Immunological investigations in post-traumatic granulomatous and non-granulomatous uveitis

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.

Postsurgical sympathetic ophthalmia: retrospective analysis of a rare entity

PURPOSE

To describe clinical manifestations, management and visual outcome in postsurgical sympathetic ophthalmia (SO).

METHODS

Retrospective study.

RESULTS

Mean age of the patients was 41.1 years, and males were affected 1.8 times than the female. Vitrectomy and scleral buckling were the most common inciting surgeries followed by cataract surgery. Among 10 eyes with anterior uveitis, mutton-fat keratic precipitate was seen in only two eyes. Mean follow-up duration was 1556.50 ± 1470.75 days. Vision significantly improved in 11 patients (78.6%; p = 0.005).

CONCLUSION

Postsurgical SO is a rare entity, but it is a bilateral blinding disease and SO following surgical intervention can have variable presentations. Rapid, effective management of postsurgical sympathetic ophthalmia can give improved visual outcomes.

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.

Keloids - the sebum hypothesis revisited

The aetiology of the keloid scar has not been completely elucidated. Numerous hypotheses have been proposed in the past to explain the unusual characteristics of the keloid scar. While we do know that there is excessive and ongoing collagen-deposition, the exact triggering stimulus is a subject of conjecture. We present some of our photographic records of keloids and electron microscopic findings of keloid edges and reiterate the sebum hypothesis. We also attempt to explain the features of keloids in the light of the present knowledge of immunology and cell biology.

High incidence of sympathetic ophthalmia after contact and noncontact neodymium:YAG cyclotherapy

BACKGROUND

Two cases of sympathetic ophthalmia occurring after noncontact neodymium:YAG (Nd:YAG) cyclotherapy have previously been reported. In each case, the patient had undergone filtering surgery in the exciting eye. Although in each case Nd:YAG cyclotherapy was the last surgery performed, the inciting event of sympathetic ophthalmia was unclear.

METHODS

The authors studied three additional patients who developed sympathetic ophthalmia after Nd:YAG cyclotherapy for glaucoma.

RESULTS

Two patients developed sympathetic ophthalmia 4 months after noncontact Nd:YAG cyclotherapy, and 1 patient developed sympathetic ophthalmia 18 months after contact Nd:YAG cyclotherapy. All patients had previous cataract extractions but no filtering surgery in the exciting eye. Clinical features included chronic iridocyclitis, choroidal folds, Dalen-Fuchs nodules, and optic disc edema. Combining these cases with the two previously reported cases, the incidence of sympathetic ophthalmia at our institution thus far is 5.8% (4 of 69) and 0.67% (1 of 150) after noncontact and contact Nd:YAG cyclotherapy, respectively.

CONCLUSIONS

The incidence of sympathetic ophthalmia after Nd:YAG cyclotherapy is high compared with other ocular procedures. The clinician should vigilantly monitor patients after Nd:YAG cyclotherapy and report additional cases that may have occurred at other institutions.

Immune mechanisms in choroido-retinal inflammation in man

The immunohistopathological findings of enucleated eyes and immunological abnormalities in several clinical disorders which result in intraocular inflammation are presented. With current immunological techniques, it is possible to define the type and activation status of the cells infiltrating the tissues. In all eyes examined, the predominant cell type was of activated CD4+ T-cells suggesting that the mechanisms involved in the perpetuation of the inflammatory response are similar and it is the initiating events which are likely to determine the site of pathology. The effects of activated CD4+ T-cells and the lymphokines they secrete in the chronic inflammatory process in the ocular tissues are discussed.

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.

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 multisystem ocular disease

In this review based on Prof. James' 1983 George Nelms Wise Lecture, the authors summarize proven and speculated relationships involved in the immunology of multisystem ocular disease. Extensive tables elucidate the mechanisms underlying such conditions as, systemic lupus erythematosus, polyarteritis nodosa, Sjögren's syndrome, Wegener's granulomatosis, scleritis, sarcoidosis, Behcet's disease, idiopathic retinal vasculitis, sympathetic ophthalmia, Vogt-Koyanagi-Harada syndrome, and dysthyroid eye disease.

