Sympathetic Ophthalmia in Western India - All India ...

606 AIOC 2009 PROCEEDINGS
AUTHORS’S PROFILE:
DR. VINITA GIRISH RAO: M.B.B.S., Calcutta National Medical College, Calcutta, West
Bengal; M.S., Post graduation in Ophthalmology (DNB) from Sankar Nethralaya, Chennai,
1998; Fellowship in General Ophthalmology, Sankara Nethralaya, Chennai, 1997-’98. Presently,
Senior consultant, Department of Cataract, Uveitis and Glaucoma, Shri Ganapati Netralaya,
Jalna , Maharashtra. Founder member of the executive committee of the USI.
E-mail: vnair@netralaya.org
Sympathetic Ophthalmia in Western India
Sympathetic Ophthalmia (SO) is a bilateral
granulomatous panuveitis which occurs after
a penetrating injury that involves the uveal
tissue. Although the exact pathogenesis is
unknown, the hypothesis of an autoimmune
disease has received increasing support. Steroids
and immunosuppressives form the mainstay of
treatment and the visual outcome has been
variable. There are few Indian studies 3,4 which
assess the visual outcome in our patients and this
study was undertaken to assess the prognosis in
these patients.
Materials and Methods
23 patients of sympathetic ophthalmia (SO), were
seen at our referral institute based in
Maharashtra, between Jan 2000 and Jan 2008. The
patients were identified from a computerized
database and their records were analysed
retrospectively. The records were analysed for
the age, sex and occupation of the patient, the
type of injury sustained, the interval from the
injury to the onset of symptoms and interval
from onset of symptoms to presentation at our
clinic. All the patients were examined by slitlamp
and indirect ophthalmoscopy , and wherever
required ancillary investigations were done.
Diagnosis was made on the basis of history,
clinical features and test results.
Results
Of the 23 patients of SO, 13 were males and 10
were females. 15 patients (69.57%) were in the
age group 21- 55 yrs, 3 patients (13.04%) were
20yrs or lesser and 5 patients (21.74%) were more
than 55 yrs of age. In 21 patients (91.30%) the
cause was penetrating injury and in 2 patients
there was blunt trauma. The most common cause
of penetrating injury was accidental trauma in 16
Dr. Vinita Rao, Dr. Girish Rao
(Presenting Author: Dr. Vinita Rao)
(69.57%) of the 23 patients. In 5 patients it
occurred after ocular surgery. 2 patients were
significant in that the SO occurred secondary to
perforated corneal ulcer and one of them
developed the inflammation after evisceration.
SO occurred most commonly between 2weeks to
3 months after injury (14 patients – 60.87%). In 6
patients it occurred between 3 months and 1 year
and in 3 patients more than a year after injury. In
no patient the inflammation was seen to occur
within 2 weeks of the injury. The earliest
occurrence of SO was seen within 21 days of the
injury and the latest after 96 months.
14 patients presented to our clinic within 2 weeks
of development of symptoms. 1 patient within
one month, 5 patients between 1 month and 3
months and 3 patients after 3months from onset
of symptoms. Of the 14 patients who presented
early 2 had no light perception in both the
exciting and the sympathizing eye. 2 others who
had no light perception in the exciting eye,
underwent enucleation . Other 10 eyes had a
vision of counting fingers close to face at least
and hence were not considered for early
enucleation.
The vision in the exciting eye was less than 6/60
in 12 eyes (52.17%) and the remaining 11 eyes
(47.83%) had no light perception at presentation
when the other eye developed sympathetic
ophthalmia. The vision in the symapthising eye
was less than 6/60 in 14 eyes (60.87%), between
6/18 and 6/60 in 5 eyes and 6/12 or better in 4
eyes. There was no anterior segment
inflammation in 4 eyes and 2 eyes had
granulomatous anterior uveitis while the rest had
nongranulomatous anterior uveitis. Vitritis was
absent in 3 eyes and in one eye it was minimal.
21 of the 23 eyes had retinal detachment at

