SYMPATHETIC OPHTHALMIA

Introduction
Sympathetic ophthalmia (SO) is a rare eye condition that can develop after an eye injury or
within days or weeks after eye surgery. This condition presents itself as a type of uveitis (eye
inflammation), and it occurs because the body’s immune system attacks the healthy eye. The
healthy eye is called the "sympathizing eye” because it shows sympathy to the injured one and
becomes inflamed. Sympathetic ophthalmia is vision-threatening if not treated quickly.

CAUSES AND RISK FACTORS

Injury to the eye or eye surgery are the only known causes of sympathetic ophthalmia. Some
studies have found SO affects more men than women, but these studies are few. One 2018 report
reported in the journal International Ophthalmology found post-eye surgery, men are affected
1.8 times more than women by SO.22
As for age, SO is normally distributed among adults and children. Higher incidences of SO are
common in older populations due to an increased need for intraocular surgeries, such
as cataract surgery.

There are no racial differences related to sympathetic ophthalmia. There have been no studies
showing that sympathetic ophthalmia is associated with any medical health conditions, such as
diabetes or high blood pressure.

There are 2 key risk factors for Sympathetic Ophthalmia and these include:

 Eye injury or trauma to the eye, which was not resolved completely or adequately:
o The eye injury, which may affect the uvea, can be a penetrating wound
o This may occur from participation in high-risk sports, violence, or eye injuries
sustained even on battlefields
 A previous surgery to the eye (typically surgery to the retina):
o The surgeries may include vitreoretinal surgery, surgery for glaucoma, cataract
repair, or surgery to partially remove the iris (iridectomy)
o Sometimes, multiple (intraocular) surgeries may have been performed involving
the same eye

SIGNS AND SYMPTOMS

Sympathetic Ophthalmia can have a silent and menacing onset, or the onset of signs and
symptoms can be sudden and acute (which is true in many cases). Both the eyes may appear the
same, although the onset is in one eye. The main affected eye is called the ‘exciting eye’, while
the other eye is called the ‘sympathizing eye’, which was not affected by past trauma/surgery;
hence, the condition is called Sympathetic Ophthalmia.
The signs and symptoms can range from reduced vision to permanent vision loss and may
include:
  Small specks, called floaters, that may be seen moving through one's field of vision
 Blurred vision
 Reduced vision or vision loss is observed in a majority of cases
 Light-sensitivity (photophobia)
 Conjunctivitis-like symptoms including red eyes and tearing
 Some individuals may experience pain
 There may be periods when the signs and symptoms get better and then worsen;
Sympathetic Ophthalmia can be a chronic condition

In rare cases, additional signs and symptoms may be present including:

 Loss of hearing
 Headaches
 Vitiligo (discoloration of skin occurring in patches)

DIAGNOSIS

A healthcare professional may diagnose Sympathetic Ophthalmia using the following tests and
procedures:

 Physical examination and analysis of previous medical history (including history of any
eye injury or eye-related surgical procedure)
 Eye examination by an eye specialist
 Fundoscopic (ophthalmoscopic) examination by an eye specialist, who examines the back
part of the eye (or the fundus)
 Visual acuity test using a special and standardized test chart (Snellen chart)
 Slit-lamp examination: Examination of the eye structure using a special instrument called
a slit-lamp. In this procedure, the pupils are dilated and the internal eye structure is
examined. Slit-lamp exams indicate large inflammatory cell clumps on the cornea, called
‘mutton-fat' keratic precipitates, which is a characteristic feature of the condition
 Tonometry: Measurement of intraocular pressure or eye fluid pressure, especially to
detect conditions such as glaucoma
 Fundus fluorescein angiography (FFA): In this technique, the eye blood vessels are
examined using a fluorescein dye
 Fundus autofluorescence (FAF) imaging: It is a diagnostic technique to examine the
fundus of the eye using a fluorescent dye
 Indocyanine green (ICG) angiography: It is used to examine the blood vessels of the
choroid using a dye, called indocyanine green, particularly to study the choroid
 B-scan ultrasonography: Special ultrasound scan of the eye through a non-invasive
diagnostic tool, to assess health of the eye structures
 Electroretinogram (ERG): It is a technique to measure electrical activities in the retinal
cells
 Optical coherence tomography (OCT) of eye: Radiological imaging technique to
visualize the eye structure
  Blood tests that include:
o To check for the presence of antibodies in blood
o Blood culture for infections
o Complete blood count (CBC) with differential
o Erythrocyte sedimentation rate (ESR)
 Rarely, a biopsy of the choroid may be performed to help with the diagnosis
 Other tests to determine any underlying condition causing Sympathetic Ophthalmia

MEDICAL MANAGEMENT

A prompt diagnosis and emergency treatment of Sympathetic Ophthalmia is extremely crucial in

preventing complications that can result in permanent damage to the eye. With immediate and
aggressive treatment, a complete loss of vision may be avoided.
The treatment of Sympathetic Ophthalmia may include the following measures:

 Oral medications (including pain medications)

 Use of cycloplegic eye drops for controlling the signs and symptoms (through a
mechanism known as ciliary muscle paralysis)
 High dose corticosteroids may be given to control inflammation. Steroids may also be
administered intravenously
 Dark glasses may be prescribed for light-sensitivity
 Administration of immunomodulators, which are medications to control dysfunctional
immune system
 If choroidal neovascularization is observed, then laser therapy may be helpful
 Very close observation and monitoring of the condition is essential and highly
recommended
 For milder conditions, topical steroid applications and medications that cause papillary
dilation may be recommended. Extremely rarely, with mild cases, self resolution is
known to occur

It is important to note that steroids may not be used in all cases, since it can worsen the condition
(especially if there is an infection). A healthcare provider will provide the best treatment options
based upon each individual’s specific circumstances.

COMPLICATIONS

Complications of Sympathetic Ophthalmia may lead to serious vision abnormalities and/or SO

may be associated with the following conditions:

 Choroidal neovascularization (CNV): An abnormal development of blood vessels in the

choroid, which if left untreated can result in permanent loss of vision
 Macular edema (fluid in the macula) and papillary edema (swelling of the optic disc)
 Glaucoma: A condition that can cause blindness due to higher intraocular pressure
 Cataracts: When the lens of the eye becomes clouded and cause vision loss
 Retinal detachment is observed in most cases: It is an eye condition wherein the retina
gets separated from the eye structures that holds the retinal layers together
 Poliosis: A condition causing decreased melanin pigment in the eyebrows and eyelashes
 Severe inflammation causing complete loss of vision
 If left undiagnosed and/or untreated, the condition usually leads to permanent blindness
 Kidney damage, high blood sugar, and high blood pressure due to steroid treatment