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Weinlander E, Erb B, Thiessen C. An Eye for an Eye?: Problematic Risk-Benefit Trade-Offs in Whole Eye Transplantation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:75-79. [PMID: 38635428 DOI: 10.1080/15265161.2024.2328285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
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Hall N, Douglas VP, Ivanov A, Ross C, Elze T, Kempen JH, Miller JW, Sobrin L, Lorch A. The Epidemiology and Risk Factors for the Progression of Sympathetic Ophthalmia in the United States: An IRIS Registry Analysis. Am J Ophthalmol 2024; 258:208-216. [PMID: 37726044 DOI: 10.1016/j.ajo.2023.09.011] [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: 05/19/2022] [Revised: 09/11/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE To investigate the demographic and clinical characteristics of patients with sympathetic ophthalmia (SO) and define the risk factors for its incidence following trauma and ophthalmic procedures. DESIGN Retrospective cohort study. PARTICIPANTS Patients in the American Academy of Ophthalmology's (Academy) IRIS Registry (Intelligent Research in Sight) who were (n=1523) or were not diagnosed with SO following a documented procedure or trauma between January 1, 2013, and December 31, 2019. METHODS Multiple demographic and clinical factors were collected, descriptive statistics and prevalence were calculated, and multivariate linear regression models were fit to the data. MAIN OUTCOME MEASURES Prevalence of SO, demographic and clinical characteristics, and beta coefficient (β) estimates of demographic and clinical characteristics impacting time to SO onset after procedure (Procedure Only cohort) or trauma (Trauma cohort). RESULTS Of 65,348,409 distinct IRIS Registry patients, 1523 (0.0023%) were diagnosed with SO between 2013 and 2019, and also had a documented preceding trauma or procedure. Of these, 927 (60.87%) were female, 1336 (87.72%) belonged to the Procedure Only cohort, and 187 (12.28%) belonged to the Trauma cohort. The prevalence of SO after trauma was 0.0207%, whereas after procedures it was 0.0124%. The highest risk of procedure-related SO was seen in patients with history of "other anterior segment" (0.122%) followed by glaucoma (0.066%) procedures, whereas the lowest prevalence was noted with cataract surgeries (0.011%). The average time to onset of SO across both cohorts combined was 527.44 (±715.60) days, with statistically significant differences between the 2 cohorts (P < .001). On average, the time to onset from inciting event to SO was shorter with increasing age, by 9.02 (95% CI: -11.96, -6.08) days for every 1-year increase. CONCLUSIONS SO following trauma and ophthalmic procedure is potentially rarer than previously reported, as measured in this large ophthalmic medical record database. Female sex may be a risk factor for SO. Older age may be a risk factor for quicker onset. These findings can guide clinical decision-making and management.
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Affiliation(s)
- Nathan Hall
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian Paraskevi Douglas
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander Ivanov
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Connor Ross
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Tobias Elze
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Kempen
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Joan W Miller
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucia Sobrin
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Alice Lorch
- From the Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA.
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Ullrich K, Patel BCK, Malhotra R. Material risk: vitreoretinal surgery, evisceration, enucleation and sympathetic ophthalmia-where are we currently? Eye (Lond) 2023; 37:3542-3550. [PMID: 37198435 PMCID: PMC10686393 DOI: 10.1038/s41433-023-02562-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 04/04/2023] [Accepted: 04/24/2023] [Indexed: 05/19/2023] Open
Abstract
Sympathetic ophthalmia (SO) is known to occur after severe penetrating eye injury, evisceration and even enucleation surgery. Recent evidence suggests that a greater risk lies after multiple vitreoretinal procedures. The risk of SO following evisceration is only minimally greater than that following enucleation surgery. This review evaluates literature on SO to date and provides figures for the risk of developing SO for the purposes of the consent process. The issue of SO and Material Risk following vitreoretinal surgery is reviewed and figures for the purposes of consent are outlined. This is of particular relevance for patients in whom the contralateral eye is and will likely remain the better seeing eye. Sympathetic ophthalmitis is known to occur after severe penetrating eye injury, after evisceration and enucleation. More recently, sympathetic ophthalmitis has been recognised to occur after vitreoretinal surgery. This article reviews the evidence on material risk when consenting patients for elective and emergency eye procedures after ocular trauma or surgery. When a globe needs to be removed because of irreparable ocular injury, previous publications dictated the procedure to be an enucleation because of the fear of an increased risk of SO after an evisceration. Perhaps the issue of material risk of sympathetic ophthalmia (SO) remains over-emphasised by ophthalmic plastic surgeons and under-recognised by vitreoretinal surgeons during the consent process for evisceration, enucleation and vitreoretinal surgery. Antecedent trauma and number of previous surgeries may actually be a more significant risk factor than the type of eye removal. Recent medicolegal cases also help us understand the importance of the discussion of this risk. We present our current understanding of the risk of SO after different procedures and suggest how this information may be included in a patient consent.
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Affiliation(s)
- K Ullrich
- Corneoplastic Unit, Queen Victoria Hospital NHS Trust, East Grinstead, West Sussex, RH19 3DZ, UK.
- Department of Ophthalmology, Queen Elizabeth Hospital, 28 Woodville Road, Woodville, SA, Australia.
| | - B C K Patel
- Department of Ophthalmology, Division of Ophthalmic Plastic and Reconstructive Surgery, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - R Malhotra
- Corneoplastic Unit, Queen Victoria Hospital NHS Trust, East Grinstead, West Sussex, RH19 3DZ, UK
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Zhao T, Cao Q, Zhou C, Wang Y, Du L, Yang P. Association Between HLA Polymorphisms and Sympathetic Ophthalmia in Han Chinese. Ocul Immunol Inflamm 2023:1-8. [PMID: 37145421 DOI: 10.1080/09273948.2023.2205930] [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: 05/06/2023]
Abstract
PURPOSE Sympathetic ophthalmia (SO) is considered as an autoimmune disease with unclear mechanisms. This study investigated the relationship between HLA polymorphisms and SO. METHODS HLA typing was performed using the LABType reverse SSO DNA typing method. The allele and haplotype frequencies were assessed using the PyPop software. Statistical significance of genotype distributions between 116 patients and 84 healthy individuals (control) was determined using Fisher's exact test or Pearson's chi-squared test. RESULTS The SO group had a higher frequency of HLA-DRB1 * 04:05, HLA-DQB1 * 04:01, DRB1 * 04:05-DQB1 * 04:01 haplotype as compared to the control group (Pc < 0.001 for all). CONCLUSION This study revealed that DRB1 * 04:05 and DQB1 * 04:01 alleles, as well as DRB1 * 04:05-DQB1 * 04:01 haplotye could be potential risk factors for SO.
