Sympathetic ophthalmia associated with pars plana vitrectomy without antecedent penetrating trauma

Sympathetic Ophthalmia after Vitreoretinal Surgery without Antecedent History of Trauma: A Systematic Review and Meta-Analysis

Background: To evaluate the morbidity frequency measures in terms of the cumulative incidence of sympathetic ophthalmia (SO) triggered by single or multiple vitreoretinal (VR) surgery procedures in eyes without an antecedent history of trauma and previous ocular surgery, except for previous or concomitant uneventful lens extraction, and to further investigate the relationship between VR surgery and SO. Methods: A literature search was conducted using PubMed, Embase, and Scopus from inception until 11 November 2022. The Joanna Briggs Institute (JBI) critical appraisal checklist for the case series and the Newcastle–Ottawa Scale were used to assess the risk of bias. The research was registered with the PROSPERO database (identifier, CRD42023397792). Meta-analyses were conducted using the measurement of risk and a 95% confidence interval (CI) for each study. Results: A random-effect meta-analysis demonstrated that the pooled cumulative incidence of SO triggered by single or multiple VR surgery procedures in eyes without an antecedent history of trauma and previous ocular surgery, except for previous or concomitant uneventful lens extraction among patients who developed SO regardless of the main trigger, was equal to 0.14 with a CI between 0.08 and 0.21 (I2 = 78.25, z: 7.24, p < 0.01). The pooled cumulative incidence of SO triggered by single or multiple VR surgery procedures in eyes without an antecedent history of trauma and previous ocular surgery, except for previous or concomitant uneventful lens extraction among patients who underwent VR surgery, was equal to 0.03 for every 100 people, with a confidence interval (CI) between 0.02% and 0.004% (I2 = 27.77, z: 9.11, p = 0.25). Conclusions: Despite postsurgical SO being a rare entity, it is a sight-threatening disease. VR surgery should be viewed as a possible inciting event for SO and considered when counseling patients undergoing VR surgery.

Sympathetic ophthalmia: A comprehensive update

Sympathetic ophthalmia is a rare, bilateral, granulomatous, panuveitis following penetrating trauma or surgery to one eye. Clinical presentation commonly occurs within the first year of trauma occurrence but can be delayed by several years. It manifests as acute/chronic granulomatous uveitis with yellowish-white choroidal lesions or Dalen-Fuchs nodules. Initially, patients respond rapidly to corticosteroid therapy, but a majority require long-term use of corticosteroid-sparing agents to prevent recurrences. The purpose of this review is to elaborate on the current understanding of the pathophysiology, the importance of multimodal imaging in early diagnosis, and the role of newer immunomodulatory and biological agents in recalcitrant cases.

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.

Clinical classification, visual outcomes, and optical coherence tomographic features of 48 patients with posterior sympathetic ophthalmia

Background

To investigate the clinical manifestations, visual outcomes and optical coherence tomographic (OCT) features of patients with posterior sympathetic ophthalmia (PSO).

Methods

We performed a retrospective review of 48 patients diagnosed with PSO between January 2013 and December 2019. We compared the clinical and OCT features among different clinical types of PSO.

Results

PSO could be classified into two types according to whether the fundus exhibited serous retinal detachment (SRD) or multifocal choroiditis (MFC). There were 41 patients (85.4%) with SRD and 7 patients (14.6%) with MFC. The latent period of patients with MFC was significantly longer than that of patients with SRD (P = 0.002). The final visual acuity of patients with MFC was significantly worse than that of patients with SRD (P = 0.0001). In patients with acute SRD, OCT revealed that the mean height of retinal detachment in the fovea was 528.8 ± 437.5 μm. After treatment, the retina reattached in all patients and the band structures of the outer retina were restored in most patients (92.7%). In patients with acute MFC, the OCT images revealed inflammatory lesions on the retinal pigment epithelium layer. After treatment, the OCT images showed hyperreflective fibrosis of the lesions and loss of the outer retinal band structures in all patients.

Conclusions

We found that PSO could be classified according to the presence of SRD or MFC. The visual prognosis differed significantly between these types of PSO. OCT imaging is useful for clinical classification and monitoring of retinal changes after treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02258-0.