Serum antibody level to S-antigen in children with chronic uveitis

Bovine S-antigen was purified by gel filtration and ion exchange chromatography according to previously described techniques. An enzyme linked immunosorbent assay (ELISA) using antiserum to bovine S-antigen raised in guinea-pigs was employed to detect S-antigen in the chromatographic fractions. The purity of the S-antigen was determined by SDS-PAGE electrophoresis, where a single band was found. The purified S-antigen in microgram quantities together with Freund's complete adjuvant induced uveitis in rats two weeks after injection into the foot pad. Serum samples from children suffering from chronic uveitis and healthy children were tested for antibodies to S-antigen by the ELISA. A statistically significant difference in the level of specific antibodies between patients and controls was found. There was no clear-cut correlation between the severity of uveitis and antibody titre, but cases with retinal involvement and aggressive uveitis all showed definite elevations of antibodies to S-antigen.

Testicular exocrine malfunction after torsion

The exocrine and endocrine functions of the testis were assessed in 67 patients a median of 4.0 years after unilateral torsion (range 3 months-12 years). Of 54 patients who underwent orchidopexy, some atrophy of the affected testis developed in 46; the degree of atrophy was significantly correlated with the duration of torsion (r = -0.56, p less than 0.001). The remaining 13 patients had undergone orchidectomy after a mean duration of torsion of 71 h. Seminal analysis was abnormal in 44 of 51 patients tested (86%), and the low total motile sperm count correlated with the duration of torsion (r = -0.53, p less than 0.001). Sperm counts were much lower in men with torsion for longer than 8 h than those with a shorter period of torsion (median 7.2 X 10(6) v 83.5 X 10(6); p less than 0.00003). Serum levels of luteinising hormone, prolactin, testosterone, and follicle-stimulating hormone were generally within normal limits. An acute ischaemic episode affecting only one testis causes bilateral loss of exocrine function in most patients, while endocrine function is preserved.

Sympathetic orchidopathia

Subfertility has recently been shown to follow unilateral torsion of the spermatic cord in more than half the patients studied. Since the anatomical anomaly that predisposes to torsion (a high investment of the tunica vaginalis) is commonly bilateral, there could be an associated congenital defect in spermatogenesis on each side. Alternatively, autoantigens escaping from the ischaemic or 'exciting' testis could trigger an immunological response which damages the contralateral or 'sympathising' testis. Demonstration of an autoallergic (sympathetic) orchidopathia, analogous to sympathetic ophthalmia, would fundamentally alter the management of testicular torsion.

Light and electron microscopic study of Dalén-Fuchs nodules in sympathetic ophthalmia

A light and electron microscopic study was undertaken in an effort to establish the origin of the "epithelioid" cells in Dalén-Fuchs nodules from an eye enucleated because of sympathetic ophthalmia. The nodules were visible as minute (130-160 microns), round, grayish-white mounds elevating the retinal pigment epithelium. Bruch's membrane appeared intact in all the sections examined. By electron microscopy the "epithelioid" cells had round to oval nuclei with abundant, relatively lucent cytoplasm containing parallel profiles of rough-surfaced endoplasmic reticulum, prominent Golgi lamellae, clusters of polyribosomes, and scattered mitochondria. Many interdigitations of the plasma membranes, some of which exhibited fascia adherens type attachments, were observed. Some cells within the nodules showed large membrane-bound phagosomes containing laminated structures. Other "epithelioid" cells displayed moderately electron dense membrane-bound granules that appeared to be early precursors of lipofuscin granules. Examination of the nodules under ultraviolet light showed myriad autofluorescent yellowish-orange dots consistent with lipofuscin. Additionally, a montage of electron micrographs from the edge of the nodule, coupled with the above findings, provided support to the concept proposed by Ishikawa and Ikui (1972) that the "epithelioid" cells in Dalén-Fuchs nodules represent transformed retinal pigment epithelial cells forming a cage-like framework within the nodule. This study also emphasizes the remarkable capabilities for differentiation by the retinal pigment epithelial cells.

Sixty-five years of sympathetic ophthalmia. A clinicopathologic review of 105 cases (1913--1978)

A retrospective clinicopathologic review of 105 cases of sympathetic ophthalmia showed histologic features of prognostic significance and evaluated the role of therapy. Classic descriptions omit retinal changes, but 58.0% of our cases had retinal detachment and 42.2% showed intraretinal inflammation. The optic nerve and/or meninges were inflamed in 51%. Optic atrophy was seen in 54.4%. Plasma cells are said to be characteristically absent, but 65.0% of steroid-treated and 85.7% of cases before the steroid era showed plasma cell infiltration. Severity of inflammation pathologically correlated with final visual outcome, and corticosteroid therapy changed both the character and severity of inflammation. Early enucleation of the exciting eye after onset of symptoms in the fellow eye was found to improve visual prognosis. Electron microscopy performed on fresh tissue and choroidal cell cultures revealed no viral particles, and viral and mycoplasma cultures all proved negative.

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.