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Affiliation(s)
- Tingting Zhao
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, Chongqing Branch (Municipality Division) of National Clinical Research Center for Ocular Diseases, Chongqing, People's Republic of China
| | - Qingfeng Cao
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, Chongqing Branch (Municipality Division) of National Clinical Research Center for Ocular Diseases, Chongqing, People's Republic of China
| | - Chunjiang Zhou
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, Chongqing Branch (Municipality Division) of National Clinical Research Center for Ocular Diseases, Chongqing, People's Republic of China
| | - Yao Wang
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, Chongqing Branch (Municipality Division) of National Clinical Research Center for Ocular Diseases, Chongqing, People's Republic of China
| | - Liping Du
- Department of Ophthalmology, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, Zhengzhou, People's Republic of China
| | - Peizeng Yang
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ophthalmology, Chongqing Eye Institute, Chongqing Branch (Municipality Division) of National Clinical Research Center for Ocular Diseases, Chongqing, People's Republic of China
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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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Özdemir Yalçınsoy K, Özdamar Erol Y, Çakar Özdal P. Sympathetic Ophthalmia: Demographic Characteristics, Clinical Findings, and Treatment Results. Turk J Ophthalmol 2023; 53:23-29. [PMID: 36847630 PMCID: PMC9973214 DOI: 10.4274/tjo.galenos.2022.53383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Objectives To evaluate the demographic characteristics, clinical findings, and treatment approach of patients with sympathetic ophthalmia (SO). Materials and Methods The records of 14 patients with SO between 2000 and 2020 were retrospectively reviewed. The patients' Snellen best corrected visual acuity (BCVA), detailed ophthalmological examination, optical coherence tomography (OCT), enhanced depth imaging-OCT (EDI-OCT), fundus fluorescein angiography findings, and treatment approaches were recorded. Results The study included the 14 sympathizing eyes of 14 patients with SO (7 female, 7 male). The mean age was 48.5±15.4 years (range: 28-75), and the mean follow-up duration was 55.1±48.7 months (range: 6-204). Ten patients (71%) had a history of ocular trauma and 4 (29%) had a history of ocular surgery. The time to symptom onset in the sympathizing eye after trauma or ocular surgery ranged from 15 days to 60 years. The most common posterior segment findings were optic disc edema (36%) and exudative retinal detachment (36%). In the acute period, the mean choroidal thickness value on EDI-OCT was 716.5±63.6 μm (range: 635-772) and decreased to 296±81.6 μm (range: 240-415) after treatment. Treatment with high-dose systemic corticosteroid was given to 8 patients (57%), azathioprine (AZA) to 7 (50%), AZA and cyclosporine-A combination to 7 (50%), and tumor necrosis factor-alpha inhibitors to 3 patients (21%). Recurrence was observed in 4 patients (29%) during follow-up. At last follow-up, BCVA values were better than 20/50 in 11 (79%) of the sympathizing eyes. Remission was achieved in 13 patients (93%), but 1 patient (7%) lost her vision due to acute retinal necrosis. Conclusion SO is a bilateral inflammatory disease that presents with granulomatous panuveitis after ocular trauma or surgery. Favorable functional and anatomical results can be obtained with early diagnosis and initiation of appropriate treatment.
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Affiliation(s)
- Kübra Özdemir Yalçınsoy
- University of Health Sciences Türkiye Ulucanlar Eye Training and Research Hospital, Ankara, Türkiye
| | - Yasemin Özdamar Erol
- University of Health Sciences Türkiye Ulucanlar Eye Training and Research Hospital, Ankara, Türkiye
| | - Pınar Çakar Özdal
- University of Health Sciences Türkiye Ulucanlar Eye Training and Research Hospital, Ankara, Türkiye
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Chen SC, Sheu SJ, Wu TT. Changing etiology of sympathetic ophthalmia: A 10-year study from a tertiary referral center in Taiwan. Taiwan J Ophthalmol 2023. [DOI: 10.4103/tjo.tjo-d-22-00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Toiv A, Durrani AF, Zhou Y, Zhao PY, Musch DC, Huvard MJ, Zacks DN. Risk Factors for Enucleation Following Open Globe Injury: A 17-Year Experience. Clin Ophthalmol 2022; 16:3339-3350. [PMID: 36237492 PMCID: PMC9553313 DOI: 10.2147/opth.s377137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/22/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose At the time of open globe injury (OGI), it may be difficult for clinicians to predict which eyes are at highest risk for requiring enucleation. We performed a 17-year retrospective cohort study to report outcomes and risk factors for enucleation following open globe injuryto better aid clinicians counseling patients at OGI diagnosis. Methods A retrospective cohort study of all patients who presented to the University of Michigan with open globe injury (OGI) and were surgically managed between January 2000 and July 2017 was conducted. At least 30 days of follow-up was required. All eyes that ultimately underwent enucleation following OGI were identified and their clinical course analyzed. The main outcome measured was the rate of enucleation after OGI. Results There were 587 eyes meeting inclusion criteria. The mean patient age was 40.75 ± 25.1 (range 1–91). 441/585 (75.4%) patients were male. Average follow-up time was 1029.9 ± 1285.9 days. 116/587 eyes (19.8%) required enucleation after OGI, with 81.9% undergoing enucleation less than 30 days from injury. In enucleated eyes, the mean presenting logMAR vision was 2.91 ± 0.47 (Snellen equivalent between hand motion and light perception). The most common mechanism of injury requiring enucleation was globe rupture, 89/116 (76.7%), with 14/116 (12.1%) penetrating injuries and 13/116 (11.2%) perforating injuries. The mean age of patients that underwent enucleation was 45.6 ± 22.5 (range 3–91). Conclusion Open globe injuries are often visually devastating and a significant number of cases ultimately require enucleation. Despite emergent closure within 24 hours, 19.8% of eyes managed for OGI at our institution required eventual enucleation. 81.2% of these eyes required enucleation within 30 days of injury. Wound length greater than 10 mm, uveal prolapse, higher zone of injury, IOFB, and RAPD were identified as risk factors that predict future need for enucleation.
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Affiliation(s)
- Avi Toiv
- Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Asad F Durrani
- Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Yunshu Zhou
- Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Peter Y Zhao
- Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David C Musch
- Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael J Huvard
- Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David N Zacks
- Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA,Correspondence: David N Zacks, Department of Ophthalmology and Visual Sciences, W K Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI, 48105, USA, Tel +1 734-232-8404, Fax +1 734-232-8030, Email
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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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12
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Jones NP, Pockar S, Steeples LR. Changing Trends in Uveitis in the United Kingdom: 5000 Consecutive Referrals to a Tertiary Referral Centre. Ocul Immunol Inflamm 2022:1-6. [PMID: 35442852 DOI: 10.1080/09273948.2022.2067067] [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
PURPOSE To demonstrate changes in the demography and diagnosis of uveitis in a specialist clinic in the United Kingdom. METHODS Retrieval of data including all new referrals to Manchester Uveitis Clinic from 1991 to 2020. The incidence and proportions of diagnoses between 4 quartiles was compared. RESULTS 5000 patients with uveitis were seen. Referral rates trebled over time. Highly significant increases in referrals were seen for multiple evanescent white dot syndrome-spectrum disorders, syphilis and tuberculosis; increases were also seen for herpetic retinitis, vitreoretinal lymphoma and sarcoidosis. Highly significant decreases were seen for Fuchs' uveitis, Behçet's uveitis and ocular toxoplasmosis. CONCLUSIONS Subspecialisation and de-skilling has changed referral patterns to specialist clinics; changes cannot be entirely attributed to disease incidences, which also vary between countries. International data are non-comparable. There are clear changes in referral patterns and disease incidence in this population, influenced by evolving diagnosis. Local data should steer care planning.
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Affiliation(s)
- N P Jones
- School of Biological Sciences, The University of Manchester, UK
| | - S Pockar
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - L R Steeples
- Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
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13
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Enucleation in pediatric open globe injuries: demographics and risk factors. Graefes Arch Clin Exp Ophthalmol 2022; 260:3115-3122. [PMID: 35294638 DOI: 10.1007/s00417-022-05618-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/04/2022] [Accepted: 03/01/2022] [Indexed: 11/04/2022] Open
Abstract
PURPOSE The purpose of this study is to report the demographics and risk factors for undergoing primary enucleation in the setting of acute open globe injury (OGI) in the pediatric population in the USA. METHODS This retrospective, cross-sectional study of pediatric patients with OGIs in the USA between 2002 and 2014 was conducted utilizing data from the National Inpatient Sample Database. Descriptive statistics, chi-square testing, and univariate and multivariable analyses were performed. RESULTS In the USA, 8944 cases of pediatric OGI were identified between 2002 and 2014 in the NIS Database, of which 344 underwent primary enucleation. Blacks and Asian/Pacific Islanders made up higher proportions of enucleated cases compared to non-enucleated cases. Older age, male sex, being Black or Asian/Pacific Islander, OGI with an intraocular foreign body, rupture type OGI, and concurrent endophthalmitis were identified as risk factors for undergoing enucleation. There was no significant difference in insurance status among enucleated versus non-enucleated cases. Mean length of hospital stay (in days) was almost 3 times higher in enucleated OGIs. By hospital's geographic location, the Midwest hospitals had a greater proportion of enucleated versus non-enucleated cases compared to other regions. CONCLUSION Significant demographic differences were identified in OGI patients that underwent primary enucleation versus repair with regard to age, sex, race, the geographic location of hospital admission, mean length of hospital stay, type of ocular injury, and other ocular complications. Most pediatric traumatic enucleations between 2002 and 2014 were reported in teenagers (16-20 age group), in males, and in Blacks.
