression in three cases of sympathetic ophthalmia.

MATERIALS AND METHODS

Retrospective chart review of three cases of sympathetic ophthalmia with peripapillary choroidal atrophy.

RESULTS

Three patients with sympathetic ophthalmia were managed with steroid pulse therapy and triple-agent immunosuppression. All three patients subsequently developed peripapillary choroidal atrophy.

CONCLUSIONS

Peripapillary choroidal atrophy can occur in sympathetic ophthalmia and may indicate a severe form of inflammation which would benefit from triple-agent immunosuppression.