The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis

TOPIC

Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial.

CLINICAL RELEVANCE

This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat.

METHODS

Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR).

RESULTS

Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data.

DISCUSSION

Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Epidemiology and Risk Factors for the Progression of Sympathetic Ophthalmia in the United States: An IRIS Registry Analysis

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.

The Incidence of Sympathetic Ophthalmia After Trauma: A Meta-analysis

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.

Pediatric Sympathetic Ophthalmia: 20 Years of Data From a Tertiary Eye Center in India

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.].

Development of sympathetic ophthalmia following globe injury

BACKGROUND

Sympathetic ophthalmia (SO), a rare, bilateral, diffuse granulomatous uveitis, usually occurs after open globe injury or intraocular surgery. We sought to identify the risk factors for the development of SO after open globe injury and describe their demographic and clinical features and outcomes of treatments.

METHODS

A retrospective study of inpatients with globe injury in 15 tertiary referral hospitals of China from January 2001 to December 2005 was conducted. The information of demography, nature and mechanism of injury, time and ways of treatments and outcomes was reviewed. Diagnosis of SO was made based on a history of ocular trauma or surgery and subsequent development of bilateral or contralateral uveitis consistent with SO. Any association between related parameters and development of SO was analyzed.

RESULTS

Among 9103 patients (9776 eyes) of globe injury, SO occurred after open globe injury in 18 cases with an occurrence rate of 0.37%, vitrectomy of closed globe injury in 2 (0.37%) and perforation of burned eyes in another 2. For open globe injury, the median age ((36.72 +/- 13.59) years, P = 0.01) was higher in patients with SO; there were no significant effects of sexes, injury type, uvea proplaps, once or multi-intraocular surgery, once or multi-vitrectomy and endophthalmitis on incidence of SO; 0.70% endophthalmitis concurred with SO; 83.33% of SO occurred within 1 year after injury or last ocular surgery. SO developed in a fellow eye one week after evisceration of the perforating burned eye. Good final visual acuity was obtained in sympathizing eyes with prompt treatment.

CONCLUSIONS

For open globe injuries, SO sufferers were relatively older and any injury type could induce SO with equal possibility. The initial open globe injury was more likely to be the trigger of SO than subsequent intraocular surgeries including vitrectomy. Prophylactic enucleation after injury is not recommended.

Sympathetic ophthalmia: incidence of ocular complications and vision loss in the sympathizing eye

PURPOSE

To report the frequency on presentation and subsequent incidence of ocular complications and vision loss in patients with sympathetic ophthalmia (SO) and to describe factors associated with decreased vision in the sympathizing eye.

DESIGN

Multicenter retrospective case series.

METHODS

SETTING

Three academic tertiary care uveitis clinics.

STUDY POPULATION

Eighty-five patients with SO from 1976 to 2006.

OBSERVATION PROCEDURES

Review of existing medical records.

MAIN OUTCOME MEASURES

Incident visual acuity (VA) loss to 20/50 or worse and 20/200 or worse and the median acuity over time.

RESULTS

Twenty-six percent of patients with SO presented with a VA of 20/200 or worse in their sympathizing eye. Further development of vision loss to 20/200 or worse occurred at the rate of 10% per person-year (PY). Ocular complications were seen in the sympathizing eye in 47% of patients at presentation; further development of new complications occurred at the rate of 40%/PY. The ocular complications most often associated with decreased vision were cataract and optic nerve abnormality. Exudative retinal detachment and active intraocular inflammation were significantly associated with poorer VA in the sympathizing eye. The benefits of corticosteroids were indirectly demonstrated as their use led to more rapid disease inactivation. Fifty-nine percent of patients maintained a VA of better than 20/50 in their sympathizing eye; and 75% maintained a VA of better than 20/200.

CONCLUSIONS

Although ocular complications were seen in many sympathizing eyes with SO, most patients maintained functional VA. The presence of an exudative retinal detachment and active intraocular inflammation correlated with poorer vision in the sympathizing eye.

Sympathetic ophthalmia in Singapore: new trends in an old disease

BACKGROUND

Sympathetic ophthalmia (SO) is an uncommon uveitic condition that occurs after injury to the uvea of one eye and may occur after accidental ocular trauma or ocular surgery. We sought to investigate the common causes of SO in Singapore and the demographic profile as well as the final visual acuity after treatment in these patients.

METHODS

This was a retrospective, non-comparative case series in which patients with SO were identified from the Singapore National Eye Centre uveitis database in the period between 1993 and 2003. The patients' case records were examined for a history of ocular trauma or surgery and subsequent development of bilateral or contralateral uveitis consistent with SO or histopathological evidence of SO in enucleated eyes. The medical records of these patients were reviewed for details of the inciting event, presentation, treatment, and visual acuity.

RESULTS

A total of ten patients (six men and four women) were diagnosed with SO in the period of study. SO occurred after accidental trauma in three patients and following ocular surgery in seven. Vitreoretinal surgery was responsible for four of these cases, and diode laser cyclophotoablation for another two, whereas neodymium:yttrium-aluminium-garnet (Nd:YAG) laser cyclotherapy was the cause in the last patient. Overall, six of ten patients underwent at least one vitreoretinal procedure. Four of the patients had a final visual acuity of 6/15 or better, whereas five had a visual acuity of 6/30 or worse. Good final visual acuity appeared to be associated with early initiation of immunosuppressive therapy.

