A rare case of atypical sympathetic ophthalmia post therapeutic keratoplasty
© The Author(s). 2016
Received: 16 June 2016
Accepted: 31 August 2016
Published: 15 September 2016
Sympathetic ophthalmia (SO) is a rare, bilateral, diffuse granulomatous uveitis that usually occurs after open globe injury or intraocular surgery.
A patient developed SO following therapeutic penetrating keratoplasty (TPK) with cataract extraction in the exciting eye following fungal keratitis. The sympathizing eye presented with only posterior segment findings (exudative retinal detachment) and responded well with oral corticosteroids.
Graft remained clear in the left eye and the right eye; the best-corrected visual acuity (BCVA) improved to 0.2 log MAR.
SO presenting after TPK for fungal keratitis is a rare occurrence but if detected early can be managed effectively.
Sympathetic ophthalmia (SO) has been defined as a “specific bilateral inflammation of the entire uveal tract of unknown etiology, characterised clinically by an insidious onset and a progressive course with exacerbation, and pathologically by a nodular or diffuse infiltration of the uveal tract with lymphocytes and epithelioid cells” .
Sympathetic ophthalmia occurs following penetrating injury or surgical procedures in one eye threatening sight in the fellow eye. Epidemiological estimates have shown the incidence to be 0.2 to 0.5 % after penetrating ocular injuries and 0.01 % after intraocular surgery [2,3].
The time from ocular injury to onset of SO varies from a few days to decades, with 80 % of the cases occurring within 3 months after injury to the exciting eye and 90 % within 1 year . The classical description of signs include granulomatous mutton fat keratic precipitates, anterior chamber, and vitreous inflammation with or without yellow–white lesions in the retinal periphery. Other fundus lesions like retinal detachment, papillitis, optic atrophy, and vasculitis are reported uncommonly and are generally seen in conjunction with anterior segment inflammation . Mcpherson et al. have reported two cases with atypical form of sympathetic ophthalmia with only posterior segment findings and termed it as “posterior sympathetic ophthalmia” . The diagnosis of sympathetic ophthalmia is based on history and clinical examination. There are no specific laboratory studies to establish the diagnosis of SO; however, focused clinical testing can be used to rule out other disease entities with a similar clinical picture. Fluorescein angiography (FA) and indocyanine green video-angiography (ICG-V) are useful adjuncts in establishing the extent and severity of SO. Fluorescein angiography during acute sympathetic ophthalmia shows an exudative process and may provide evidence of multifocal areas of early hyperfluorescence (pinpoints) and leakage in the retinal pigment epithelium .Galor et al. found that although ocular complications were seen in many sympathizing eyes with SO, most patients maintained functional VA. The presence of an exudative retinal detachment and active intraocular inflammation correlated with poorer vision in the sympathizing eye .
A similar case of sympathetic uveitis after a tectonic corneal-scleral keratoplasty because of a fungal keratitis is reported by Magalhaes et al. where they studied the spectral-domain optical coherence tomographic changes in the sympathizing eye . To our best knowledge, this is the first reported case of SO following TPK+cataract extraction following fungal keratitis with atypical SO manifesting only with posterior segment findings.
There are no acknowledgments.
There is no source of funding.
Dr. VB helped in the diagnosis and management of this case and also in the manuscript preparation. Dr. SG helped in editing and writing of the manuscript. Dr. MR helped in designing the manuscript and also in management of the case. Dr. AB helped in manuscript preparation, editing, documentation, and uploading of the manuscript. All authors read and approved the final manuscript.
Dr. Vipul Bhandari MBBS, DO, DNB, FCRE, is the head of cornea of the Nethradhama Eye Hospital.
Dr. Sriganesh MS, DNB is the chairman of the Nethradhama Eye Hospital.
Dr. Mohan Raj MBBS, MD, is a vitreo-retina consultant at the Nethradhama Eye Hospital.
Dr. Akanksha Batra MBBS, DNB, is a fellow at the Nethradhama Eye Hospital.
The authors declare that they have no competing interests.
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