Recent advances in diagnosis and management of sympathetic ophthalmia

PURPOSE OF REVIEW

Sympathetic ophthalmia is a bilateral granulomatous uveitis that occurs following unilateral trauma or surgery and is sight-threatening in the contralateral eye. Despite significant potential morbidity, disease remains poorly understood. Variable presentations and clinical courses, as well as a lack of definitive diagnostic laboratory tests can complicate the diagnosis and result in delayed treatment, which can beget permanent vision loss. This review focuses on recent advances in areas of pathophysiology, classification, diagnosis and treatment.

RECENT FINDINGS

Sympathetic ophthalmia is thought to involve a cell-mediated immune response to retinal and uveal antigens exposed through trauma or surgery. Multiple mechanisms have been implicated, including activation of the interleukin-23/IL-17 pathway. Ongoing emphasis is placed on early disease recognition and prompt treatment with multimodal imaging. Multiple authors advocate for the routine use of optical coherence tomography (OCT) for screening and disease monitoring. Systemic steroids and steroids sparing-immunosuppressive agents remain the mainstay of treatment.

SUMMARY

Understanding pathophysiology may provide useful targets for drug development, as well as allow for identification of patients at risk. OCT is a useful tool in early diagnosis and management of sympathetic ophthalmia, as OCT changes may precede clinical symptoms and signs, allowing for early disease detection and better visual outcomes.

Sympathetic ophthalmia after vitreoretinal surgery: a report of two cases

Sympathetic ophthalmia (SO) is a panuveitis that usually occurs after trauma to one eye. We describe two cases of SO occurring after 23-gauge vitrectomy. Case 1 involved a 66-year-old woman who underwent pars plana vitrectomy (PPV) for a rhegmatogenous retinal detachment. Two months later, she presented with decreased visual acuity (VA) and bilateral uveitis. Case 2 involved a 43-year-old woman who underwent a second PPV for recurrent retinal detachment. Two months later, she presented with bilateral panuveitis. Both patients were diagnosed with SO and were treated with methylprednisolone and cyclosporine. The first patient was further treated with a dexamethasone intravitreal implant (Ozurdex®) owing to the side effects of methylprednisolone. The VA and symptoms improved significantly after treatment in both patients. Bilateral granulomatous panuveitis following PPV should alert surgeons to consider SO. Appropriate interventions for SO can produce positive outcomes.

Persumed sympathetic Ophthalmia after scleral buckling surgery: case report

Background

Scleral buckling (SB) is usually considered an extraocular operation premeditated to have a low risk of sympathetic ophthalmia (SO). Here we report a rare case of presumed SO in a young female patient following SB.

Case presentation

A nineteen-year-old female patient was referred for visual loss in her left eye due to macula off inferior long-standing rhegmatogenous retinal detachment (RRD). The best corrected visual acuity (BCVA) was 20/400 in the left eye. SB with 360 degrees encircling band, an inferior segmental tire with one spot cryoretinopexy at the break site, and subretinal fluid drainage was performed. BCVA was improved to 20/80 and the retina was totally attached 1 week after the operation. The patient referred to the hospital 6 weeks later with severe visual loss in both eyes as counting finger 1 m. Patient examination indicated bilateral multifocal serous retinal detachment (SRD) and vitreous cells. The patient, diagnosed with SO, received intravenous corticosteroid pulse therapy and mycophenolate mofetil for treatment. The inflammation was controlled and SRD resolved after a 5-day intravenous treatment without being relapsed after 6 months. Consequently, BCVA became 20/20 and 20/50 in the right and left eye, respectively, after 6 months. The findings of systemic workup were negative for any extraocular disease or systemic involvement.

Conclusion

Since SB is a procedure without manipulating intraocular tissues, it is considered to impose a low risk for SO. This report presented SO occurrence after successful SB. Some factors may induce SO, including inciting the choroid and retinal pigment epithelium with cryoretinopexy or perforating for drainage.