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He B, Tanya SM, Wang C, Kezouh A, Torun N, Ing E. The Incidence of Sympathetic Ophthalmia After Trauma: A Meta-analysis. Am J Ophthalmol 2022; 234:117-125. [PMID: 34283983 DOI: 10.1016/j.ajo.2021.06.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/10/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Sympathetic ophthalmia (SO) is a rare, bilateral panuveitis that occurs following open globe injury (OGI), with a variable incidence reported in the literature. Our objective was to determine the incidence proportion and incidence rate of SO following OGI to help guide shared physician-patient decision making. DESIGN Systematic review and meta-analysis. METHODS A systematic literature search was performed using the MEDLINE, EMBASE, and Cochrane databases from inception to November 2020 for population-based studies on OGI and SO in adults and children. Two reviewers independently screened search results. Random-effects meta-analyses were performed to calculate the incidence proportion and incidence rate. The Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tool was used to assess the risk of bias. The study was registered on PROSPERO CRD42020198920. RESULTS A total of 24 studies were utilized in the meta-analyses. After OGI, the estimated overall incidence proportion of SO was 0.19% (95% CI 0.14%-0.24%) and the incidence rate of SO was 33 per 100,000 person-years, (95% CI 19.61-56.64) with I2 of 13% and 72%, respectively. CONCLUSIONS SO after OGI is rare. The estimated incidence proportion and incidence rate are useful when counselling patients regarding management options after OGI. Further studies are needed to examine the influence of age, the extent and location of trauma, timing of repair, and prophylactic eye removal on the incidence of SO.
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Affiliation(s)
- Bonnie He
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (B.H.)
| | - Stuti M Tanya
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada (S.M.T.)
| | - Chao Wang
- Faculty of Health, Social Care and Education, Kingston University London, London, England (C.W.)
| | - Abbas Kezouh
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada (A.K.)
| | - Nurhan Torun
- Department of Ophthalmology, Harvard University, Cambridge, Massachusetts, United States of America (N.T.)
| | - Edsel Ing
- Department of Ophthalmology and Visual Sciences, University of Toronto, Toronto, Ontario, Canada (E.I.).
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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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Zhao X, Zhao Q, Meng L, Zhang W, Chen Y. Clinical and imaging features of sympathetic ophthalmia and efficacy of the current therapy. Acta Ophthalmol 2022; 100:e1403-e1411. [PMID: 35088530 DOI: 10.1111/aos.15095] [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] [Received: 04/02/2021] [Revised: 10/04/2021] [Accepted: 12/29/2021] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Xinyu Zhao
- Department of Ophthalmology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Beijing China
- Key Laboratory of Ocular Fundus Diseases Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Qing Zhao
- Department of Ophthalmology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Beijing China
- Key Laboratory of Ocular Fundus Diseases Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Lihui Meng
- Department of Ophthalmology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Beijing China
- Key Laboratory of Ocular Fundus Diseases Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Wenfei Zhang
- Department of Ophthalmology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Beijing China
- Key Laboratory of Ocular Fundus Diseases Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Youxin Chen
- Department of Ophthalmology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Beijing China
- Key Laboratory of Ocular Fundus Diseases Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
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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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Hashimoto Y, Matsui H, Michihata N, Ishimaru M, Yasunaga H, Aihara M, Kaburaki T. Incidence of Sympathetic Ophthalmia after Inciting Events: A National Database Study in Japan. Ophthalmology 2021; 129:344-352. [PMID: 34560127 DOI: 10.1016/j.ophtha.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/31/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To analyze the incidence of sympathetic ophthalmia (SO) after inciting events (eye trauma or intraocular surgery). DESIGN Retrospective cohort study. PARTICIPANTS Patients experiencing inciting events between 2012 and 2019. Onset of SO was defined as the first date of SO diagnosis. METHODS Using a nationwide administrative claims database in Japan, we calculated the cumulative incidence of SO after inciting events stratified by sex, 10-year age groups, and a categorical variable of primary or repeated, reflecting the history of inciting events in the past year (no inciting events, inciting events without trauma, or inciting events with trauma) using the Kaplan-Meier approach. We also estimated the adjusted hazard ratio (aHR) by Cox regression. We then restricted the population to those with only 1 inciting event during the observation period to investigate the pure effect of each inciting event. MAIN OUTCOME MEASURES Cumulative incidence of SO over 60 months. RESULTS A total of 888 041 inciting events (704 717 patients) were eligible. The total number of SO cases was 263, and the cumulative incidence of SO was 0.044% over 60 months. Female sex was not associated with onset of SO (aHR, 1.01; 95% confidence interval [CI], 0.79-1.29; P = 0.95). The group 40 to 49 years of age showed the highest incidence of 0.104% among the age groups (aHR vs. ≥80 years of age group [0.041%], 2.44 [95% CI, 1.56-3.80]; P < 0.001). Repeated inciting events with and without trauma showed higher incidences of SO (0.469% and 0.072%, respectively) than primary inciting events (0.036%) (aHR 11.68 [7.74-17.64] and 2.21 [95% CI, 1.59-3.07], respectively); P < 0.001 and P < 0.001, respectively). The incidence of SO after vitrectomy was much lower than after trauma (0.016% vs. 0.073%), and the incidence after scleral buckling was even lower. CONCLUSIONS The cumulative incidence of SO over 60 months was estimated to be 0.044% at minimum. Repeated inciting events, especially those with trauma, increased the risk of SO developing. Trauma was 4 to 5 times as likely to induce SO than vitrectomy. The present findings will be valuable for counseling patients about the risks of SO after trauma and before performing intraocular surgeries.
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Affiliation(s)
- Yohei Hashimoto
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Miho Ishimaru
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan; Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Makoto Aihara
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshikatsu Kaburaki
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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NOVEL OPTICAL COHERENCE TOMOGRAPHY FINDINGS OF A CASE OF SYMPATHETIC OPHTHALMIA AFTER 23-GAUGE VITRECTOMY. Retin Cases Brief Rep 2021; 15:543-547. [PMID: 30668552 DOI: 10.1097/icb.0000000000000847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Sympathetic ophthalmia (SO) is a rare panuveitis after trauma to one eye. We present a case of SO after 23-gauge transconjunctival vitrectomy, including optical coherence tomography evidence of response to treatment. To our knowledge, this is the first SO case report to include spectral domain optical coherence tomography images of Dalen-Fuchs nodules. METHODS Observational case report of a case of SO after two pars plana vitrectomies in the fellow eye. RESULTS A 67-year-old woman who had an operation for her pseudophakic left eye for a macula-off retinal detachment. She had two surgeries and later on had a total retinal detachment with vision of no perception of light. Eighteen months later, she presented back with a panuveitis with vitritis in her other eye and a visual acuity of 6/18. Dalen-Fuchs denoting SO was found. Treatment was commenced, and multimodal imaging was performed. CONCLUSION Sympathetic ophthalmia is a known complication after vitrectomy. Optical coherence tomography can be invaluable in monitoring diagnosis and progression of Dalen-Fuchs nodules.
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Classification Criteria for Sympathetic Ophthalmia. Am J Ophthalmol 2021; 228:212-219. [PMID: 33845005 PMCID: PMC8559334 DOI: 10.1016/j.ajo.2021.03.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to determine classification criteria for sympathetic ophthalmia. DESIGN Machine learning of cases with sympathetic ophthalmia and 5 other panuveitides. METHODS Cases of panuveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the panuveitides. The resulting criteria were evaluated in the validation set. RESULTS A total of 1,012 cases of panuveitides, including 110 cases of sympathetic ophthalmia, were evaluated by machine learning. The overall accuracy for panuveitides was 96.3% in the training set and 94.0% in the validation set (95% confidence interval: 89.0-96.8). Key criteria for sympathetic ophthalmia included bilateral uveitis with 1) a history of unilateral ocular trauma or surgery and 2) an anterior chamber and vitreous inflammation or a panuveitis with choroidal involvement. The misclassification rates for sympathetic ophthalmia were 4.2% in the training set and 6.7% in the validation set. CONCLUSIONS The criteria for sympathetic ophthalmia had a low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.
