Sympathetic Ophthalmia

Synonyms: sympathetic ophthalmitis, sympathetic uveitis

This is an inflammatory condition affecting both eyes that occurs after a penetrating injury (accidental or surgical) to one of the eyes. It is thought to possibly be an auto-immune reaction to the exposed tissue proteins within the damaged eye.

It is a very rare condition, occurring in about 3 out of every 10,000,000 cases of penetrating injury.¹ About two-thirds occur within a fortnight of the injury and 90% within the first year (range: 5 days to 66 years!).² The main risk is surgery - particularly retinal surgery.¹

Any inflammation of an (uninvolved) eye following trauma to the fellow eye is suspect.

History

• Bilateral deterioration of vision
• Painful red eyes
• Photophobia
• History of penetrating ocular trauma or surgery

Examination

This reveals diffuse bilateral intra-ocular inflammation. Without a slit-lamp, this will be seen as red eyes. There will usually be signs of previous injury to one eye. With a slit lamp, look for 'mutton-fat' keratic precipitates (collections of inflammatory cells sitting in large clumps on the posterior surface of the cornea) and a hazy anterior chamber which indicates inflammatory activity (if you are able to focus in there, you will see inflammatory cells which look like particles of dust crossing a light shaft in a darkened room). There is optic disc swelling and choroiditis (seen as discrete white patches on the retina). There may be peripheral anterior synechiae (the rim of the iris is stuck forwards onto the trabecular meshwork), neovascularisation of the iris and occlusion of the pupil.

• Vogt-Koyanagi-Harada syndrome
• Sarcoidosis
• Tuberculosis
• Syphilis

Blood tests (e.g. full blood count, VDRL and ACE levels) and chest x rays may be performed to rule out possible differentials and an ultrasound scan ± fluorescein angiography (injection of contrast dye to visualise the vessels at the back of the eye) may be performed to help confirm the diagnosis.

It is managed aggressively with steroids ± immunosuppressive agents. Cycloplegics may also be helpful for the symptoms. Enucleation (removal of the globe) of the previously traumatised eye may need to be considered if this is blind anyway as this may improve the sympathetic ophthalmia.⁴

They include neovascularisation of the iris (which can lead to secondary glaucoma), cataract and retinal detachment.

The prognosis is poor without rapid intervention; there is a reasonable chance that useful vision will be retained in those where diagnosis and appropriate treatment was prompt.¹ Very rarely, the uveitis follows a relatively mild and self-limiting course.⁵

In the irretrievably blind, traumatised eye, enucleation within 14 days of trauma can reduce the risk of developing this condition.