Sympathetic ophthalmitis

INTRODUCTION:
  • Sympathetic ophthalmia is an inflammation in the second eye after the other has been damaged by penetrating injury.
  • Some portion of the uvea of the injured eye has been exposed to the atmosphere for at least 1 hour.
  • The uninjured eye develops minor signs of anterior uveitis usually within 1 year.
  • Due to the inflammation of ciliary body, patients initially presents with floating spots and loss of the power of accommodation.
ETIOLOGY:
  • Sympathetic ophthalmitis or ophthalmia almost always results from a penetrating wound
  • Incarceration of the iris or lens capsule is more likely to set up sympathetic ophthalmitis than others
SYMPTOMS :
  • It is a granulomatous uveitis of both eyes following trauma to one eye.
  • Keratic precipitates at the back of cornea
  • It can leave the patient completely blind.
  • Structure commonly involved in sympathetic ophthalmia is Iris and ciliary body
  • Symptoms may develop from days to several years after a penetrating eye injury.
  • The earliest symptom of sympathetic ophthalmitis is Photophobia
  • Floating spots and loss of accommodation are among the earliest symptoms.
  • The disease may progress to severe iridocyclitis with pain
  • Commonly the eye remains relatively painless while the inflammatory may occur. disease spreads through the uvea, where characteristic focal infiltrates in the choroid named Dalen-Fuchs nodules can be seen.
  • Papilledema, secondary glaucoma, vitiligo, and poliosis of the eyelashes may accompany SO.
  • In approximately 80% of cases, the uveitis appears within 3-12 weeks after injury, and 90% occur within 1 year from the time of injury.
  • Sympathetic ophthalmia is currently thought to be an autoimmune inflammatory response toward ocular antigens, specifically a delayed hypersensitivity to melanin-containing structures from the outer segments of the photoreceptor layer of the retina.
  • The immune system, which normally is not exposed to ocular antigens, is introduced to the contents of the eye following traumatic injury.
  • Once exposed, it senses these antigens as foreign, and begins attacking them.
  • The onset of this process can be from days to years after the inciting traumatic event.
DIAGNOSIS
  • Diagnosis is clinical, seeking a history of eye injury.
  • An important differential diagnosis is Vogt-Koyanagi-Harada syndrome (VKH), which is thought to have the same pathogenesis, without a history of surgery or penetrating eye injury.
  • Giant cells located within the choroid ,T lymphocytes & Eosinophils are the histopathologic features of sympathetic ophthalmia
PREVENTION & TREATMENT:
  • Definitive prevention of SO requires prompt (within the first 7 to 10 days following injury) enucleation of the injured eye.
  • Evisceration—the removal of the contents of the globe while leaving the sclera and extraocular muscles intact—is easier to perform, offers long-term orbital stability, and is more aesthetically pleasing.
  1. There is concern, however, that evisceration may lead to a higher incidence of SO compared to enucleation
  2. The first choice of treatment may not be enucleation or evisceration, especially if there is a chance that the injured eye may regain some function
  3. Immunosuppressive therapy is the mainstay of treatment for SO.
  4. Mild cases may be treated with local application of corticosteroids and pupillary dilators.
  5. More severe or progressive cases require high-dose systemic corticosteroids for months to years.
  • Patients who become resistant to corticosteroids or develop side effects of long-term corticosteroid therapy (osteoporosis and pathologic fractures, mental status changes, etc.), may be candidates for therapy with chlorambucil, cyclophosphamide, or ciclosporin.
Exam Question
  • Giant cells located within the choroid ,T lymphocytes & Eosinophils are the histopathologic features of sympathetic ophthalmia
  • Dalen Fuch's nodules are seen in Sympathetic ophthalmia
  • If a person shows impaired vision of eye after few weeks of gun shot injury to another eye this is suggestive of Sympathetic ophthalmia
  • Photophobia, redness and watering from both eyes after sustaining a trauma to one eye month back is diagnosis of sympathetic ophthalmitis
  • Sympathetic ophthalmitis is a serious bilateral granulomatous panuveitis which occur following penetrating ocular trauma
  • Sympathetic ophthalmitis affects both eye because Uveal pigment act as allergen which inturn induce plastic uveitis in the sound eye.
  • Common features between sympathetic ophthalmitis and Vogt Kanayagi Harada syndrome is Autoimmune etiology & Uveitis
  • In sympathetic ophthalmitis first sign is Presence of KP's.
  • The earliest symptom of sympathetic ophthalmitis is Photophobia
  • Sympathetic ophthalmitis develops 3 wks-12 wks after trauma
  • Structure commonly involved in sympathetic ophthalmia is Iris and ciliary body
  • Sympathetic ophthalmitis or ophthalmia almost always results from a penetrating wound
  • Clinically in the non-injured eye, sympathetic ophthalmitis may manifest as Acute plastic iridocyclitis,Neuroretinitis,Choroiditis
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