The diagnosis of sympathetic ophthalmia is based on clinical examination and evaluation of history.12,13 However, ocular investigations like fundus fluorescein angiogram and OCT are useful adjuncts in establishing the diagnosis.14,15 It classically manifest as bilateral granulomatous pan-uveitis with a definitive history of penetrating trauma and rarely by blunt trauma.16 Posterior segment shows moderate to dense vitritis, choroiditis, and papillitis with multiple exudative retinal detachments.17,18 The onset of disease is within 1 year in 90% of patients and 17% present within 1 month.17,19 Our patient presented on the 28th day of traumatic repair and 30th day of trauma. None of the anterior segment findings as seen in typical sympathetic ophthalmia could be elucidated in our patient possibly attributed to prior steroid therapy. Kumar et al20 showed 30% of isolated posterior segment findings in their case series on sympathetic ophthalmia. Gupta et al21 demonstrated that 22 of their 40 patients presented with exudative retinal detachment with no evidence of anterior segment inflammation, leading to the conclusion that lone posterior segment findings may be indicative of early diagnosis where anterior segment has not yet involved or it is an atypical presentation. Our patient presented with lone posterior segment findings, which is very consistent with 2 of the previous case series.20,21 Isolated posterior segment findings could be explained by previous immunosuppression in the immediate postoperative period.
Optical coherence tomography is a useful noninvasive tool in the diagnosis and in determining the efficacy of treatment in sympathetic ophthalmia.22,23 Optical coherence tomography demonstrates exudative retinal detachments and its reduction marks the response to treatment. Our patient too had gradual reduction in exudative retinal separation in OCT after steroid therapy. Sympathetic ophthalmia is treated with immunosuppressive therapy. Because of the high risk of recurrence, patients needs timely follow-up. Recurrence calls for institution of other immunosuppressive therapy such as chlorambucil and azathioprine.24 In our case, there was complete resolution of exudative retinal detachment with high-dose steroids, which was maintained for 6 months and showed no signs of recurrence undermining the need of immunosuppressants.
Sympathetic ophthalmia is a rare phenomenon and can still occur despite attempted prophylaxis with corticosteroid therapy and that OCT findings parallel clinical improvement. The present case is reported owing to its rarity and unusual presentation.
1. Kilmartin DJ, Dick AD, Forrester JV. Prospective surveillance of sympathetic ophthalmia in the United Kingdom and Republic of Ireland. Br J Ophthalmol 2000;84:259–263.
2. Towler HMA, Lightman S. Sympathetic ophthalmia. Int Ophthalmol Clin 1995;35:31–42.
3. Rao NA, Forster DJ, Spalton DJ. Sympathetic ophthalmia. In: Podos SM, Yanoff M, eds. The Uvea Uveitis and Intraocular Neoplasms. Vol 2. Chapter 8. Mosby-Wolfe; 1995:8.10–8.13.
4. Nussenblatt RB. Sympathetic ophthalmia. In: Nussenblatt RB, Whitcup SM, eds. Uveitis Fundamentals and Clinical Practice. Chapter 22. 3rd ed. Elsevier; 2004:311–323.
5. Ahmad N, Soong TK, Salvi S, et al Sympathetic ophthalmia after ruthenium plaque brachytherapy. Br J Ophthalmol 2007;91:399–401.
6. Buller AJ, Doris JP, Bonshek R, et al Sympathetic ophthalmia following severe fungal keratitis. Eye (Lond) 2006;20:1306–1307.
7. Jonas JB, Back W, Sauder G, et al Sympathetic ophthalmia in vater association combined with persisting hyperplastic primary vitreous after cyclodestructive procedure. Eur J Ophthalmol 2006;16:171–172.
8. Chan CC, Benezra D, Rodrigues MM, et al Immunohistochemistry and electron microscopy of choroidal infiltrates and Dalen-Fuchs nodules in sympathetic ophthalmia. Ophthalmology 1985;92:580–590.
9. Jakobiec FA, Marboe CC, Knowles DM II, et al Human sympathetic ophthalmia. An analysis of the inflammatory infiltrate by hybridoma-monoclonal antibodies, immunochemistry, and correlative electron microscopy. Ophthalmology 1983;90:76–95.
10. Albert DM, Diaz-Rohena R. A historical review of sympathetic ophthalmia and its epidemiology. Surv Ophthalmol 1989;34:1–14.
11. Chan RV, Seiff BD, Lincoff HA, Coleman DJ. Rapid recovery of sympathetic ophthalmia with treatment augmented by intravitreal steroids. Retina 2006;26:243–247.
12. Lubin JR, Albert DM, Weinstein M. Sixty-five years of sympathetic ophthalmia. A clinicopathologic review of 105 cases (1913–19788). Ophthalmology 1980;87:109–121.
13. Damico FM, Kiss S, Young LH. Sympathetic ophthalmia. Semin Ophthalmol 2005;20:191–197.
14. Fleischman D, Say EA, Wright JD, Landers MB. Multimodality diagnostic imaging in a case of sympathetic ophthalmia. Ocul Immunol Inflamm 2012;20:300–302.
15. Castiblanco C, Adelman RA. Imaging for sympathetic ophthalmia: impact on the diagnosis and management. Int Ophthalmol Clin 2012;52:173–181.
16. Castiblanco CP, Adelman RA. Sympathetic ophthalmia. Graefes Arch Clin Exp Ophthalmol 2009;247:289–302.
17. Chu XK, Chan CC. Sympathetic ophthalmia: to the twenty-first century and beyond. J Ophthalmic Inflamm Infect 2013;3:49.
18. Arevalo JF, Garcia RA, Al-Dhibi HA, et al Update on sympathetic ophthalmia. Middle East Afr J Ophthalmol 2012;19:13–21.
19. Goto H, Rao NA. Sympathetic ophthalmia and Vogt-Koyanagi-Harada syndrome. Int Ophthalmol Clin 1990;30:279–285.
20. Kumar K, Mathai A, Murthy SI, et al Sympathetic ophthalmia in pediatric age group: clinical features and challenges in management in a tertiary center in southern India. Ocul Immunol Inflamm 2014;22:367–372.
21. Gupta V, Gupta A, Dogra MR. Posterior sympathetic ophthalmia: a single centre long-term study of 40 patients from North India. Eye (Lond) 2008;22:1459–1464.
22. Puliafito C. Acute sympathetic ophthalmia. In: Joel S. Schuman, Carmen A. Puliafito, James G. Fujimoto, eds. Optical Coherence Tomography of Ocular Diseases. 2nd ed. New York, NY: Slack; 2003:386–393.
23. Gupta V, Gupta A, Dogra MR, Singh I. Reversible retinal changes in the acute stage of sympathetic ophthalmia seen on spectral domain optical coherence tomography. Int Ophthalmol 2011;31:105–110.
24. Maruyama Y, Kishi S. Tomographic features of serous retinal detachment in Vogt- Koyanagi-Harada syndrome. Ophthalmic Surg Lasers Imaging 2004;35:239–242.