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An Atypical Presentation of Sympathetic Ophthalmia in an Intact Globe Following Mechanical Fall: A Case Report and Literature Review. Vision (Basel) 2021; 5:vision5010011. [PMID: 33669961 PMCID: PMC7930941 DOI: 10.3390/vision5010011] [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] [Received: 12/05/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To describe an atypical case of sympathetic ophthalmia presenting after blunt trauma causing disinsertion of the iris in an intact globe. METHODS Case report. RESULTS A 71-year-old lady presented to the Emergency Department following a mechanical fall. On examination, she was noted to have periocular haematoma, subconjunctival haemorrhage, hyphaema, and vitreous haemorrhage in the left eye, but there was no evidence of globe rupture. The presenting visual acuity was 6/18. As the hyphaema and vitreous haemorrhage settled, a complete loss of the iris was noted with normal fundus. She was re-admitted a month later under the medical team with urinary tract infection and reduced vision in both eyes. On examination, there was mild conjunctival injection, keratic precipitates, anterior chamber flare, 180-degree posterior synechiae, and vitritis with no fundal view of the right eye. She was diagnosed with sympathetic ophthalmia and was treated with topical and systemic corticosteroid. Her vision improved gradually with treatment and was stable at 6/6 on the right (sympathising) eye and 6/9 on the left (excited) eye at final follow-up. CONCLUSION Sympathetic ophthalmia may result from non-penetrating ocular trauma. Comprehensive history of mechanism of injury and ophthalmic examination is essential so that prompt treatment can be given to improve the visual prognosis of affected patients.
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To implant or not to implant: emergency orbital eviscerations with primary orbital implants. Eye (Lond) 2021; 35:3077-3086. [PMID: 33432166 DOI: 10.1038/s41433-020-01382-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/24/2020] [Accepted: 12/18/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND/OBJECTIVES To evaluate the outcomes of orbital evisceration with primary implant placement in acutely infected/inflamed eyes, using implant exposure/extrusion as a surrogate of success. To contextualise this with previously published literature. SUBJECTS/METHODS A retrospective case series of all patients with acutely infected/inflamed eyes undergoing urgent orbital evisceration with primary implants, at a British tertiary centre between January 2006 and August 2018. A systematic literature review of orbital eviscerations with primary implant placement in acute endophthalmitis/infection and recent trauma. RESULTS Twenty-six eyes were eviscerated in the context of acute infection/inflammation. Twenty-four eyes had primary orbital implants. Indications for evisceration included endophthalmitis (18/26, 69%), microbial keratitis with corneal perforation (4/26, 15%), non-infectious corneal perforation (3/26, 12%), and recent trauma (1/26, 4.8%). The implants used were acrylic (15/24, 63%), MEDPOR (5/24, 21%), and silicone (4/24, 17%). The follow-up period was 15 months to 14 years. Implant exposure occurred in two (8.3%), managed with implant exchange and scleral reformation in one, and implant removal with dermis fat grafting in the other. One patient (4.2%) had conjunctival wound dehiscence with spontaneous healing. Six (25%) required further surgery for minor complications as follows: conjunctival prolapse, upper lid ptosis with slight sulcus loss, lower lid entropion with shortened fornix, and lower lid ectropion. The systematic literature review showed that the mean rate of orbital implant exposure/extrusion in this subset of patients was 7.8% (95% CI: 2.7%, 12.9%, SD 8.0%), range 0-27%. CONCLUSIONS In acutely infected/inflamed eyes, the implant exposure/extrusion rate following orbital evisceration with primary implant placement is acceptable.
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Yang J, Li Y, Xie R, Li X, Zhang X. Sympathetic ophthalmia: Report of a case series and comprehensive review of the literature. Eur J Ophthalmol 2020; 31:3099-3109. [PMID: 33256432 DOI: 10.1177/1120672120977359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Jing Yang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin International Joint Research and Development Centre of Ophthalmology and Vision Science, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yan Li
- Binhai Hospital of Tianjin Medical University General Hospital, Tianjin, China
| | - Ruotian Xie
- Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaorong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin International Joint Research and Development Centre of Ophthalmology and Vision Science, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Xiaomin Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin International Joint Research and Development Centre of Ophthalmology and Vision Science, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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Gauthier AC, Oduyale OK, Fliotsos MJ, Zafar S, Mahoney NR, Srikumaran D, Woreta FA. Clinical Characteristics and Outcomes in Patients Undergoing Primary or Secondary Enucleation or Evisceration After Ocular Trauma. Clin Ophthalmol 2020; 14:3499-3506. [PMID: 33149543 PMCID: PMC7602916 DOI: 10.2147/opth.s273760] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the frequency of primary versus secondary eye removal, frequency of enucleation versus evisceration, and characteristics and outcomes of patients undergoing these procedures after presenting with severe ocular trauma. Patients and Methods Retrospective chart review of patients presenting to the emergency department (ED) with severe eye trauma necessitating enucleation or evisceration between 2010 and 2018. Results There were 92 eyes from 90 patients included in our study. Twenty-seven percent of eyes underwent primary removal (n=25, 14 enucleation, 11 evisceration), while 73% of eyes underwent secondary removal (n=67, 50 enucleation, 17 evisceration). The mean patient age was 45.2 years (range 4.2–92.6); primary enucleation/evisceration patients were older on average than secondary eye removal patients [53.8 years (range 15.9–91.2) versus 42.2 years (range 4.2–91.6 years), p=0.04]. A median of 34 days passed between ED presentation and secondary enucleation/evisceration. Before undergoing secondary enucleation/evisceration, patients underwent a median of one ocular procedure (range 0–14) for various complications of trauma including orbital infection, choroidal or retinal tear or detachment, and wound dehiscence. Open globe injury repairs comprised 43 of the 92 total procedures (47%) performed prior to secondary enucleation/evisceration. Secondary enucleations/eviscerations required a median of seven clinic visits compared to two clinic visits required after primary surgeries (p<0.01). 10.7% of all patients (n=10) had at least one implant-related complication following enucleation/evisceration, with all but one of these patients being in the secondary enucleation/evisceration group. Conclusion Primary enucleation or evisceration was performed in 27% of all eye removals, and enucleation was performed in 69.6% of all eye removals. Future research is warranted to determine if primary eye removal may be appropriate and when to consider enucleation versus evisceration.
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Affiliation(s)
- Angela C Gauthier
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Oluseye K Oduyale
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michael J Fliotsos
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sidra Zafar
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Nicholas R Mahoney
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Divya Srikumaran
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
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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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El Khatib BBE, Patel MSMP, Hacopian AAH, Dalal MMD, Sen HNHNS, Patronas MMP. Sympathetic Ophthalmia Two Weeks After 23-Gauge Vitrectomy. J Ophthalmic Inflamm Infect 2020; 10:15. [PMID: 32588152 PMCID: PMC7316918 DOI: 10.1186/s12348-020-00206-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/19/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Bahaeddin B E El Khatib
- Department of Ophthalmology, George Washington University, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA.
| | - Menka S M P Patel
- Department of Ophthalmology, George Washington University, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA
| | - Alexander A H Hacopian
- Department of Ophthalmology, George Washington University, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA
| | - Monica M D Dalal
- Department of Ophthalmology, George Washington University, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA
| | - H Nida H N S Sen
- Department of Ophthalmology, George Washington University, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA.,National Eye Institute, National Institute of Health, Bethesda, MD, USA
| | - Marena M P Patronas
- Department of Ophthalmology, George Washington University, 2150 Pennsylvania Ave NW, Washington, DC, 20037, USA
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Dutta Majumder P, Mistry S, Sridharan S, George AE, Rao V, Ganesh SK, Biswas J. Pediatric Sympathetic Ophthalmia: 20 Years of Data From a Tertiary Eye Center in India. J Pediatr Ophthalmol Strabismus 2020; 57:154-158. [PMID: 32453848 DOI: 10.3928/01913913-20200219-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 02/10/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE To examine the clinical profile of sympathetic ophthalmia among the pediatric age group. METHODS Retrospective review of patients 18 years and younger with sympathetic ophthalmia seen in a tertiary eye care center between 1997 and 2017. RESULTS Of 20 patients included in the study, 70% were male. The most common inciting event for sympathetic ophthalmia was trauma (85%), followed by vitreoretinal surgery (15%). All patients were treated with systemic steroids. Seventeen patients received additional corticosteroid-sparing immunosuppressive agents, and 4 patients (20%) required more than one immunosuppressive agent. Azathioprine was the most commonly used corticosteroid-sparing immunosuppressive agent. The most common complications were cataract (50%) and ocular hypertension (30%). The mean presenting best corrected visual acuity in the sympathizing eye was 1.15 ± 0.99 logarithm of the minimum angle of resolution (logMAR), which improved to 0.54 ± 1.00 logMAR following treatment. Visual outcome was good (6/12 or better) in 70% of the sympathizing eyes, and 3 of the exciting eyes in the current study had good visual outcomes after the treatment. CONCLUSIONS Prompt and effective management with corticosteroid-sparing immunosuppressive therapy in children with sympathetic ophthalmia allows favorable control of the disease and retention of good visual acuity. [J Pediatr Ophthalmol Strabismus. 2020;57(3):154-158.].
