Sympathetic ophthalmia

Sympathetic ophthalmia (SO) is a granulomatous uveitis (a kind of inflammation) of both eyes following trauma to one eye. It is the most dreaded complication of unilateral severe eye injury, as it can leave the patient completely blind. Symptoms may develop from days to several years after a penetrating eye injury. Recent reviews by Damico et al. (2005), Chu and Foster (2002), and Friedlaender et al. (2001) should be consulted for more details.

Additional recommended knowledge

Essential Laboratory Skills Guide

Daily Visual Balance Check

Daily Sensitivity Test

History

Although descriptions of sympathetic ophthalmia can be found in Greek texts (Albert and Diaz-Rohena, 1989), our modern understanding of SO derives from the works of William MacKenzie, who characterized and named the disease sympathetic ophthalmitis. At that time, oral mercury and leeches applied to the conjunctiva were the treatments of choice for SO (MacKenzie, 1954).

It is thought that Louis Braille, who injured his left eye as a child, lost vision in his right eye due to SO (Kaden 1977).

Clinical Features

Floating spots and loss of accommodation are among the earliest symptoms. The disease may progress to severe iridocyclitis with pain and photophobia. Commonly the eye remains relatively painless while the inflammatory disease spreads through the uvea. The retina, however, usually remains uninvolved, although perivascular cuffing of the retinal vessels with inflammatory cells may occur. Papilledema, secondary glaucoma, vitiligo, and poliosis of the eyelashes may accompany SO.

In approximately 80% of cases, the uveitis appears within 2-12 weeks after injury, and 90% occur within 1 year from the time of injury. However, isolated cases as early as 1 week (2003) or as late as 66 years after initial injury have been reported (Zaharia et al, 1984).

Epidemiology

Sympathetic ophthalmia is rare, affecting 0.2% to 0.5% of non-surgical eye wounds, and less than 0.1% of surgical penetrating eye wounds. There are no gender or racial differences in incidence of SO.

Pathophysiology

Sympathetic ophthalmia is currently thought to be an autoimmune inflammatory response toward ocular antigens, specifically a delayed hypersensitivity to melanin-containing structures from the outer segments of the photoreceptor layer of the retina. The immune system, which normally is not exposed to ocular antigens, is introduced to the contents of the eye following traumatic injury. Once exposed, it senses these antigens as foreign, and begins attacking them. The onset of this process can be from days to years after the inciting traumatic event.

Diagnosis

Diagnosis is clinical, seeking a history of eye injury. An important differential diagnosis is Vogt-Koyanagi-Harada syndrome (VKH), which is thought to have the same pathogenesis, without a history of surgery or penetrating eye injury.

Still experimental, skin tests with soluble extracts of human or bovine uveal tissue are said to elicit delayed hypersensitivity responses in these patients. Additionally, circulating antibodies to uveal antigens have been found in patients with SO and VKH, as well as those with long-standing uveitis, making this a less than specific assay for SO and VKH.

Prevention and Treatment

Definitive prevention of SO requires prompt (within the first 7 to 10 days following injury) enucleation of the injured eye. Evisceration--the removal of the contents of the globe while leaving the sclera and extraocular muscles intact--is easier to perform, offers long-term orbital stability, and is more aesthetically pleasing. There is concern, however, that evisceration may lead to a higher incidence of SO compared to enucleation (reviewed by Migliori, 2002). Several retrospective studies involving over 3000 eviscerations, however, have failed to identify a single case of SO.

Because SO is so rarely encountered following eye injury, even when the injured eye is retained, the first choice of treatment may not be enucleation or evisceration, especially if there is a chance that the injured eye may regain some function (Gurdal et al, 2002). Additionally, with current advanced surgical techniques, many eyes once considered nonviable now have a fair prognosis.

Immunosuppressive therapy is the mainstay of treatment for SO. When initiated promptly following injury, it is effective in controlling the inflammation and improving the prognosis. Mild cases may be treated with local application of corticosteroids and pupillary dilators. More severe or progressive cases require high-dose systemic corticosteroids for months to years. Patients who become resistant to corticosteroids or develop side effects of long-term corticosteroid therapy (osteoporosis and pathologic fractures, mental status changes, etc.), may be candidates for therapy with chlorambucil, cyclophosphamide, or ciclosporin.

Associated Conditions

• Vogt-Koyanagi-Harada syndrome

References

• Albert DM, Diaz-Rohena R, A historical review of sympathetic ophthalmia and its epidemiology. Surv Ophthalmol. 1989;34(1):1-14. PMID 2678549
• Chu DS, Foster CS. Sympathetic ophthalmia. Int Ophthalmol Clin. 2002;42(3):179-85. PMID 12131594
• Damico FM, Kiss S, and Young LH Sympathetic ophthalmia. Semin Ophthalmol. 2005;20(3):191-7. PMID 16282154
• Friedlaender, MH and O'Connor GR, Eye Diseases, in Medical Immunology 10th Ed. (2001), Parslow, T.G., Stites, D.P. Terr, A.I., and Imboden, J.B. (Eds). New York: Lange Medical Books/McGraw-Hill, ISBN 0-8385-6300-7
• Gurdal C, Erdener U, Irkec M, Orhan M. Incidence of sympathetic ophthalmia after penetrating eye injury and choice of treatment.Ocul Immunol Inflamm. 2002;10(3):223-7. PMID 12789598
• Kaden R (1977). "[Historic notices of Louis braille and the development of dot-writing (author's transl)]". Klinische Monatsblätter für Augenheilkunde 170 (1): 154-8. PMID 321864.
• MacKenzie WA. Practical treatise on the diseases of the eye, (1954) London: Longman, Brown, Green and Longmans, pp 611-621.
• Migliori ME.Enucleation versus evisceration. Curr Opin Ophthalmol. 2002;13(5):298-302. PMID 12218460
• Zaharia MA, Lamarche J, Laurin M. Sympathetic uveitis 66 years after injury. Can J Ophthalmol. 1984;19(5):240-3. PMID 6478310