Sympathetic ophthalmia following diode laser cyclophotocoagulation

Incidence of Sympathetic Ophthalmia after Intraocular Surgery: A Systematic Review and Meta-analysis

TOPIC

Sympathetic ophthalmia (SO) is a rare bilateral granulomatous panuveitis that can present after trauma or intraocular surgery (IOS). The incidence of SO after IOS varies among studies. The purpose of this review was to determine the incidence proportion of SO after IOS.

CLINICAL RELEVANCE

The incidence proportion of SO after IOS can provide physicians and patients with information on the risk of SO during the consent process before surgery.

METHODS

In this systematic review and meta-analysis, MEDLINE, EMBASE, and Cochrane databases were searched from inception to January 1, 2023 for population-based studies of SO after IOS. Two reviewers independently screened the results. Random-effects meta-analyses calculated incidence proportion. Subgroup analysis assessed SO incidence based on IOS type and technological advancements. Study quality and bias were assessed using the Newcastle-Ottawa scale and the Grades of Recommendation, Assessment, Development, and Evaluation framework.

RESULTS

The final meta-analyses included 19 studies, with 118 cases of SO occurring after 505 178 inciting events. The estimated overall incidence proportion of SO after IOS was 0.061% (95% confidence interval [CI], 0.033%-0.111%; I2 = 83%), and the estimated incidence rate was 9.24 cases per 100 000 person-years (95% CI, 4.03-21.19; I2 = 88%). The average study duration across these studies was 10.8 years. Within the reviewed literature, SO after glaucoma and vitreoretinal IOS was studied most, with 9 and 6 studies, respectively. Observed differences in incidence between glaucoma (0.098%; 95% CI, 0.042%-0.232%; I2 = 40%) and vitreoretinal (0.043%; 95% CI, 0.022%-0.085%; I2 = 88%) IOS were not statistically significant (P = 0.14). Also, no significant difference was found in the incidence proportion before and after 1975, when modern intraocular surgical techniques emerged (0.060% vs. 0.058%; P = 0.98). The outcome measures showed low-certainty Grades of Recommendation, Assessment, Development, and Evaluation evidence.

DISCUSSION

Sympathetic ophthalmia after IOS is rare and might not have changed over the past 5 decades. The estimated incidence proportion of SO may be useful during the consent process before surgery. Also, no significant difference may exist in the incidence of SO between glaucoma and vitreoretinal IOS, based on low-certainty evidence.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

“Persistence of Memory” – Multimodal imaging of delayed sympathetic ophthalmia

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.

Treatment of uncontrolled intraocular pressure secondary to uveal melanoma status post plaque radiotherapy with ab interno XEN gel stent implantation

Purpose

To report treatment of uncontrolled intraocular pressure in a patient with uveal melanoma status post plaque radiotherapy with ab interno XEN gel stent implantation.

Observations

A 21-year-old female with a history of iris and ciliary body melanoma underwent treatment with plaque radiotherapy with subsequent elevation of intraocular pressure refractory to maximum medical therapy. In order to control the pressure, ab interno XEN gel stent implantation with mitomycin C was recommended. Preoperatively, the patient was on four topical medications and oral acetazolamide with intraocular pressure of 39 mmHg by Goldmann applanation tonometry. The patient's intraocular pressure was reduced to 10 mmHg at her final postoperative visit on no medications. Visual acuity showed minimal degradation measuring 20/100 preoperatively and 20/150 eleven months after XEN gel stent implantation with VA improvement to 20/60 with refraction after cataract extraction at eighteen months. There were no postoperative complications and no recurrence or seeding of the uveal melanoma at follow up 18 months after her XEN gel stent implantation.

Conclusions and Importance

Ab interno XEN gel stent implantation with mitomycin C may offer an effective method to control intraocular pressure in patients with refractory intraoperative pressure control following plaque radiotherapy treatment for uveal melanoma.

Sympathetic Ophthalmia - An Overview

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incidence of Sympathetic Ophthalmia after Inciting Events: A National Database Study in Japan

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.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma

PURPOSE

Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion.

METHODS

A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures.

RESULTS

Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term.

CONCLUSION

Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy of Care for Blind Painful Eyes

PURPOSE

Pain relief for a blind painful eye often follows an escalating paradigm of interventions. This study compares the efficacy of common interventions.

METHODS

A retrospective chart review of blind painful eye cases was conducted at a single tertiary institution from April 2012 to December 2016. Demographics, etiology, treatment, and pain level were assessed.