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Khan Z, Bergeron S, Burnier M, Kalin-Hajdu E, Aubin MJ. Optical coherence tomography as a tool to detect early sympathetic ophthalmia in an asymptomatic patient. Can J Ophthalmol 2019; 55:e9-e13. [PMID: 31712032 DOI: 10.1016/j.jcjo.2019.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/18/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Zainab Khan
- Maisonneuve-Rosemont Hospital, Montreal, Que.; Université de Montréal, Montreal, Que.; McGill University, Montreal, Que..
| | | | | | - Evan Kalin-Hajdu
- Maisonneuve-Rosemont Hospital, Montreal, Que.; Université de Montréal, Montreal, Que
| | - Marie-Josée Aubin
- Maisonneuve-Rosemont Hospital, Montreal, Que.; Université de Montréal, Montreal, Que.; École de Santé Publique de l'Université de Montréal, Montreal, Que
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Das D, Krishnakumar S, Biswas J. Sympathetic ophthalmia with incidental finding of chicken pox supported by histopathology and immunohistochemistry. INDIAN J PATHOL MICR 2019; 62:592-594. [PMID: 31611447 DOI: 10.4103/ijpm.ijpm_192_19] [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: 11/04/2022] Open
Abstract
Sympathetic ophthalmia (SO) is a rare bilateral diffuse granulomatous panuveitis that occurs in few days to several years after penetrating injury. This intraocular inflammation can occur in any age group without a sex predilection. Pathology and immunohistochemistry-supported evidence is important to know the disease in a better way. We present a case of a 24-year-old female with clinical diagnosis of SO with an atypical past history of chicken pox in that eye and residual corneal opacity.
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Affiliation(s)
- Dipankar Das
- Department of Ocular Pathology, Uveitis and Neuro-Ophthalmology, Sri Sankaradeva Nethralaya, Guwahati, Assam, India
| | | | - Jyotirmay Biswas
- Larsen and Toubro Ocular Pathology Department, Sankara Nethralaya, Chennai, Tamil Nadu, India
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Holmes CJ, McLaughlin A, Farooq T, Awad J, Murray A, Scott R. Outcomes of ocular evisceration and enucleation in the British Armed Forces from Iraq and Afghanistan. Eye (Lond) 2019; 33:1748-1755. [PMID: 31165770 DOI: 10.1038/s41433-019-0480-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/29/2019] [Accepted: 03/25/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/OBJECTIVES To evaluate outcomes from all British military patients who underwent eye removal during the Iraq and Afghanistan wars. SUBJECTS/METHODS Retrospective case note review of all patients (n = 19) who had undergone either evisceration or enucleation, on a database of all military patients repatriated to the Royal Centre for Defence Medicine, Birmingham. RESULTS Twenty eye removals were performed on 19 patients, of which 14 (70%) were eviscerations and 6 (30%) were enucleations. Orbital wall fractures were seen in 12 (61%) patients, with orbital floor fractures being the most common. The eye removal was a primary procedure in five of fourteen eviscerations, and five of six enucleations. Complications were seen after four (28.6%) eviscerations patients and two (33.3%) enucleations. Postoperative pain was problematic after three (21.4%) eviscerations but no enucleations. Orbital implants were placed during three of the five primary enucleations, with good outcomes in two. One patient however required implant retrieval and wound washout due to a high risk of infection and communication with the intra-cranial space. CONCLUSIONS Evisceration and enucleation are both viable options in the management of severe ocular trauma in military patients. Evisceration and enucleation have similar complication rates and outcomes, and both have low rates of sympathetic ophthalmia. Primary orbital implants can be at high risk in cases with orbital roof fracture, but can provide good outcomes in select patients.
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Affiliation(s)
| | | | | | - John Awad
- University Hospitals, Birmingham, UK
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Affiliation(s)
- Emmett T Cunningham
- a Department of Ophthalmology , California Pacific Medical Center , San Francisco , California , USA.,b The Department of Ophthalmology , Stanford University School of Medicine , Stanford , California , USA.,c The Francis I. Proctor Foundation, UCSF School of Medicine , San Francisco , California , USA
| | - Dara Kilmartin
- d Research Foundation, Royal Victoria Eye & Ear Hospital , Dublin , Ireland
| | - Mamta Agarwal
- e Uveitis Services, Medical Research Foundation, Sankara Nethralaya , Chennai , India
| | - Manfred Zierhut
- f Centre for Ophthalmology, University Tuebingen, Elfriede-Aulhorn-Str , Tuebingen , Germany
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Enucleations and Eviscerations for Combat Ocular Trauma Performed During Operations Iraqi and Enduring Freedom: 2001 to 2011. J Craniofac Surg 2019; 30:767-770. [PMID: 30817532 DOI: 10.1097/scs.0000000000005294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To describe the demographics and clinical outcomes of patients who underwent posttraumatic enucleation or evisceration during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) from 2001 to 2011. METHODS The Walter Reed Ocular Trauma Database is a retrospective case series of US Servicemembers and Department of Defense civilians who had combat ocular injuries in OIF and OEF. Data regarding posttraumatic enucleations and eviscerations performed during OIF and OEF were extracted. The main outcomes analyzed were the number of enucleations and eviscerations performed, location of the surgery, laterality, and graft type. The secondary outcome measures included: mechanism of injury and Ocular Trauma Score classification. RESULTS One hundred nine enucleations and eviscerations were performed on the 890 eyes (12.24%). Sixty-three (57.80%) primary enucleations, 36 (33.03%) secondary enucleations, 5 (4.59%) postretinal detachment repair enucleations, and 5 (4.59%) primary eviscerations were completed. The surgeries were completed at a combat support hospital (57; 52.3%), or Walter Reed Army Medical Center (49; 45.0%). All surgeries were unilateral except in 2 patients. The most common graft type used was silicone (n = 56; 51.38%). Improvised explosive devices caused 76 (69.72%) eye injuries. Ocular Trauma Score were recorded as 56 (51.38%) between 0 and 44, 44 (40.37%) between 45 and 65, and unknown in 9 (8.26%). CONCLUSION Posttraumatic enucleation or evisceration due to devastating ocular trauma is required in about 15% of ophthalmic patients in modern combat trauma. The psychosocial impact on veterans who have required an enucleation or evisceration from combat trauma has been poorly studied and requires further review.
