Sympathetic ophthalmitis

Sympathetic ophthalmitis

• Sympathetic ophthalmia is an inflammation in the second eye after the other has been damaged by penetrating injury.
• Some portion of the uvea of the injured eye has been exposed to the atmosphere for at least 1 hour.
• The uninjured eye develops minor signs of anterior uveitis usually within 1 year.
• Due to the inflammation of ciliary body, patients initially presents with floating spots and loss of the power of accommodation.

ETIOLOGY:

• Sympathetic ophthalmitis or ophthalmia almost always results from a penetrating wound
• Incarceration of the iris or lens capsule is more likely to set up sympathetic ophthalmitis than others

SYMPTOMS :

• It is a granulomatous uveitis of both eyes following trauma to one eye.
• Keratic precipitates at the back of cornea
• It can leave the patient completely blind.
• Structure commonly involved in sympathetic ophthalmia is Iris and ciliary body
• Symptoms may develop from days to several years after a penetrating eye injury.
• The earliest symptom of sympathetic ophthalmitis is Photophobia
• Floating spots and loss of accommodation are among the earliest symptoms.
• The disease may progress to severe iridocyclitis with pain
• Commonly the eye remains relatively painless while the inflammatory may occur. disease spreads through the uvea, where characteristic focal infiltrates in the choroid named Dalen-Fuchs nodules can be seen.
• Papilledema, secondary glaucoma, vitiligo, and poliosis of the eyelashes may accompany SO.
• In approximately 80% of cases, the uveitis appears within 3-12 weeks after injury, and 90% occur within 1 year from the time of injury.
• 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.
• Giant cells located within the choroid ,T lymphocytes & Eosinophils are the histopathologic features of sympathetic ophthalmia 

PREVENTION & 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.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.
• There is concern, however, that evisceration may lead to a higher incidence of SO compared to enucleation
• 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
• Immunosuppressive therapy is the mainstay of treatment for SO.
• 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.