Sympathetic Ophthalmia after Vitreoretinal Surgeries: Incidence, Clinical Presentations and Outcomes of a Rare Disease

Aim: To evaluate clinical presentation, course and outcomes in patients without a history of penetrating ocular trauma who developed Sympathetic Ophthalmia (SO) following vitreoretinal surgeries Methods: Retrospective review of clinical records of all patients diagnosed and treated as S.O was done . All cases without a previous history of trauma were included and were analyzed with respect to clinical presentations, anatomic and visual outcomes. Results: 175 cases of sympathetic ophthalmia were diagnosed and treated till June 2017. 16 of these cases had undergone a pars plana vitrecomy (PPV) in the past and had no history of prior ocular trauma. SO after vitreoetinal surgeries accounted for 9.14 percent of all cases of SO .In the same duration, till 2017,a total 41365 PPV were done. Thus 0.038 percent of PPV cases developed a SO . 10 patients were males and 6 were females. The median age at presentation was 45.7 years. The time interval from surgery to diagnosis of sympathetic ophthalmia ranged from 22 days to 4 years after undergoing a surgery. The mean visual acuity in the sympathizing eye was 1.26 logMAR (snellens equivalent of 20/320) which improved to 0.62 logMAR(snellens equivalent of 20/80) after treatment. The most common anterior segment finding was non granulomatous anterior uveitis, seen in 8 cases (50%) while neurosensory detachments were the most common posterior segment presentation (10 cases, 62.5%).12 patients had undergone more than 1 surgery (mean number of surgeries was 1.88). 10 patients had undergone a sutureless PPV (6 cases of 23 gauge and 4 cases of 25 gauge vitrectomy) while 4 patients had undergone a 20 gauge vitrectomy where all sclerotomies were sutured after surgery All patients were treated with systemic steroids and immunosuppresants and 15 out of 16 patients showed significant improvement in the final visual acuity in the sympathizing eye Conclusions: Sympathetic ophthalmia after vitreoretinal surgeries is a rare but potentially sight threatening disease occurring in 0.038 percent of all cases of Pars Plana Vitrectomy. Presence of inflammation in the fellow eye after a vitreoretinal surgery in the other eye should alert the surgeon to possibility of sympathetic ophthalmia.

Surgical Intervention in Inciting Eyes of Patients with Sympathetic Ophthalmia: A Case Series and Review of Literature

Purpose: To analyze the outcomes of surgical procedures on inciting eye of patients with Sympathetic ophthalmia (SO). Methods: Retrospective study of patients with SO who underwent surgical procedures on inciting eyes between January 2000 and December 2015. Outcome measures included flare up of inflammation in either eye and change in visual acuity in the inciting eye. Results: Four SO patients underwent surgeries in their inciting eyes after adequate control of inflammation. Surgical procedures included penetrating keratoplasty, glaucoma drainage device implantation, pars plana vitrectomy, and silicon oil removal. Keratoplasty, glaucoma surgery, and silicon oil removal were well tolerated, with no flare up of disease. The patient who underwent pars plana vitrectomy, however, had a poor outcome. Conclusions: Surgical intervention in inciting eyes of patients with SO, after being adequately treated with oral steroids and immunosuppression, is a viable option for improving anatomic and functional outcomes in these eyes.

Dexamethasone Implant as Sole Therapy in Sympathetic Ophthalmia

We present the case of a 46-year-old woman with sympathetic ophthalmia occurring 27 years after complicated juvenile cataract surgeries. The patient declined systemic immunosuppressive therapy. Dexamethasone implant in the sympathizing eye allowed good visual recovery up to 18 months of follow-up with a total of 6 implants. Intraocular pressure rise was controlled medically. This is a unique report of sympathetic ophthalmia treated solely with slow-release dexamethasone implant without systemic therapies.

Sympathetic Ophthalmia after successful Retinal Reattachment Surgery with Vitrectomy

PURPOSE

To report a case of sympathetic ophthalmia (SO) following one successful pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment.

METHODS

Case report.

RESULTS

A 50-year-old man developed SO 5 weeks after successful repair of rhegmatogenous retinal detachment with PPV and intraocular gas tamponade. The patient presented with bilateral multifocal exudative retinal detachments and inflamed optic nerve with characteristic changes of SO detected by fluorescein angiography, indocyanine green angiography, and optical coherence tomography. Prompt use of systemic steroids and cyclosporin A resulted in control of the uveitis with significant visual improvement.

CONCLUSIONS

PPV should be viewed as a major risk factor for development of SO.

Sympathetic ophthalmitis following vitreoretinal surgery: Does antecedent trauma make a difference?

