Sympathetic Ophthalmitis Research Articles

Vogt-Koyanagi-Harada Disease: A Narrative Review.

Vogt-Koyanagi-Harada (VKH) disease is an idiopathic immune-related sickness that affects multiple systems and melanocytes in organs such as the uvea, ear, and meninges. The primary cause of activity is cellular immunological responses. Vogt-Koyanagi disease is identified primarily by skin abnormalities and anterior uveitis. Harada's illness is distinguished by neurological symptoms and exudative retinal detachments, which are associated with the HLA-DR4 and HLA-DRw53 genes.Pigmented races, such as Hispanics and Native Americans, are more likely to have VKH disease. Clinical features are blurred vision, floaters, alopecia, vitiligo, diffuse choroidal inflammation with disc edema, and exudative retinal detachment. Differential diagnoses include posterior scleritis, uveal effusion syndrome, central serous chorioretinopathy, and sympathetic ophthalmitis. The investigations used are optical coherence tomography (OCT), fundus fluorescein angiography (FA), and B-scan ultrasonography (USG). Treatment is done by using systemic steroids, cycloplegics, and immunosuppressants.

Material risk: vitreoretinal surgery, evisceration, enucleation and sympathetic ophthalmia-where are we currently?

Sympathetic ophthalmia (SO) is known to occur after severe penetrating eye injury, evisceration and even enucleation surgery. Recent evidence suggests that a greater risk lies after multiple vitreoretinal procedures. The risk of SO following evisceration is only minimally greater than that following enucleation surgery. This review evaluates literature on SO to date and provides figures for the risk of developing SO for the purposes of the consent process. The issue of SO and Material Risk following vitreoretinal surgery is reviewed and figures for the purposes of consent are outlined. This is of particular relevance for patients in whom the contralateral eye is and will likely remain the better seeing eye. Sympathetic ophthalmitis is known to occur after severe penetrating eye injury, after evisceration and enucleation. More recently, sympathetic ophthalmitis has been recognised to occur after vitreoretinal surgery. This article reviews the evidence on material risk when consenting patients for elective and emergency eye procedures after ocular trauma or surgery. When a globe needs to be removed because of irreparable ocular injury, previous publications dictated the procedure to be an enucleation because of the fear of an increased risk of SO after an evisceration. Perhaps the issue of material risk of sympathetic ophthalmia (SO) remains over-emphasised by ophthalmic plastic surgeons and under-recognised by vitreoretinal surgeons during the consent process for evisceration, enucleation and vitreoretinal surgery. Antecedent trauma and number of previous surgeries may actually be a more significant risk factor than the type of eye removal. Recent medicolegal cases also help us understand the importance of the discussion of this risk. We present our current understanding of the risk of SO after different procedures and suggest how this information may be included in a patient consent.

Spectral-domain optical coherence tomography biomarkers in vitreoretinal lymphoma.

Although early detection is critical, diagnosing vitreoretinal lymphoma (VRL) remains difficult. We sought to assess the potential diagnostic value of spectral-domain optical coherence tomography (SD-OCT) in VRL. We reviewed the clinical records and pre-treatment SD-OCT images of biopsy-confirmed VRL and uveitis patients, with primary involvement of the sub-retinal pigment epithelium (RPE) and the outer retina, including acute syphilitic posterior placoid chorioretinitis (ASPPC), chronic stage sympathetic ophthalmitis (SO), and idiopathic multifocal choroiditis (MFC). We included 45 eyes of 45 VRL patients and 40 eyes of 40 uveitis patients (17 ASPPC eyes, eight chronic SO eyes, and 15 MFC eyes). On SD-OCT, lymphoma cell infiltration was observed in various retinal layers, most commonly in the sub-RPE (80%) and sub-retinal space (62%). Highly sensitive features for VRL as compared to uveitis included vitreous cells (93%), focal hyper-reflective sub-retinal infiltration (51%), and diffuse RPE elevations (56%). The features strongly specific for VRL included preretinal deposits (92.5%), intra-retinal infiltration (except the incomplete vertical hyper-reflective type, 100%), banded hyper-reflective sub-retinal infiltration (90%), and confluent RPE detachments (100%). We identified an approach to VRL diagnosis based on these SD-OCT findings: (1) two highly sensitive features plus one strongly specific feature; or (2) one highly sensitive feature plus two strongly specific features, demonstrated a sensitivity of 80% and specificity of 95% for VRL. The SD-OCT may enable the detection of detailed lymphoma infiltration characteristics and provide significant supplemental value for VRL diagnosis, particularly when combining highly sensitive and specific VRL-associated SD-OCT features.

