Presumed occult globe rupture resulting in sympathetic ophthalmia

A 30-year-old gentleman attended the eye casualty service complaining of blurred vision in the left eye (OS) following alleged blunt trauma during an assault 5 days previously. On presentation, the vision in the affected eye was 6/18. There was a superior sub-conjunctival hemorrhage, extensive iridodialysis (7 to 11 clock hours) (Fig. 1), anterior chamber inflammation (cells 2+) and hyphema. The intraocular pressure (IOP) was recorded at 14 and 15 mmHg in the right and left eye, respectively. The view of the left fundus was hazy, however, with a flat retina. Treatment was conservative with topical steroids.

The patient failed to attend his follow-up reviews in the clinic. Five weeks later, the patient presented again to the eye casualty service complaining of blurred vision, pain, and photophobia in his right eye (OD). On this occasion, there was no history of trauma. The vision in the right eye was recorded at 4/60. There were inflammatory cells (cells 3+) in the anterior chamber associated with vitreous cells (cells 3+), multiple areas of serous retinal detachments (RD; Fig. 2a), discrete deep yellow lesions typical of Dalen Fuchs nodules (Fig. 3) and optic disk swelling. Although comfortable, there were inflammatory cells (cells 1+) in the anterior chamber of the left eye associated with vitreous cells (cells 1+). There was sub-conjunctival pigmentation superiorly and nasally (Fig. 1). Fundoscopy revealed multiple areas of serous RDs (Fig. 2c) and optic disk swelling in the same eye. The vision in the left eye was recorded at 2/60.

A diagnosis of sympathetic ophthalmia following presumed occult globe rupture was made. Other possible causes were considered including sarcoidosis, syphilis, and Vogt Koyanagi Harada syndrome (VKH). The patient did not give a history of respiratory problems. Serum calcium and ACE levels were within normal limits. Treponema serology was negative. With regards to VKH, the patient was a Caucasian and did not manifest any features of neurological deficit, alopecia, or poliosis. Furthermore, the occurrence of the ocular signs and symptoms in such close proximity to the history of trauma favored a diagnosis of SO.

The patient was admitted to hospital for pulsed intravenous methylprednisolone 1 g daily for 3 days. The patient’s vision improved to 6/6 bilaterally with the steroids. The inflammation subsided and the serous RDs improved (Fig. 2b, d). He was eventually discharged from the eye ward on 60 mg oral prednisolone and tacrolimus 1 mg BD. One month following discharge, the patient was still doing well with stable visual acuities.

However, during the subsequent visit (4 weeks later), it was noted that compliance with treatment was sub-optimal due to the social circumstances of the patient. This was reflected in diminishing visual acuities in both eyes (OD 6/24; OS 2/60) and reactivation of the bilateral granulomatous panuveitis. Attempts to re-admit the patient to hospital were declined. The patient has failed to attend all further follow-up reviews. This therefore limited the length of follow-up period to just 2 months post discharge from hospital.