SYMPATHETIC OPHTHALMITIS

Sympathetic ophthalmitis is a serious bilateral
granulomatous panuveitis which follows a penetrating
ocular trauma. The injured eye is called exciting eye
and the fellow eye which also develops uveitis is
called sympathizing eye. Very rarely, sympathetic
ophthalmitis can also occur following an intraocular
surgery.
Incidence
Incidence of sympathetic ophthalmitis has
tremendously decreased in the recent years due to
meticulous repair of the injured eye utilizing
microsurgical techniques and use of the potent
steroids.
Etiology
Etiology of sympathetic ophthalmitis is still not
known exactly. However, the facts related with its
occurrence are as follows:
A. Predisposing factors
1. It almost always follows a penetrating wound.
2. Wounds in the ciliary region (the so-called
dangerous zone) are more prone to it.
3. Wounds with incarceration of the iris, ciliary
body or lens capsule are more vulnerable.
4. It is more common in children than in adults.
5. It does not occur when actual suppuration
develops in the injured eye.
B. Pathogenesis. Various theories have been put
forward. Most accepted one is allergic theory, which
postulates that the uveal pigment acts as allergen
and excites plastic uveitis in the sound eye.
Pathology
It is characteristic of granulomatous uveitis, i.e., there
is nodular aggregation of lymphocytes, plasma cells,
epitheloid cells and giant cells scattered throughout
the uveal tract.
Dalen-Fuchs’ nodules are formed due to
proliferation of the pigment epithelium (of the iris,
ciliary body and choroid) associated with invasion
by the lymphocytes and epitheloid cells. Retina shows
perivascular cellular infiltration (sympathetic
perivasculitis).
Clinical picture
I. Exciting (injured) eye. It shows clinical features of
persistent low grade plastic uveitis, which include
ciliary congestion, lacrimation and tenderness.
Keratic precipitates may be present at the back of
cornea (dangerous sign).
II. Sympathizing (sound) eye. It is usually involved
after 4-8 weeks of injury in the other eye. Earliest
reported case is after 9 days of injury. Most of the
cases occur within the first year. However, delayed
and very late cases are also reported. Sympathetic
ophthalmitis, almost always, manifests as acute
plastic iridocyclitis. Rarely it may manifest as
neuroretinitis or choroiditis. Clinical picture of the
iridocyclitis in sympathizing eye can be divided into
two stages:
1. Prodromal stage. Symptoms. sensitivity to light
(photophobia) and transient indistinctness of near
objects (due to weakening of accommodation) are
the earliest symptoms.
Signs. In this stage the first sign may be presence of
retrolental flare and cells or the presence of a few
keratic precipitates (KPs) on back of cornea. Other
signs includes mild ciliary congestion, slight
tenderness of the globe, fine vitreous haze and disc
oedema which is seen occasionally.
2. Fully-developed stage. It is clinically characterised
by typical signs and symptoms consistent with acute
plastic iridocyclitis (see page 141).
Treatment
A. Prophylaxis
I. Early excision of the injured eye. It is the best
prophylaxis when there is no chance of saving useful
vision.
II. When there is hope of saving useful vision,
following steps should be taken:
1. A meticulous repair of the wound using
microsurgical technique should be carried out,
taking great care that uveal tissue is not
incarcerated in the wound.
2. Immediate expectant treatment with topical as
well as systemic steroids and antibiotics along
with topical atropine should be started.
3. When the uveitis is not controlled after 2 weeks
of expectant treatment, i.e., lacrimation,
photophobia and ciliary congestion persist and if
KPs appear, this eye should be excised
immediately.