Pattern of uveitis from a tertiary eye care center in Himalayan belt of North India.

Purpose:To study the clinical characteristics of uveitis in patients presenting to a tertiary care institute in the northern part of India, predominantly serving the population of Himalayan belt.Methods:In this retrospective descriptive case series, data of 141 eyes of 102 patients diagnosed between January 2019 and January 2021 were analyzed. Patients were diagnosed, named, and meshed as per the Standardization of Uveitis Nomenclature. A panel of investigations (systemic and ocular ancillary investigations) were done, which was individualized according to the clinical picture.Results:The mean age of presentation was 39.1 ± 14.62 years. A male predominance (62.7%) was noted. Unilateral presentation was seen in 61.8% of patients. Specific etiological diagnosis was not reached in 56.7% of cases. The incidence of infectious and noninfectious uveitis was 23.4% and 19.9%, respectively. The frequency of anterior, intermediate, posterior, and panuveitis was 23.4%, 11.3%, 46.8%, and 18.5%, respectively. Posterior uveitis was the most frequent anatomical location (46.8%). Tuberculous uveitis was the most common definitive etiology irrespective of location (18.5%). Anterior, intermediate, and posterior uveitis were more frequently idiopathic in origin. Sympathetic ophthalmitis was the most common cause for panuveitis.Conclusion:Uveitis significantly affected the working age group population. Despite the evolution of diagnostic investigations, etiology remained unknown in many cases of uveitis. Infectious etiology was more common. Posterior uveitis as the most frequent anatomical location in our study may be attributed to the tertiary care referral bias.

Diagnosis of Choroidal Disease With Deep Learning-Based Image Enhancement and Volumetric Quantification of Optical Coherence Tomography.

PurposeThe purpose of this study was to quantify choroidal vessels (CVs) in pathological eyes in three dimensions (3D) using optical coherence tomography (OCT) and a deep-learning analysis.MethodsA single-center retrospective study including 34 eyes of 34 patients (7 women and 27 men) with treatment-naïve central serous chorioretinopathy (CSC) and 33 eyes of 17 patients (7 women and 10 men) with Vogt-Koyanagi-Harada disease (VKH) or sympathetic ophthalmitis (SO) were imaged consecutively between October 2012 and May 2019 with a swept source OCT. Seventy-seven eyes of 39 age-matched volunteers (26 women and 13 men) with no sign of ocular pathology were imaged for comparison. Deep-learning-based image enhancement pipeline enabled CV segmentation and visualization in 3D, after which quantitative vessel volume maps were acquired to compare normal and diseased eyes and to track the clinical course of eyes in the disease group. Region-based vessel volumes and vessel indices were utilized for disease diagnosis.ResultsOCT-based CV volume maps disclose regional CV changes in patients with CSC, VKH, or SO. Three metrics, (i) choroidal volume, (ii) CV volume, and (iii) CV index, exhibit high sensitivity and specificity in discriminating pathological choroids from healthy ones.ConclusionsThe deep-learning analysis of OCT images described here provides a 3D visualization of the choroid, and allows quantification of features in the datasets to identify choroidal disease and distinguish between different diseases.Translational RelevanceThis novel analysis can be applied retrospectively to existing OCT datasets, and it represents a significant advance toward the automated diagnosis of choroidal pathologies based on observations and quantifications of the vasculature.