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Effective treatment of refractory sympathetic ophthalmia with glaucoma using adalimumab. Am J Ophthalmol Case Rep 2019; 14:1-4. [PMID: 30766937 PMCID: PMC6360245 DOI: 10.1016/j.ajoc.2019.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 09/13/2018] [Accepted: 01/19/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Sympathetic ophthalmia (SO) is an autoimmune, bilateral, granulomatous panuveitis, which occurs following penetrating eye injury or eye surgery. We report two cases of refractory SO in patients with a history of trabeculectomy, which were treated effectively with adalimumab. Observations Case 1: A 69-year-old male with a history of trabeculectomy for rubeotic glaucoma of the right eye, secondary to diabetic retinopathy 8 years prior, presented with a decrease in visual acuity of the left eye due to SO. After two rounds of pulse corticosteroid therapy (intravenous infusion of 1 g methylprednisolone/day for 3 days), serous retinal detachment (SRD) was resolved. As oral prednisolone was tapered to avoid deterioration of the diabetes mellitus, we shifted to other immunosuppressive therapies to control inflammation. Methotrexate 6mg/week (0.1 mg/kg) was introduced first, but was discontinued owing to side effects. After 6 months of cyclosporine 100 mg/day (1.5 mg/kg, max. dose 2.3 mg/kg), the SRD relapsed. Adalimumab was then introduced, which led to remission of SRD, and inflammation was controlled for 7 months. Case 2: A 43-year-old male, with a history of trabeculectomy for primary open-angle glaucoma of the right eye 4 years prior, presented with blurred vision in the right eye. Optical coherence tomography revealed SRD and choroidal thickening in both eyes. Pulse corticosteroid therapy (intravenous infusion of 1 g methylprednisolone/day for 3 days) was initiated, followed by oral prednisolone. SRD gradually improved, but it did not resolve completely. Given the severe visual loss the patient had experienced due to the primary open-angle glaucoma, oral prednisolone was tapered quickly to avoid steroid-induced intraocular pressure (IOP) elevation. Cyclosporine 125 mg/day (1.8 mg/kg, max. dose 2.1 mg/day) was introduced first, but was later discontinued because of side effects. Adalimumab was then administered, causing the SRD to disappear; and IOP was well-controlled. After the introduction of adalimumab, control of intraocular inflammation was achieved and IOP remained within the target range for 7 months. Conclusions and importance SO requires long-term immunosuppressive treatment. Adalimumab is an effective treatment in cases of steroid or immunosuppressant refractory SO, particularly for glaucoma patients, in whom long-term steroid therapy should be avoided.
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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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Chawla R, Kapoor M, Mehta A, Tripathy K, Vohra R, Venkatesh P. Sympathetic Ophthalmia: Experience from a Tertiary Care Center in Northern India. J Ophthalmic Vis Res 2018; 13:439-446. [PMID: 30479714 PMCID: PMC6210884 DOI: 10.4103/jovr.jovr_86_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Rohan Chawla
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Monika Kapoor
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Aditi Mehta
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Koushik Tripathy
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rajpal Vohra
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Pradeep Venkatesh
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Suetsugu T, Yasukawa T, Uemura A, Higaki M, Ogura Y. Sympathetic ophthalmia in fellow eye after vitrectomy for massive subretinal hemorrhage secondary to polypoidal choroidal vasculopathy. Int Med Case Rep J 2018; 11:293-296. [PMID: 30464649 PMCID: PMC6214347 DOI: 10.2147/imcrj.s183836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We experienced a case of sympathetic ophthalmia in a fellow eye after vitrectomy for subretinal hemorrhage related to polypoidal choroidal vasculopathy. A 60-year-old male consulted us for polypoidal choroidal vasculopathy with subretinal hemorrhage in his left eye. The recurrence of massive subretinal hemorrhage refractory to repeated pars plana vitrectomies leads to phthisis bulbi. Two months later, multiple serous retinal detachments were observed in his right eye. Positive human leukocyte antigen-DR4 and the uveitis were helpful in distinguishing between sympathetic ophthalmia and age-related macular degeneration. High-dose pulse intravenous steroid contributed to recovery of visual acuity after resolution of serous retinal detachment.
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Affiliation(s)
- Tetsuyuki Suetsugu
- Department of Ophthalmology, Jyuzen Kinen Hospital, Hamamatsu, Shizuoka, Japan
| | - Tsutomu Yasukawa
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan,
| | - Akiyoshi Uemura
- Department of Ophthalmology, Jyuzen Kinen Hospital, Hamamatsu, Shizuoka, Japan.,Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan,
| | - Masahiko Higaki
- Department of Ophthalmology, Jyuzen Kinen Hospital, Hamamatsu, Shizuoka, Japan
| | - Yuichiro Ogura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan,
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Tan XL, Seen S, Dutta Majumder P, Ganesh SK, Agarwal M, Soni A, Biswas J, Aggarwal K, Mahendradas P, Gupta V, Ling HS, Teoh S, Pavesio C, Agrawal R. Analysis of 130 Cases of Sympathetic Ophthalmia - A Retrospective Multicenter Case Series. Ocul Immunol Inflamm 2018; 27:1259-1266. [PMID: 30207811 DOI: 10.1080/09273948.2018.1517894] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: To analyze the demographic profile, treatment, and visual outcome of the patients with sympathetic ophthalmia (SO) in a multicenter collaborative retrospective cohort study.Methods: Medical records of the patients with SO from UK, Singapore, India were reviewed for history of ocular trauma or surgery and subsequent development of uveitis consistent with SO, presenting symptoms, treatment, and visual outcomes.Results: A total of 130 patients were diagnosed with SO during the study period. Eighty-one (62.3%) patients were men. The mean age was 48.4 ± 15.5 years. The most common presenting symptom was blurring of vision (89.2%), followed by pain (29.2%) and floaters (23.8%). Ninety-two (70.7%) required additional immunosuppressive therapy. Thirty-six (27.9%) patients underwent enucleation of the inciting eye.Conclusions: SO is a potentially sight-threatening disease with high rates of visual loss. It warrants prompt evaluation and treatment. With the advances and availability in immunotherapy, the visual prognosis is relatively good.
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Affiliation(s)
- Xiu Ling Tan
- Department of Ophthalmology, National Healthcare Group Eye Institute, Singapore
| | - Sophia Seen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Sudha K Ganesh
- Medical Research Foundation, Sankara Netralaya, Chennai, Tamil Nadu, India
| | - Mamta Agarwal
- Medical Research Foundation, Sankara Netralaya, Chennai, Tamil Nadu, India
| | - Aniruddh Soni
- Medical Research Foundation, Sankara Netralaya, Chennai, Tamil Nadu, India
| | - Jyotirmay Biswas
- Medical Research Foundation, Sankara Netralaya, Chennai, Tamil Nadu, India
| | - Kanika Aggarwal
- Uveitis Department, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Vishali Gupta
- Uveitis Department, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ho Su Ling
- Department of Ophthalmology, National Healthcare Group Eye Institute, Singapore
| | - Stephen Teoh
- Department of Ophthalmology, National Healthcare Group Eye Institute, Singapore
| | - Carlos Pavesio
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Rupesh Agrawal
- Department of Ophthalmology, National Healthcare Group Eye Institute, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Moorfields Eye Hospital, NHS Foundation Trust, London, UK
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Dogra M, Samanta R, Singh P, Singh SR, Bajgai P, Sharma A, Bansal R, Gupta V, Dogra MR, Singh R. Surgical Intervention in Inciting Eyes of Patients with Sympathetic Ophthalmia: A Case Series and Review of Literature. Ocul Immunol Inflamm 2018; 27:1154-1159. [PMID: 30081702 DOI: 10.1080/09273948.2018.1497663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Purpose: To analyze the outcomes of surgical procedures on inciting eye of patients with Sympathetic ophthalmia (SO). Methods: Retrospective study of patients with SO who underwent surgical procedures on inciting eyes between January 2000 and December 2015. Outcome measures included flare up of inflammation in either eye and change in visual acuity in the inciting eye. Results: Four SO patients underwent surgeries in their inciting eyes after adequate control of inflammation. Surgical procedures included penetrating keratoplasty, glaucoma drainage device implantation, pars plana vitrectomy, and silicon oil removal. Keratoplasty, glaucoma surgery, and silicon oil removal were well tolerated, with no flare up of disease. The patient who underwent pars plana vitrectomy, however, had a poor outcome. Conclusions: Surgical intervention in inciting eyes of patients with SO, after being adequately treated with oral steroids and immunosuppression, is a viable option for improving anatomic and functional outcomes in these eyes.