CONCLUSION

In this series, ocular surgery, especially vitreoretinal surgery, had overtaken non-surgical trauma as the major cause of SO. A good outcome was possible in most cases if an early diagnosis was made and immunosuppressive treatment started promptly.

[Sympathetic ophthalmia caused by ocular penetration with endophthalmitis]

PURPOSE

To summarize the clinical features, diagnosis and treatment of sympathetic ophthalmia caused by ocular penetration with endophthalmitis.

METHODS

Retrospective analysis was done on clinical data of 3 cases of sympathetic ophthalmia with ocular penetration and endophthalmitis.

RESULTS

5,253 cases of ocular penetration and fracture were hospitalized from 1993 to 2002, while 87 cases of sympathetic ophthalmia were found at the same period of time, with the ratio of 1.65%. 3 cases had history of ocular penetration with endophthalmitis. Fluorescein angiography indicated that these 3 cases had developed sympathetic ophthalmia. Microscopic examination showed that 1 case had typical histological changes of sympathetic ophthalmia.

CONCLUSION

Sympathetic ophthalmia caused by ocular penetration with endophthalmitis is infrequent, but this situation should not be neglect.

Incidence of sympathetic ophthalmia after penetrating eye injury and choice of treatment

INTRODUCTION

Sympathetic ophthalmia, a diffuse bilateral granulomatous panuveitis, is a serious potential complication after penetrating eye injury. Many surgeons recommend enucleation within two weeks of trauma to prevent this condition. We retrospectively reviewed the medical records of patients with penetrating ocular injuries who had either evisceration or enucleation to determine the incidence of sympathetic ophthalmia and to evaluate the surgical interventions and their complications. Age at surgery, time after penetrating trauma, surgery technique, follow-up period, ophthalmic examination of the fellow eye, and surgical complications were evaluated.

RESULTS

In total, 217 patients were included in the study with a mean follow-up period of 10.3 +/- 6.6 years. The longest time between the trauma and time of surgery was 43 years. Postoperative uveitis was observed in only one patient (0.5%) who had primary repair after injury. Histopathological review did not reveal typical sympathetic ophthalmia. Complications after enucleation were significantly higher than after evisceration.

CONCLUSION

There was no histopathologically supported sympathetic ophthalmia in our series. Sympathetic ophthalmia is very rare even when the injured eye is retained. With this in mind, the first choice of treatment may not be enucleation. Furthermore, evisceration may be the procedure of choice if primary repair cannot be performed or for patients who have panophthalmitis.

Prospective surveillance of sympathetic ophthalmia in the UK and Republic of Ireland

AIMS

To establish current epidemiological data, risks, and interventional outcomes of newly diagnosed sympathetic ophthalmia (SO).

METHODS

Prospective surveillance took place of all permanently employed ophthalmologists in the UK and Republic of Ireland by a monthly reporting card through the British Ophthalmological Surveillance Unit. Case ascertainment was made of newly diagnosed SO from July 1997 and questionnaire data were returned at baseline, 6 months, and 1 year after diagnosis.

RESULTS

23 patients with newly diagnosed SO were recruited over 15 months, corresponding to a minimum estimated incidence of 0.03/100 000. Baseline data were available on 18 patients, in whom SO occurred after surgery in 11 patients, after retinal surgery alone in six patients, and after accidental trauma in seven patients. 12 of the 16 patients with 1 year follow up had a visual acuity of 6/12 or better. Good visual outcome was related to prompt and adequate systemic immunosuppressive therapy.

CONCLUSIONS

The incidence of sympathetic ophthalmia is very low. The main current risk is surgery, particularly retinal surgery, but visual prognosis is good if early diagnosis is made and rapid, adequate immunotherapy is commenced.

Postoperative sympathetic ophthalmia

Although uncommon, SO is a fearful postoperative complication because of its potential to blind both eyes. It can result not only from penetrating ocular surgery but also from nonpenetrating ocular procedures. Thus, it is important to consider in any patient who has undergone ocular surgery and develops bilateral uveitis, particularly because prompt, sufficient treatment is required to maximize visual outcome. It is also important to note that the disease may present with a spectrum of clinical findings, none of which is pathognomonic. Thus, suspicion is important for making the diagnosis. Treatment should address the T-cell-mediated nature of the disease. With appropriate treatment, visual acuity of no less than 20/60 is likely. However, before the start of treatment, which consists of immunosuppressants, infection must be ruled out and potential side effects of treatments must be considered. Furthermore, any patient with a history of SO needs ample immunosuppressant coverage for ocular procedures. Better understanding of the pathogenesis of the disease may lead to safer treatments that result in improved visual outcome and a cure. Meanwhile, because of its relapsing nature, SO requires continual, close surveillance, even after many years of quiescence.

The 1998 Wendell Hughes Lecture. Evisceration: is sympathetic ophthalmia a concern in the new millennium?