STEROID PULSE THERAPY IN SEVERE SYMPATHETIC OPHTHALMITIS – A CASE SERIES OF 4 PATIENTS

Sympathetic ophthalmitis (SO) is a rare bilateral, granulomatous uveitis that occurs following surgical or accidental trauma to one eye. Injured eye is the Exciting eye and the fellow eye is the Sympathizing eye. Most accepted patho-physiology is immune mediated. In this series, 4 patients with varied presentations were started on steroid pulse therapy (SPT) following routine blood investigation. 1 gram i.v methyl-prednisolone was given on 3 consecutive days in 300 ml Normal Saline under close observation. The patients were then shifted to oral steroid which was gradually tapered over 11 days. The patients were followed up for a minimum period of 14 days and the visual outcome was recorded.

Epidemiology of 2000 Chinese uveitis patients from Northeast China

AimsTo study the clinical characteristics of 2000 patients with uveitis admitted to the ophthalmology centre of the Second Hospital of Jilin University.MethodsWe retrospectively analysed 2000 patients with uveitis who were...

Sympathetic ophthalmitis: A rare case presentation

Sympathetic Ophthalmitis is a rare, granulomatous uveitis occurring after perforating eye injury or ocular surgical procedure to one eye. The pathophysiologyis not clearly understood. We report a rare case of sympathetic ophthalmitis that presented to us in our hospital.Journal of Kathmandu Medical College, Vol. 4, No. 2, Issue 12, Apr.-Jun., 2015 page: 65-67

Recurrent sympathetic ophthalmitis

Sympathetic ophthalmitis (SO) is a rare, bilateral granulomatous uveitis occurring after perforating eye injury or ocular surgical procedure to one eye. The pathophysiology of this entity is not clearly understood, but an autoimmune hypersensitivity reaction against exposed ocular antigens in the injured eye is believed to be responsible for this disease. In this article, we present a patient with clinical diagnosis of SO with it recurrence.

Sympathetic ophthalmitis following adherent leucoma: A rare association

Introduction: Sympathetic ophthalmitis is a rare condition. It occurs due to bilateral granulomatous pan uveitis following penetrating trauma or surgery in one eye. Penetrating injury to eye causes exposure of uveoretinal antigens to regional lymph nodes via conjunctival lymphatics thereby inciting delayed T cell hypersensitivity. Case Report: A 35-year-old male patient presented with headache and sudden painless dimunition of vision in both eyes preceded by development of adherent leucoma in left eye due to a perforated bacterial corneal ulcer five months before. Best corrected visual acuity was finger counting close to face in both eyes. Anterior segment examination revealed few keratic precipitates (KPs), 1+ cells and retrolenticular flare in both eyes. Fundus examination revealed exudative retinal detachment in right eye but left eye could not be assessed due to adherent leucoma. B-scan ultrasonography (B-scan) revealed exudative retinal detachment in both eyes. Patient was managed medically with intravenous methyl prednisolone 1 g for 3 days followed by oral steroids which led to complete resolution of disease process in both eyes. After treatment the best corrected visual acuity was 20/30 in right and 20/80 in left eye. Conclusion: Patients with adherent leucoma subsequent to a perforated corneal ulcer may remain at an increased risk of developing sympathetic ophthalmitis during their lifetime. However, timely medical intervention can lead to good visual prognosis for both exciting as well as the sympathizing eye. Long-term follow-up is necessary as recurrences following cessation of treatment are known to occur.