RESULTS

Among 99 blind painful eyes, 96 eyes initially received medical therapy (topical steroids, cycloplegics, and/or hypotensives), with pain relief in 39% of eyes. Minimally invasive interventions (laser cyclophotocoagulation, retrobulbar injection, or corneal electrocautery) were performed 41 times in 36 eyes, 34 of which had failed medical therapy, and led to pain relief in 75% of eyes. Evisceration or enucleation was performed in 28 eyes, and long-term pain relief was achieved in 100% of eyes. Surgery allowed discontinuation of oral analgesics in 100% of cases versus 20% for minimally invasive therapy (p = 0.005) and 14% for medical therapy (p = 0.0001). Compared with medical therapy, minimally invasive therapy was 2.5 times more likely to achieve lasting pain relief (p = 0.003) and surgical therapy 35.6 times more likely to achieve lasting pain relief (p = 0.011). High initial pain score was associated with nonsurgical treatment failure.

CONCLUSIONS

Medical therapy provides pain relief in a moderate number of patients with a blind painful eye. When medical therapy fails, minimally invasive therapy and surgical interventions are successively more effective in relieving ocular pain. High initial pain score is a risk factor for nonsurgical therapy failure and may merit an earlier discussion of surgical intervention.

Postsurgical sympathetic ophthalmia: retrospective analysis of a rare entity

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.

Cyclophotocoagulation-induced sympathetic ophthalmia in a Coats' disease patient supported by histopathology and immunohistochemistry

We describe a case of a 13-year-old male patient of Coats' disease who developed sympathetic ophthalmia (SO) following contact diode laser cyclophotocoagulation. There was no history of invasive surgery or any perforating injuries preceding cyclodestructive therapy. The eye had neovascular glaucoma secondary to Coats' disease, which was treated once with contact cyclophotocoagulation. Subsequently, the intraocular pressure slowly decreased, and the eye became phthisical. Intraocular inflammation developed in the fellow eye and SO was suspected, which was confirmed by characteristic findings seen on fluorescein angiography. The case was successfully managed with the help of topical and systemic immunosuppression. Enucleation with silicone ball implantation was performed in the right phthisical eye and specimen was sent for histopathological examination. Histopathology and immunostaining supported the diagnosis of SO.

Intraocular Pressure Outcomes Following Transscleral Diode Cyclophotocoagulation Using Long and Short Duration Burns

PURPOSE

The purpose of this study was to compare outcomes of transscleral diode cyclophotocoagulation using short duration (SD) versus longer duration (LD) treatment.

PATIENTS AND METHODS

Data were collected retrospectively on patients with glaucoma who underwent cyclophotocoagulation with LD (4000 ms) treatment with variable power ≤1000 mW versus SD using 1500 ms with variable power ≤2000 mW. The outcome measures included: intraocular pressure (IOP) at 12 months, decrease in number of antiglaucoma medications, complications and visual acuity (VA) at the final follow-up visit.

RESULTS

There were 71 patients and 70 patients in the SD and LD groups, respectively. The mean IOP±SD pretreatment baseline was 33±10 versus 36±10 mm Hg for SD and LD groups, respectively (P>0.05). At 1 year postoperatively, the IOP decreased significantly in both groups (16.7 vs. 17.4 mm Hg for SD and LD, respectively; P<0.0001). This decrease in IOP was comparable between groups (P=0.5). The average number of IOP lowering medications were 2.5 and 2.9 at baseline in the SD and LD groups, respectively, and decreased to 1.3 in both groups (P=0.83). The mean LogMAR VA decreased significantly from 1.87 at baseline to 1.96 at 1 year in the SD group (P=0.276), and 2.03 to 2.3 (P≤0.001) in the LD group, this change was comparable (0.19; P=0.075) between the 2 groups. Complications were also comparable.

CONCLUSIONS

Both LD and SD burns during cyclophotocoagulation effectively lowered IOP at 1 year. Neither treatment resulted in a greater reduction of IOP. LD treatment appeared to result in a decrease in VA and greater postoperative inflammation.

Current and Future of Laser Therapy in the Management of Glaucoma

There has been tremendous progress in the past decades in the utilization of lasers for treating patients with glaucoma. This article reviews the use of lasers in different areas of glaucoma, including the shift from argon laser trabeculoplasty (ALT) to selective laser trabeculoplasty (SLT), laser trabeculoplasty as an initial treatment for glaucoma, new laser trabeculoplasty procedures under investigation, and other recent laser treatment modalities such as endoscopic cyclophotocoagulation and laser-assisted deep sclerectomy.