UVEA SESSION
607
presentation of which 7 had bullous retinal
detachment. In the remaining 2 patients, there
was chronic uveitis, attached retina and a sunset
glow fundus. 12 of the 23 eyes had disc
hyperaemia. The typical sunset glow fundus with
peripheral RPE defects was present in 7 eyes. In
5 eyes there were Dalen-Fuch’s nodules.
Systemic features were seen in 5 patients, which
included headache and neck ache (5), vertigo (1)
and tinnitus and hearing loss (3) and alopecia (1)
Fluorescein angiography was done in 4 patients
and all of them showed early leaks with late
pooling of the dye. In other patients the
fluorescein angiography was omitted due to the
vitritis or the diagnostic clinical picture.
Ultrasonography showed a diffuse choroidal
thickening of average 2.6mm.
All patients were treated with systemic steroids.
In addition 7 patients received IV methyl
prednisolone at presentation with sympathetic
ophthalmia. During the course of treatment 12
patients needed immunosuppressive treatment
either in addition or as a switchover. The
immunosuppressive used in all patients was oral
azathioprine tablets. The average duration of
treatment was 6.65 months including those who
were lost to follow up.
The commonest complication was partial or
complete optic atrophy which was seen in 11
eyes. Cataract was seen in 6 eyes of which 3 eyes
underwent phacoemulsification with intraocular
lens implantation with a good visual outcome. 3
eyes developed glaucoma, which was managed
medically. 2 eyes developed subretinal fibrosis
and 1 eye developed recurrent neovascularisation
of the disc and repeated vitreous
haemorrhage and had to undergo vitrectomy and
endolaser photocoagulation.
The final vision in the sympathetic eye was 6/12
or better in 12 eyes, between 6/18 to 6/60 in 2
eyes and less than 6/60 in 9 eyes. All the 9 eyes
which had vision less than 6/60, had optic
atrophy either due to severe inflammation or
due to inadequate treatment .In addition 2 eyes
in the same group had subretinal fibrosis.
Discussion
The result of the present study broadly agrees
with previous studies in the literature. 1,2 A
marginal male predominance seen in our series
is probably because ocular trauma is the
occupational hazard associated with outdoor
work and manual labor and our institute caters
to a population who are predominantly farmers.
SO occurs more often after accidental injury
rather than planned surgery. Hence we saw a
predominance of this condition in the age group
of 20-60 years which again has the maximum
number of young working adults.
The typical presentation of SO is a bilateral
panuveitis that occurs after ocular trauma or
intraocular surgery. 1 There is circumciliary
congestion, keratic precipitates, posterior
synechiae, vitritis, choroidal infiltration,
vasculitis, disc oedema and exudative retinal
detachment. Although panuveitis is common, 1
there are instances when SO presents with just
posterior segment inflammation, 4 which was the
case with 4 patients in our series. It was believed
earlier, that purulent endophthalmitis would
destroy uveal antigens to such an extent that SO
would not occur, but more recent studies 3 have
proven histopathologically that it could occur. In
our series we had 2 cases of SO occurring after
perforated corneal ulcers leading to
endophthalmitis and then SO. In one,
evisceration was performed at our institute and
the SO developed 2weeks after the evisceration.
It is also important to note that we had 2 cases of
blunt trauma in our series. We looked closely for
any signs of occult penetrating injury but could
not find any. Systemic features are rarely
associated with SO 1 , but in our series 5 patients
had extraocular symptoms. Although classically
SO is associated with granulomatous uveitis, we
have seen more cases presenting with non
granulomatous uveitis. There are reports of SO
presenting with just posterior segment
inflammation, without panuveitis 4 which has
been our observation in the present series in 4
cases. The clinical picture may sometimes closely
resemble Vogt-Koyanagi- Harada disease and
in the absence of histopathological confirmation,
presence of penetrating injury may be the only
differentiating feature of SO. Previously, SO was
considered to be a dreaded disease, but in our
series as well as in the other recent studies 1,4 it
has been seen that if treated early and
adequately, it has a good visual outcome. This is
because of the rapid onset of optic atrophy in
inadequate treatment or in fulminant disease.

608 AIOC 2009 PROCEEDINGS
One of the rarer complications we noted was the
recurrent vitreous hemorrhage due to
neovascularisation of the disc in one of our
patients in this series and it has also been noted
by Sampangi 5 et al in a recent study. We have
also shown that cataract surgery and intraocular
1. Chi-Chao Chan, Roberge FG,WhitcupSM,
NussenblattRB. 32 cases of sympathetic
ophthalmia. Arch Ophthalmol. 1995;113:597-600.
2. Jennings T, TesslerHH. Twenty cases of
sympathetic ophthalmia . Br J ophthalmol 1989;73:
140-5.
3. Rathinam SR, Rao NA. Sympathetic ophthalmia
following postoperative bacterial endophthalmitis:
References
lens is a safe option in these patients.
This study shows that it is possible to achieve
good visual outcome (52.17% -6/12 or better) in
SO provided an early diagnosis and thereby
adequate treatment is started.
a clinicopathologic study.
4. Gupta V, Gupta A, Dogra MR. Posterior
sympathetic ophthalmia : a single centre study of 40
patients from north India. Eye. 2007.
5. Sampangi R, Venkatesh P, Mandal S, Garg SP.
Recurrent neovascularization of the disc in
sympathetic ophthalmia. Indian J Ophthalmol. 2008;
56:232-4.