Dalen Fuch′s nodules and serous retinal detachment on optical coherence tomography in sympathetic ophthalmitis

Dear Editor, Sympathetic Ophthalmitis (SO) is a rare, diffuse granulomatous uveitis characterized by Dalen Fuchs (DF) nodules. We present a case of SO where DF nodules and serous retinal detachment have been documented by spectral domain optical coherence tomography (OCT). To the best of our knowledge there is only one published report of DF nodules imaged by OCT.[1] Till recently, the confirmation of DF nodules could only be done by Electron Microscopy of histopathological samples. A 28-year-old man sustained a penetrating injury to his left eye for which he underwent surgical repair at a local hospital. Two weeks later he presented with pain, redness and blurring of vision in his right eye. On examination, the best corrected visual acuity (BCVA) of right eye was 6/12p, N10 while the left eye had no perception of light. Slit lamp examination of right eye showed circumcorneal congestion, multiple fine keratic precipitates with 2+ cells and flare and retrolental cells. Fundus examination revealed three small yellowish-white lesions suggestive of DF nodules, temporal to the fovea with an area of bullous elevation measuring 3 disc diameters seen supero-temporal to the fovea. Examination of the left eye showed a 2 mm sutured corneal wound with 3+ cells and flare, a 6 mm non-reactive pupil and early cataract. Vascularized tissue was seen in the retrolental area and there was no view of the fundus. Ultrasound B scan showed total retinal detachment with diffuse choroidal thickening in the left eye. OCT of right eye showed a localized small area of disorganized retinal pigment epithelium (RPE) with trans-retinal hyperactivity suggestive of DF nodule [Figs. ​[Figs.11 and ​and2].2]. The nodule appeared to have caused dome shaped elevation and destruction of the pigment epithelium corresponding to the third type of DF nodule described by Reynard et al.[2] Extensive disintegration of RPE and choriocapillaries have been described by Gallagher et al.[3] but in our case, the destruction was more focal. However, these earlier descriptions of DF nodules based on electron microscopy of tissue samples, might be at variance with the findings on OCT. There was also a large area of serous retinal detachment [Fig. 3] as seen in the case series of Gupta et al.[4] temporal to the macula causing disruption of the normal photoreceptor layer. Intra ocular pressures measured 14 and 4 mmHg in the right and left eyes respectively. Figure 1 Optical coherence tomography of the right eye showing Dalen Fuchs Nodule (arrow) Figure 2 Optical coherence tomography of right eye: Retinal pigment epithelial surface map showing dome shaped elevations corresponding to the area of the Dalen Fuchs nodule (arrows) Figure 3 Optical coherence tomography of the right eye showing serous retinal detachment The patient was treated with topical steroids and cycloplegics in both eyes and with oral prednisolone 1 mg/kg which was tapered over a period of 2 months. After 2 weeks, his BCVA in the right eye was 6/6, N6 with a quiet anterior segment and fundus examination showed resolving DF nodules and serous detachments. Six weeks later, OCT showed complete resolution of DF nodules as well as the sub-retinal fluid with restoration of photoreceptors and inner and outer segments [Figs. ​[Figs.44 and ​and55]. Figure 4 and 5 Optical coherence tomography of right eye showing complete resolution of Dalen Fuchs nodule and serous retinal detachment SO is now rarely seen and so it is important for ophthalmologists to be aware of this dreaded complication. Early diagnosis and prompt treatment with systemic corticosteroids is absolutely necessary to prevent irreversible damage of the photoreceptor layer and to restore vision.[4] DF nodules can be clearly imaged by OCT which has emerged as an essential diagnostic tool in early detection, timely management and follow-up of patients with SO.[1]

Severe bilateral vision loss due to a unilateral penetrating injury by sympathetic ophthalmitis

April 2011, Vol. 101, No. 4 SAMJ The patient sustained an accidental injury that resulted in broken glass causing a penetrating eye injury in her left eye. A corneal laceration with iris prolapse was not identified at a secondary hospital. Eight weeks after the injury, she presented at Groote Schuur Hospital complaining of decreased vision and severe pain in both eyes. The diagnosis was sympathetic ophthalmitis after all infective and inflammatory causes were excluded. Her visual acuities were counting fingers at 30 cm with her left eye and 6/60 in her right eye. On cursory examination, the left eye seemed normal (Fig. 1) but a corneal scar with prolapsing intra-ocular tissue was visible on elevating the upper lid (Fig. 2). She was treated with systemic immunosuppression (intravenous methylprednisolone) and topical corticosteroids. The prolapsed iris was excised and the corneal laceration repaired. Vision in the left eye did not improve but improved to 6/36 in the right eye.