PURPOSE

To investigate a possible relationship between evisceration and sympathetic ophthalmia.

METHODS

Data from Mt. Sinai Medical Center and University Hospitals of Cleveland were collected and histopathologic specimens were reviewed for 51 of 90 patients who underwent evisceration between 1980 and 1996 and who returned for follow-up examinations. Additionally, a survey was sent to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, the Uveitis Society, and the Eastern Ophthalmic Pathology Society to determine the number of enucleations and eviscerations performed and the documented incidence of sympathetic ophthalmia after evisceration.

RESULTS

No clinical or histopathologic evidence of sympathetic ophthalmia after evisceration was found among patients treated at the two medical centers. The collective surveys showed a strong preference for enucleation over evisceration, but did not document evidence of sympathetic ophthalmia after evisceration.

CONCLUSIONS

Evisceration is an effective and safe procedure with a low risk for sympathetic ophthalmia.

[Epidemiological characteristics and risk factors of sympathetic ophthalmia]

Clinical factors of risk of sympathic ophthalmia (SO) determined by the type of injury, methods of surgical and drug treatment, and supported by published data were distinguished as a result of treating 158 patients with SO at the Helmholts Research Institute of Ophthalmic Diseases from 1965 to 1994. Special attention is paid to the possibility of SO development during steroid therapy of posttraumatic uveitis. In such cases SO develops in case of 1) sudden discontinuation of a course of steroids; 2) discontinuation of a short course of steroid therapy in the presence of persisting signs of posttraumatic uveitis; and 3) in surgery on the traumatized (operated on) eyes and low steroid doses.

A historical review of sympathetic ophthalmia and its epidemiology

Sympathetic ophthalmia was given its complete clinical description by William Mackenzic in 1840, and fully described in terms of its histopathology by Ernst Fuchs in 1905. A review of epidemiologic data from the 19th and 20th centuries reveals that acceptable statistical studies have yet to be carried out, but suggests that the disease has always been of extremely low incidence. Further, there does not appear to be a markedly decreased incidence in the "modern era." The etiology of the disease remains elusive, although the pathogenesis appears to be due to delayed hypersensitivity (cell-mediated immunity), possibly directed at a surface membrane antigen that is shared by photoreceptors, retinal pigment epithelium and choroidal melanocytes. The only effective therapy remains preventive enucleation of the injured eye, despite modern usage of immunosuppressive agents. Studies have suggested that early enucleation of a blind exciting eye can improve the prognosis for the sympathizing eye.

Sympathetic ophthalmia: a comparison of the histopathological features from a Chinese and American series

The importance of this comparison between two large series of cases of sympathetic ophthalmia lies in its confirmation of our previous findings, which differ somewhat from the classical pathological description. Sympathetic ophthalmia remains a clinicopathological diagnosis, relying on a history of perforating injury to one eye, followed after a variable incubation period by inflammation in the fellow eye. The inflammatory changes in both eyes consist of a diffuse, granulomatous proliferation throughout the uveal tract, which involves the choriocapillaris and the retina late in its course. The infiltrate is composed predominantly of lymphocytes and plasma cells, with a variable number of epitheloid and giant cells. Corticosteroid therapy may modify this picture. The epithelioid cells contain phagocytosed pigment granules, but there is not sign of necrosis. Eosinophils appear early in the course of the disease and disappear late. The granulomatous inflammation may spread to involve the optic nerve sheath, the nerve itself, the scleral emissaria, and the scleral stroma. Dalén-Fuchs nodules appear early peripherally, and it is over these nodules that retinal granulomas, when present, usually are found. In the Shanghai series, it was found that corticosteroid therapy and prompt enucleation of the exciting eye reduced the number of exacerbations experienced by these patients but did not improve visual prognosis. The MEEI data, while they did show a bimodal distribution to the visual result, seemed to indicate that prompt enucleation of a blind eye combined with aggressive corticosteroid therapy may improve visual prognosis.

Recent advances in sympathetic ophthalmia

Recent advances in understanding the pathogenesis of sympathetic ophthalmia are helping to remove the pigmented cloud which has obstructed the view of researchers on this disease for many years. Clinical features, diagnostic testing, histopathologic variations and principles of treatment are evaluated in the context of our increasing understanding of the pathogenesis of this disease. The relationship of sympathetic ophthalmia to Harada's disease and phacoantigenic uveitis are reviewed.

[Recent details of the frequency and immunologic reactivity of sympathetic ophthalmia (author's transl)]

When giving details of the frequency of Sympathetic Ophthalmia a clear distinction must be made between this disorder and the Phacogenic Ophthalmia also affecting the second eye. The latter is found with lens damage, whereas genuine Sympathetic Ophthalmia in relation to enucleation, eye damage and eye opening surgery at Heidelberg University between 1937 and 1973 is less than 1%, a figure markedly below figures quoted in the earlier literature. In two out of three patients with recent genuine Sympathetic Ophthalmia we found an augmented stimulation index in the LTT with retina antigen, not choroid antigen, as compared to control groups. This can be regarded as due to an individually augmented immunologic reactivity towards eye specific tissue antigens.