Sympathetic ophthalmia after penetrating keratoplasty: a case report evaluated by spectral-domain optical coherence tomography

Sympathetic Ophthalmia: Where Do We Currently Stand on Treatment Strategies?

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.

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.

Choroidal Structural Changes in Sympathetic Ophthalmia on Swept-Source Optical Coherence Tomography

Purpose: To analyze choroidal angioarchitecture in sympathetic ophthalmia (SO) using swept-source optical coherence tomography (SS-OCT) images.Methods: Case-control study of six patients with SO. Qualitative changes and quantitative parameters, including choroidal thickness (CT) and choroidal vascularity index (CVI), were analyzed.Results: Qualitative findings in the acute phase of SO on SS-OCT included retinal serous detachment with hyperreflective septa, choroidal folds, alterations in angioarchitecture with loss of vascular lacunae, and Dalen-Fuchs nodules. There was significantly higher CT in SO (284.05 ± 24.12 µm) compared to healthy controls (229.57 ± 46.67 µm, p = 0.04) and also increased CVI in SO (62.06 ± 2.07% vs 56.79 ± 3.15%, p = 0.006).Conclusions: CVI was significantly increased in SO, representing a novel noninvasive biomarker of disease activity. SS-OCT provides a useful qualitative and quantitative parameter, which can be potentially explored in the diagnosis and monitoring of patients with SO.

Sympathetic Ophthalmia: Experience from a Tertiary Care Center in Northern India

Purpose:

To describe our clinical experience with sympathetic ophthalmia (SO) at a tertiary eye care center in north India.

Methods:

In this retrospective case series, analysis of the clinical features and visual outcomes of patients diagnosed with SO between March 2012 and March 2016 were performed.

Results:

Ten male and four female patients (median age, 15.5 years) with SO following penetrating trauma (10 patients) or ocular surgery (four patients) were included. SO developed 2 weeks to 3 years after the insult. Mean presenting visual acuity of the sympathizing eyes was 1.086 (LogMAR). Anterior chamber reaction was documented in all eyes in which it could be assessed (14 sympathizing eyes; five exciting eyes). Neurosensory detachment was seen in 10 of 14 patients (71.5%). Five patients (35.7%) were managed with oral steroids alone, whereas nine (64.3%) were treated with intravenous pulse dexamethasone followed by oral steroids. Inflammation recurred in three patients during steroid tapering, necessitating restarting of steroid therapy with or without additional immunosuppressants. At the last follow-up, all 14 patients were in remission with low-dose oral steroids; seven patients were also on immunosuppressants. At the final follow-up, 12 of 14 (85.7%) sympathizing eyes achieved 20/40 or better visual acuity and three exciting eyes achieved at least 6/24 visual acuity.

Conclusion:

Although SO is a potentially blinding disorder, early detection and individualized treatment allow most patients achieve good final visual acuity.

A rare case of atypical sympathetic ophthalmia post therapeutic keratoplasty

Introduction

Sympathetic ophthalmia (SO) is a rare, bilateral, diffuse granulomatous uveitis that usually occurs after open globe injury or intraocular surgery.

Methods

A patient developed SO following therapeutic penetrating keratoplasty (TPK) with cataract extraction in the exciting eye following fungal keratitis. The sympathizing eye presented with only posterior segment findings (exudative retinal detachment) and responded well with oral corticosteroids.

Results

Graft remained clear in the left eye and the right eye; the best-corrected visual acuity (BCVA) improved to 0.2 log MAR.

Conclusion

SO presenting after TPK for fungal keratitis is a rare occurrence but if detected early can be managed effectively.