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Affiliation(s)
- Mohit Dogra
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ramanuj Samanta
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Pallavi Singh
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Simar Rajan Singh
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Priya Bajgai
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Aman Sharma
- Department of Rheumatology, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Reema Bansal
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Vishali Gupta
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Mangat R Dogra
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
| | - Ramandeep Singh
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER) , Chandigarh , India
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Cernichiaro-Espinosa LA, Gold AS, Berrocal AM, Dubovy SR, Chang TC, Orcutt-Hayes A, Murray TG. Sympathetic Ophthalmia in a 22-Month-Old Infant With Sturge-Weber Syndrome With Atypical Histopathological Correlation. ACTA ACUST UNITED AC 2018; 2:248-252. [PMID: 34291184 DOI: 10.1177/2474126418782068] [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: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Linda A Cernichiaro-Espinosa
- Department of Ophthalmology, Miller School of Medicine, Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Aaron S Gold
- Murray Ocular Oncology & Retina, South Miami, FL, USA
| | - Audina M Berrocal
- Department of Ophthalmology, Miller School of Medicine, Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Sander R Dubovy
- Department of Ophthalmology, Miller School of Medicine, Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Ta Chen Chang
- Department of Ophthalmology, Miller School of Medicine, Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
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Forrester JV, Kuffova L, Dick AD. Autoimmunity, Autoinflammation, and Infection in Uveitis. Am J Ophthalmol 2018; 189:77-85. [PMID: 29505775 DOI: 10.1016/j.ajo.2018.02.019] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE To review the pathogenesis of uveitis in light of recent advances in our understanding of innate and adaptive immune responses and their regulation. DESIGN Perspective. METHODS Methods included a review of prevailing views on the pathogenesis of uveitis and an analysis of developments in immunology that impact on its conceptual basis, particularly the concept of immunologic tolerance and its loss in autoimmunity. Importantly, the role of infection in the pathogenesis of uveitis is evaluated. RESULTS The results comprise a reappraisal of the pathogenesis of anterior vs posterior uveitis in the context of the blood-retinal barrier and its relation to autoimmune, autoinflammatory, and infectious uveitis. Autoimmunity is seen as a possible cause of certain forms of uveitis but definitive proof is lacking. Autoinflammatory disease, involving activated innate immune mechanisms, is considered causative in a second set of uveitis conditions. A place for infection in uveitis generally is proposed within a unifying concept for the pathogenesis of uveitis. CONCLUSION Infection may be implicated directly or indirectly in many forms of noninfectious or undifferentiated uveitis. In addition to the growing recognition that foreign antigen, including reactivatable infectious agents, might hide within ocular tissues, the possibility that a dysregulated microbiome might generate T cells that cause immune-mediated ocular inflammation has now been demonstrated experimentally. An uncontrolled, overexuberant host immune response may cause continuing irreversible tissue damage even after the infection has been cleared.
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Affiliation(s)
- John V Forrester
- Section of Immunology and Infection, Division of Applied Medicine, School of Medicine and Dentistry, Institute of Medical Science, Foresterhill, University of Aberdeen, Aberdeen, Scotland, United Kingdom; Ocular Immunology Program, Centre for Ophthalmology and Visual Science, The University of Western Australia, Crawley, Western Australia, Australia; Centre for Experimental Immunology, Lions Eye Institute, Nedlands, Western Australia, Australia.
| | - Lucia Kuffova
- Section of Immunology and Infection, Division of Applied Medicine, School of Medicine and Dentistry, Institute of Medical Science, Foresterhill, University of Aberdeen, Aberdeen, Scotland, United Kingdom; NHS Grampian, Aberdeen, Scotland, United Kingdom
| | - Andrew D Dick
- Translational Health Sciences (Ophthalmology), University of Bristol, Bristol, United Kingdom; University College London, Institute of Ophthalmology, and the National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital and UCL-Institute of Ophthalmology, London, United Kingdom
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41
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Jabs DA, Dick A, Doucette JT, Gupta A, Lightman S, McCluskey P, Okada AA, Palestine AG, Rosenbaum JT, Saleem SM, Thorne J, Trusko B. Interobserver Agreement Among Uveitis Experts on Uveitic Diagnoses: The Standardization of Uveitis Nomenclature Experience. Am J Ophthalmol 2018; 186:19-24. [PMID: 29122577 DOI: 10.1016/j.ajo.2017.10.028] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the interobserver agreement among uveitis experts on the diagnosis of the specific uveitic disease. DESIGN Interobserver agreement analysis. METHODS Five committees, each comprised of 9 individuals and working in parallel, reviewed cases from a preliminary database of 25 uveitic diseases, collected by disease, and voted independently online whether the case was the disease in question or not. The agreement statistic, κ, was calculated for the 36 pairwise comparisons for each disease, and a mean κ was calculated for each disease. After the independent online voting, committee consensus conference calls, using nominal group techniques, reviewed all cases not achieving supermajority agreement (>75%) on the diagnosis in the online voting to attempt to arrive at a supermajority agreement. RESULTS A total of 5766 cases for the 25 diseases were evaluated. The overall mean κ for the entire project was 0.39, with disease-specific variation ranging from 0.23 to 0.79. After the formalized consensus conference calls to address cases that did not achieve supermajority agreement in the online voting, supermajority agreement overall was reached on approximately 99% of cases, with disease-specific variation ranging from 96% to 100%. CONCLUSIONS Agreement among uveitis experts on diagnosis is moderate at best but can be improved by discussion among them. These data suggest the need for validated and widely used classification criteria in the field of uveitis.
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Abu El-Asrar AM, Al Kuraya H, Al-Ghamdi A. Sympathetic Ophthalmia after successful Retinal Reattachment Surgery with Vitrectomy. Eur J Ophthalmol 2018; 16:891-4. [PMID: 17191203 DOI: 10.1177/112067210601600622] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report a case of sympathetic ophthalmia (SO) following one successful pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment. METHODS Case report. RESULTS A 50-year-old man developed SO 5 weeks after successful repair of rhegmatogenous retinal detachment with PPV and intraocular gas tamponade. The patient presented with bilateral multifocal exudative retinal detachments and inflamed optic nerve with characteristic changes of SO detected by fluorescein angiography, indocyanine green angiography, and optical coherence tomography. Prompt use of systemic steroids and cyclosporin A resulted in control of the uveitis with significant visual improvement. CONCLUSIONS PPV should be viewed as a major risk factor for development of SO.
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Affiliation(s)
- A M Abu El-Asrar
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Dutta Majumder P, Anthony E, George AE, Ganesh SK, Biswas J. Postsurgical sympathetic ophthalmia: retrospective analysis of a rare entity. Int Ophthalmol 2017; 38:2487-2493. [PMID: 29164454 DOI: 10.1007/s10792-017-0759-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 10/19/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe clinical manifestations, management and visual outcome in postsurgical sympathetic ophthalmia (SO). METHODS Retrospective study. RESULTS Mean age of the patients was 41.1 years, and males were affected 1.8 times than the female. Vitrectomy and scleral buckling were the most common inciting surgeries followed by cataract surgery. Among 10 eyes with anterior uveitis, mutton-fat keratic precipitate was seen in only two eyes. Mean follow-up duration was 1556.50 ± 1470.75 days. Vision significantly improved in 11 patients (78.6%; p = 0.005). CONCLUSION Postsurgical SO is a rare entity, but it is a bilateral blinding disease and SO following surgical intervention can have variable presentations. Rapid, effective management of postsurgical sympathetic ophthalmia can give improved visual outcomes.