Background:

Sympathetic ophthalmitis (SO) has been reported following vitrectomy; however, there is a lack of data on the role of antecedent penetrating ocular trauma impacting the disease manifestation in eyes developing SO following vitrectomy.

Aim:

To report differences in the presentation and outcomes of SO in eyes with or without a history of antecedent penetrating trauma; SO being diagnosed after vitreoretinal (VR) surgery.

Design:

Comparative case series.

Methods:

Seventeen consecutive patients presenting with SO following VR surgery, diagnosed between 1995 and 2011 were included. Eyes with and without prior penetrating injury were included in Group I (n = 7) and Group II (n = 10), respectively. All Group I patients had received systemic steroids prior to presentation. Demographic and clinical parameters were evaluated.

Results:

Differences were observed between Group I and Group II mainly with regards to time interval between VR surgery and diagnosis of SO (1.5 months vs. 8 months, P = 0.10), presence of neurosensory detachments (100% vs. 30%, P = 0.01), and the inciting eye vision at presentation (nil light perception in 28.5% vs. 80%, P = 0.049). Other differences observed though not statistically significant were optic disc and retinal vessel involvement (42% vs. 70%, P = 0.28), Dalen-Fuchs nodules (localized vs. diffuse) and leaks on fundus fluorescein angiography (pin-head vs. pin-point leak).

Conclusion:

SO in patients with antecedent penetrating ocular trauma present early with the central serous chorioretinopathy-like picture. Prior use of systemic steroids might have a bearing on the differences in presentation and the visual acuities between the two groups.

Continued vision loss from progressive expansion of inactive chorioretinal scars in a myopic patient with well-controlled sympathetic ophthalmia

PURPOSE

To describe significant vision loss caused by enlargement of chorioretinal scars related to sympathetic ophthalmia despite adequate control of intraocular inflammation.

METHODS

A case report of a 62-year-old man who developed sympathetic ophthalmia after a vitrectomy, which was successful in repairing a rhegmatogenous retinal detachment.

RESULTS

Progressive expansion of chorioretinal scars occurred despite successful control of intraocular inflammation related to sympathetic ophthalmia. The visual acuity declined from 20/20 to no light perception in the right eye and from 20/400 to light perception in the left eye over 11 years of follow-up.

CONCLUSION

Progressive enlargement of chorioretinal scars and visual loss may occur despite adequate control of intraocular inflammation in patients with sympathetic ophthalmia. Similar patterns of scar expansion have been reported in eyes after laser photocoagulation, but we believe this is the first report of scar enlargement in the setting of well-controlled sympathetic ophthalmia.

[Sympathetic ophthalmia]

Sympathetic ophthalmia is a rare, bilateral granulomatous uveitis that occurs after either surgical or accidental trauma to one eye. The etiology is still not completely clear, but evidence suggests that sympathetic ophthalmia represents an autoimmune inflammatory response against choroidal melanocytes mediated by T cells. Key features are vision impairment and symptoms associated with inflammation. The diagnosis is based on a history of previous ocular trauma or surgery and clinical findings. Differential diagnoses include other causes of granulomatous uveitis, such as Vogt-Koyanagi-Harada disease, sarcoidosis, tuberculosis, and syphilis. Depending on the suspected etiology, treatment of sympathetic ophthalmia consists of systemic anti-inflammatory agents, including corticosteroids and immunomodulating drugs. The role of enucleation after the diagnosis of sympathetic ophthalmia remains controversial. Visual prognosis is reasonably good with prompt appropriate wound repair and immunomodulatory therapy. As the occurrence of sympathetic ophthalmia is probably more frequent following vitreoretinal surgery, more attention has to be paid to this potentially bilateral blinding disorder.

Sympathetic ophthalmia

BACKGROUND

Sympathetic ophthalmia (SO) is a rare, bilateral, non-necrotizing, granulomatous uveitis that occurs after ocular trauma or surgical procedures to one eye threatening sight in the fellow eye. The pathophysiology is not clearly understood, but it appears that the disrupted integrity of the inciting eye leads to an autoimmune hypersensitivity reaction against the exposed ocular antigens in the injured eye as well as in the sympathizing eye. More recently, vitreoretinal surgery has been noted to be a risk factor for the development of SO.

