Sympathetic ophthalmia. Ample room for controversy

PENETRATING TRAUMA ASSOCIATED WITH FINDINGS OF MULTIPLE EVANESCENT WHITE DOT SYNDROME IN THE SECOND EYE

PURPOSE

To report a case of sympathetic ophthalmia (SO) resembling multiple evanescent white dot syndrome (MEWDS).

METHODS

Retrospective chart review.

RESULTS

A 17-year-old girl with a ruptured globe in the right eye underwent prompt primary repair and vitrectomy, scleral buckling, and silicone oil infusion 3 weeks later. Eight weeks after injury, she presented with visual loss in the left eye. Fundus examination in the left eye disclosed optic disk swelling and well-circumscribed, 100 to 500 microm diameter gray-white lesions at the level of the retinal pigment epithelium (RPE) posterior to the equator, sparing the fovea. On fluorescein angiography, the lesions appeared as areas of blocked choroidal fluorescence in the arterial phase and were associated with dye leakage in a wreathlike pattern during venous filling. Dye leakage occurred at the optic disk. Visual field testing showed depressed central sensitivity and an enlarged blind spot in the left eye. The patient was treated with prednisone and underwent diagnostic enucleation of the right eye. Histopathology showed rare choroidal granulomata and pigment phagocytosis. Vision improved to 20/20 in the left eye, and the window defects persisted. Visual field testing 6 months later was normal. One month after discontinuing prednisone, new areas of RPE hypopigmentation developed. Two weeks later, choroidal inflammation recurred and periphlebitis developed.

CONCLUSION

This case indicates that SO can mimic MEWDS.

Relationship between sympathetic ophthalmia, phacoanaphylatic endophthalmitis, and Vogt-Koyanagi-Harada disease

The more than coincidental occurrence of phacoanaphylatic endophthalmitis (PE) in sympathetic ophthalmia, and the similarity of the dissimilarity between Vogt-Koyanagi-Harada (VKH) disease and sympathetic ophthalmia have been well described both clinically and histopathologically. The etiology and pathogenesis of these three diseases are still not fully understood. Identifying and distinctive characteristics among them include the history of ocular trauma in sympathetic ophthalmia, rupture of the lens capsule in phacoanaphylatic endophthalmitis, and involvement of the skin, ear, and central nervous system in VKH disease. A T-cell-mediated immune reaction to ocular antigens seems to play a major role in sympathetic ophthalmia and VKH disease. A B-cell-related Arthus reaction to lens antigen seems to be the principle mechanism of PE. Thus, these three diseases may represent a spectrum of uveitis. At one end is the delayed-type hypersensitivity disease of sympathetic ophthalmia, whereas at the opposite end is the immune complex disease of PE, with VKH disease in the middle of this uveitic spectrum.

Sympathetic ophthalmia. Immunopathological findings

Ocular tissue from six patients with a clinical diagnosis of sympathetic ophthalmia (SO) was examined using immunohistochemical techniques. All patients presented with a history of bilateral panuveitis after penetrating ocular injury or multiple intraocular surgeries and clinical features of SO. In four cases, classic histopathological features of SO were observed, including granulomatous uveal tract infiltration and subretinal pigment epithelium (RPE) collections of inflammatory cells (Dalen-Fuchs nodules). Bone marrow derived monocytes were the major cellular components in these granulomas. In two cases, histopathology failed to demonstrate typical Dalen-Fuchs nodules or granulomas in the choroid. However, the choroidal infiltrates were composed primarily of T-helper and B lymphocytes, without macrophages or epithelioid cells. The eyes examined in this report indicate that a varied spectrum of immunopathological and histopathological findings may occur in clinically diagnosed SO.

Immunology of chorioretinal disorders

Because of its uniqueness, the eye has long been a favored site for immunological study. It is a highly active tissue immunologically, with virtually all types of immune reactions present. This article reviews the ocular immune response, chorioretinal diseases with immunologic features, and immunology of ocular tumors. Immunologic data is discussed as it relates to the pathogenesis, clinical features, and therapy of chorioretinal disease.