Management and Clinical Outcome of Penetrating Keratoplasty for Long-Term Corneal Changes in Sympathetic Ophthalmia

Purpose. To report the visual outcome of penetrating keratoplasty performed on the sympathizing eye in three cases of sympathetic ophthalmitis. Methods. Interventional case series of three patients, diagnosed with sympathetic ophthalmitis, with corneal changes in the form of band keratopathy and decompensation underwent penetrating keratoplasty to the sympathizing eye. They had each sustained penetrating trauma as a child and had undergone previous cataract surgery and superficial keratectomy. Two patients had undergone lamellar keratoplasty prior to this procedure. One patient had undergone trabeculectomy for glaucoma, and she was on antiglaucoma medication. The preoperative visual acuity was 1/60 in the affected eye of each patient. Penetrating keratoplasty was performed in the sympathizing eye and the donor graft size was 7.50 mm, and the host graft size was 7.25 mm. Our patients were immunosuppressed prior to the procedure to help prevent graft rejection. Result. At one year follow-up, a BCVA of 6/36 or better was achieved in all three patients. Postoperative examination of the fundus showed peripheral chorioretinal atrophy with pigmentary changes at the macula, accounting for the limited vision. The grafts remain clear to date, and there has been no recurrence of uveitis or rejection. Conclusion. Penetrating keratoplasty can be considered as a surgical option to restore useful vision in a stable sympathizing eye in sympathetic ophthalmitis, and this depends on the extent of the pathology. However, these cases require treatment with immunosuppressives to prevent graft rejection and to prolong graft survival.

Histopathological Changes of Cornea in Long-Term Sympathetic Ophthalmitis

To report the histopathological changes occurring in the cornea in sympathetic ophthalmitis. Observational case series of 3 patients with sympathetic ophthalmitis who were treated with penetrating keratoplasty. We report the histopathological features of the cornea. In all 3 cases, the epithelium was edematous and bullous with extensive loss of the Bowman layer and calcification of the superficial stroma in all the 3 eyes. The deep stroma was unremarkable in appearance. Descemet membrane showed thickening in 2 of the corneas with nodular excrescences and folds noted in 1 of the specimens. The endothelium was attenuated with some residual cells containing pigment granules in 1 case. Endothelial loss and development of bullous keratopathy associated with band keratopathy are predominate histopathological features of the cornea. These changes are nonspecific and reflect a chronic anterior uveitis.

Penetrating Keratoplasty for the Exciting Eye in Sympathetic Ophthalmia

We report a case of sympathetic ophthalmitis where we performed penetrating keratoplasty on the exciting eye many years after the initial injury. Case report. After penetrating keratoplasty, the patient achieved vision of 3/60 from preoperative perception of light. Our experience shows that penetrating keratoplasty can restore useful vision in the previously injured exciting eye in sympathetic ophthalmitis. This case highlights a unique example where the inciting eye has ultimately become the eye with the better vision as the damage was limited.

Sympathetic Ophthalmitis in Nigerians - Case Reports

We describe two cases of sympathetic uveitis in two Nigerian patients. The first case occurred after a penetrating injury while the second was after surgery in a painful blind eye. The aetiopathogenesis as well as the management of the condition in Nigeria are discussed. KEY WORDS: Sympathetic Ophthalmitis (Uveitis), Management, Nigeria [Nig. J. Ophthalmology Vol.10(1): 24-27]

Serum sialic acid levels in patients with sympathetic ophthalmitis.