METHODS

Medline search for case reports of sympathetic ophthalmia with links to full text in English yielded articles for review of patient demographics, clinical presentation and examination, therapies and final visual acuity.

RESULTS

Eighty-six patients with SO were included in this review. Sixty-two patients were male and 24 were female with an average age of 46 years. Injuries accounted for 47% of patients while ocular surgery was reported in 44% of patients with pars plana vitrectomy occurring in 21%. Most patients reported reduced vision and presented with uveitis. Ninety-five percent of them received systemic corticosteroid therapy and 75% of patients also received immunomodulators. About 70% of patients had improved visual acuity in their sympathizing eye at their last reported evaluation.

CONCLUSIONS

Sympathetic ophthalmia warrants prompt evaluation and treatment to maintain a favorable visual outcome. Ocular surgeries including vitreoretinal surgery and cyclodestructive procedures have been noted to be risk factors for the development of sympathetic ophthalmia. With current medical management including corticosteroids and immunomodulators visual prognosis is relatively good.

Recurrent neovascularization of the disc in sympathetic ophthalmia

Sympathetic ophthalmia following parsplana vitrectomy is a known complication. We describe here a case of recurrent disc neovascularization in a patient of sympathetic ophthalmia. It promptly responded to steroids initially but later recurred with inflammation.

Use of intravitreal triamcinolone acetonide injection in unilateral idiopathic juxtafoveal telangiectasis

Idiopathic juxtafoveal telangiectasis (IJT) is one of the primary retinal telangiectasia that can result in visual impairment attributed to resultant cystoid macular oedema and rarely, choroidal neovascularization. The authors herein report successful treatment using intravitreal triamcinolone acetonide in a case of unilateral IJT that did not respond to prior laser photocoagulation. Serial optical coherence tomography was used to monitor the effectiveness of intravitreal triamcinolone acetonide in the treatment of IJT.

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.

Clinical Case Notes. Changing trends in sympathetic ophthalmia

Sympathetic ophthalmia is a rare and potentially visually devastating bilateral panuveitis, typically following non-surgical penetrating injury to one eye. Three patients are presented where sympathetic ophthalmia developed after repeated vitreoretinal surgery. Prompt and effective management with systemic immunosuppressive agents permitted control of their disease and retention of good visual acuity in their remaining eye. Vitreoretinal surgery is an important risk factor in sympathetic ophthalmia. Informed consent for vitreoretinal surgery (especially in the re-operation setting) should now include the risk of sympathetic ophthalmia (approximately 1 in 800). Diverse clinical presentations are possible in sympathetic ophthalmia and any bilateral uveitis following vitreoretinal surgery should alert the surgeon to the possibility of sympathetic ophthalmia. Modern immunosuppressive therapy with systemic steroids and steroid-sparing agents such as cyclosporin A and azathioprine have improved the prognosis. This is particularly so in cases where early diagnosis is made and prompt and suitable immunotherapy is commenced.

Intravitreal triamcinolone acetonide injection in blind painful eyes. Intraocular steroids as a treatment for blind painful red eyes

PURPOSE

Phthisis bulbi results from different ocular conditions. We evaluated intravitreal triamcinolone acetonide as a treatment option in blind painful eyes.

METHODS

Thirty-one patients with unilateral phthisis were randomly divided into two groups. Group A received 0.3 ml (12.5 mg) triamcinolone acetonide intravitreally and Group B 0.3 ml balanced salt solution after retrobulbar anesthesia. Treatment success was assessed by subjective response to pain and clinically by biomicroscopic evaluation of conjunctival congestion. Tonometry was done before and after treatment. Follow-ups were at 24 hours, 3 weeks, 3 and 6 months, and 1 and 2 years.

RESULTS

Throughout the two-year follow-up, only two patients in Group A reported pain after the procedure and were retreated, one at week 4 and the other at week 7. Conjunctival congestion was significantly lower in Group A. Two patients with hypotony before treatment had normal tension after triamcinolone. All Group B patients were reinjected with triamcinolone because pain continued after balanced salt solution injection. No severe complications were found.

CONCLUSIONS

Intravitreal triamcinolone acetonide may be effective and safe for treating blind painful eyes.