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Affiliation(s)
| | - Eliza Anthony
- Department of Uvea, Medical Research Foundation, Sankara Nethralaya, Chennai, 600006, India
| | - Amala Elizabeth George
- Department of Uvea, Medical Research Foundation, Sankara Nethralaya, Chennai, 600006, India
| | - Sudha K Ganesh
- Department of Uvea, Medical Research Foundation, Sankara Nethralaya, Chennai, 600006, India
| | - Jyotirmay Biswas
- Department of Uvea, Medical Research Foundation, Sankara Nethralaya, Chennai, 600006, India
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Abstract
In this study, we report a case of bilateral exudative retinal detachment due to sympathetic ophthalmia after successful limbal corneal laceration repair. Steroids remain mainstay management in controlling this disorder; however, there is no role of prophylactic steroid to prevent it. On the contrary, steroid use may alter the course of the disease. Background/Purpose: To report a case of atypical sympathetic ophthalmia after limbal corneal laceration. Methods and Results: An 11-year-old child had a successful left eye corneal laceration repair at the temporal limbus with excision of exposed nonnecrotic iris tissue, resulting in good visual acuity of 20/80 and 20/25 on postoperative Days 1 and 7, respectively. The patient was prescribed 1 mg/kg oral prednisolone in a tapering dose as prophylaxis. On postoperative Day 21, the patient presented with acute onset decreased vision in both eyes. Visual acuity was counting fingers 3 feet in both eyes. On examination, anterior segment examination was quiet without any inflammation, anterior vitreous face showed 1+ cells, and dilated funduscopy revealed bilateral symmetrical serous retinal detachments along the posterior pole. Optical coherence tomography demonstrated separation and elevation of inner neurosensory layers from the outer segment marking presence of hyperreflective material along with subretinal fluid between detached surfaces. There was stippled hyperfluorescence along the posterior pole as seen in fluorescein angiography. With a diagnosis of sympathetic ophthalmia confirmed, oral prednisolone (2 mg/kg body weight) was instituted after which, there was gradual decrease in macular elevation with corresponding improvement in visual acuity with no recurrence for the last 6 months. Conclusion: To our knowledge, this is the first reported instance of an atypical presentation of sympathetic ophthalmia, and antecedent corticosteroid therapy would have mitigated robust anterior segment findings usually associated with the condition.
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Goudot M, Groh M, Salah S, Monnet D, Blanche P, Brézin AP. Lymphocytic Meningitis in Patients with Sympathetic Ophthalmia. Ocul Immunol Inflamm 2017; 25:196-201. [DOI: 10.1080/09273948.2017.1291841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Mathilde Goudot
- Department of Ophthalmology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Matthieu Groh
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Sawsen Salah
- Department of Ophthalmology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Dominique Monnet
- Department of Ophthalmology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Philippe Blanche
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Antoine P. Brézin
- Department of Ophthalmology, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Université Paris Descartes, Paris, France
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OLIGOARTRITE E ENTESITE ASSOCIADAS À OFTALMIA SIMPÁTICA: RELATO DE CASO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Rishi E, Rishi P, Appukuttan B, Walinjkar J, Biswas J, Sharma T. Sympathetic ophthalmitis following vitreoretinal surgery: Does antecedent trauma make a difference? Indian J Ophthalmol 2016; 63:692-8. [PMID: 26632123 PMCID: PMC4705703 DOI: 10.4103/0301-4738.170980] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Sympathetic ophthalmitis (SO) has been reported following vitrectomy; however, there is a lack of data on the role of antecedent penetrating ocular trauma impacting the disease manifestation in eyes developing SO following vitrectomy. Aim: To report differences in the presentation and outcomes of SO in eyes with or without a history of antecedent penetrating trauma; SO being diagnosed after vitreoretinal (VR) surgery. Design: Comparative case series. Methods: Seventeen consecutive patients presenting with SO following VR surgery, diagnosed between 1995 and 2011 were included. Eyes with and without prior penetrating injury were included in Group I (n = 7) and Group II (n = 10), respectively. All Group I patients had received systemic steroids prior to presentation. Demographic and clinical parameters were evaluated. Results: Differences were observed between Group I and Group II mainly with regards to time interval between VR surgery and diagnosis of SO (1.5 months vs. 8 months, P = 0.10), presence of neurosensory detachments (100% vs. 30%, P = 0.01), and the inciting eye vision at presentation (nil light perception in 28.5% vs. 80%, P = 0.049). Other differences observed though not statistically significant were optic disc and retinal vessel involvement (42% vs. 70%, P = 0.28), Dalen-Fuchs nodules (localized vs. diffuse) and leaks on fundus fluorescein angiography (pin-head vs. pin-point leak). Conclusion: SO in patients with antecedent penetrating ocular trauma present early with the central serous chorioretinopathy-like picture. Prior use of systemic steroids might have a bearing on the differences in presentation and the visual acuities between the two groups.
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Affiliation(s)
- Ekta Rishi
- Sankara Nethralaya, Chennai, Tamil Nadu, India
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Guzman-Salas PJ, Serna-Ojeda JC, Guinto-Arcos EB, Pedroza-Seres M. Characteristics of Sympathetic Ophthalmia in a Single International Center. Open Ophthalmol J 2016; 10:154-9. [PMID: 27651849 PMCID: PMC5009293 DOI: 10.2174/1874364101610010154] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 07/21/2016] [Accepted: 08/16/2016] [Indexed: 11/22/2022] Open
Abstract
AIM To report the main features of sympathetic ophthalmia in a referral ophthalmology center. METHODS Retrospective clinical study. We reviewed clinical records of patients with diagnosis of sympathetic ophthalmia attending the Uveitis Department from 2007 to 2013. Patients were selected by clinical criteria. Descriptive statistics were used to assess variables. RESULTS Twenty patients were included for analysis, 13 males and 7 females. Mean follow up was 1 year. The median age of presentation was 50 years. Fifty percent had history of ocular trauma and 50% had history of intraocular surgery, of which 40% underwent phacoemulsification. The time between injury and onset of symptoms ranged from 1 to 456 months. Most common ocular manifestations were mutton fat keratic precipitates and anterior chamber inflammation. All patients received oral prednisone as single or combined therapy. Sixty percent of the sympathizing eyes improved two or more lines of vision and 20% lost two or more lines of vision. CONCLUSION This report from a single center adds to the body of literature of sympathetic ophthalmia occurring in a specific population. Our data found a high proportion of patients with sympathetic ophthalmia after phacoemulsification.
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Affiliation(s)
- Pablo Jose Guzman-Salas
- Department of Uveitis and Ocular Immunology. Instituto de Oftalmologia "Conde de Valenciana", Mexico City,Mexico
| | - Juan Carlos Serna-Ojeda
- Department of Uveitis and Ocular Immunology. Instituto de Oftalmologia "Conde de Valenciana", Mexico City,Mexico
| | - Ethel Beatriz Guinto-Arcos
- Department of Uveitis and Ocular Immunology. Instituto de Oftalmologia "Conde de Valenciana", Mexico City,Mexico
| | - Miguel Pedroza-Seres
- Department of Uveitis and Ocular Immunology. Instituto de Oftalmologia "Conde de Valenciana", Mexico City,Mexico
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Peng X, Zhang J. Differentiation of severe bilateral panuveitis following phacoemulsification: a case report. BMC Ophthalmol 2016; 16:84. [PMID: 27277218 PMCID: PMC4898448 DOI: 10.1186/s12886-016-0252-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 05/21/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cataract surgery typically offers instant visual rehabilitation with rare postoperative complications. However, if complications occur, these complications may be confusing and threatening. We present a case of severe bilateral panuveitis following phacoemulsification and intraocular lens implantation and discuss the importance of a correct diagnosis and management. CASE PRESENTATION A 75-year-old Asian male with bilateral phacoemulsification and intraocular lens implantation developed severe inflammation with sharp vision loss in both eyes after the surgeries. Physical examination indicated bilateral panuveitis. With a presumptive diagnosis of suppurative endophthalmitis and a history of effective treatment with intravenous antibiotics plus ofloxacin and steroid drops, intravenous ceftazidime and vancomycin were administered. However, the effects were minimal. With a supplemental history of recurrent oral, perineal, and gastrointestinal ulcers, a diagnosis of Behcet's disease was made, and systemic immune inhibitors were prescribed instead of invasive treatments, which might exacerbate the condition. After 5 days of medication, the inflammation was markedly relieved, and no recurrence was observed 2 weeks later. CONCLUSION Correct differentiation of confusing conditions is crucial to implement appropriate management. Postoperative complications of cataract surgery should be differentiated carefully, and perioperative management in patients with autoimmune uveitis should be provided with caution.
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Affiliation(s)
- Xi Peng
- Department of Ophthalmology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Junjun Zhang
- Department of Ophthalmology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, Sichuan, China.
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Payal AR, Foster CS. Long-Term Drug-Free Remission and Visual Outcomes in Sympathetic Ophthalmia. Ocul Immunol Inflamm 2016; 25:190-195. [DOI: 10.3109/09273948.2015.1092557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Abhishek R. Payal
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - C. Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, Massachusetts, USA
- Ocular Immunology and Uveitis Foundation, Waltham, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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