Serum sialic acid levels were measured in 16 patients with sympathetic ophthalmitis, 36 with neglected traumatic uveitis following penetrating injury and 40 healthy subjects. There was no significant alteration of its level in patients with traumatic uveitis. However, its level was significantly elevated in patients with sympathetic ophthalmitis. It was high even in the early stage of the disease. It decreased significantly at the remission stage. It is proposed that measurement of sialic acid level in serum can be used as a diagnostic aid when the diagnosis of sympathetic ophthalmitis remains doubtful on clinical grounds. The extent of rise in its level may be considered a good parameter of the degree of severity of sympathetic ophthalmitis. It may also act as a useful tool to evaluate the drug efficacy in this disease.

Retinal antigen specific lymphocytes, TCR-gamma delta T cells and CD5+ B cells cultured from the vitreous in acute sympathetic ophthalmitis.

CD5+ B lymphocytes and TCR gamma-delta T lymphocytes, phenotypes implicated in the pathogenesis of autoimmune disease, were isolated from the vitreous in a case of acute sympathetic ophthalmitis. These cells were obtained using a method which allows the selective maintainance in vitro of in vivo activated T lymphocytes. Dual colour flow cytometry showed that after 3 days culture in IL-2 containing medium 61% of cells were CD5/CD19 + ve and 41% CD3/TCR gamma delta + ve. Of the total CD3 + ve population, 15% were gamma/delta negative. These cells formed a population which also responded in a proliferation assay to retinal antigens. Histologically the eye showed a marked mononuclear cell infiltration of the retina, ciliary body and choroid. Granulomatous lesions within the choroid contained lymphocytes, plasma cells and multinucleate giant cells. Immunocytochemistry showed lymphocyte populations to be predominantly CD2 + ve CD3 + ve T lymphocytes of the CD4 sub-set. Distribution of monocytes/macrophages throughout the lesions and restriction of B-lymphocytes to granulomata were all consistent with a DTH type reaction. Despite immunosuppressive therapy, the expression of activation antigens HLA-DR and ICAM-1 on infiltrating and resident ocular tissue cells was high, although IL-2 receptor (CD25) expression was virtually absent. Flow cytometric analysis of peripheral blood cells prior to treatment with Cyclosporin-A showed systemic activation of lymphocytes, with high levels of HLA-DR and CD25 expression and a raised CD4/CD8 ratio.

Greer's Ocular Pathology

Inflammation, immunity and the eye intraocular inflammation due to specific agents idiopathic intraocular inflammation sympathetic ophthalmitis and related conditions the conjunctiva, cornea and sclera the eyelids pigmented lesions of the eyelids and conjunctiva pigmented and other tumours of the uveal tract the lens the retina tumours of neuroepithelium glaucoma optic nerve tumours of the orbit the phacomatoses lymphoid hyperplasias and lymphomas congenital anomalies accidental and surgical trauma. Appendices: examining eye sections types of collagen complex carbohydrates common staining reactions.

Ocular trauma caused by airgun pellets: A ten year survey

Forty-one consecutive cases of ocular injury related to air gun pellets occurring over a ten year period have been reviewed retrospectively. The male to female ratio was 7:1 and the average age was fifteen years. Hyphaema was the most common injury (78%) while the main cause of poor final visual outcome was retinal detachment. Thirty-eight percent of the involved eyes had a final corrected visual acuity of less than 6/60 including four eyes (10%) which were enucleated following severe perforating injuries. Neither sympathetic ophthalmitis nor lead poisoning was detected in this study. The fact that these injuries are largely of an accidental nature, predominantly involve young people and appear to be occurring more frequently suggests that present legislation does not offer adequate protection. The authors suggest that the best method of prevention is through a public education campaign aimed at children and their parents.