108 Vol. 31, No. 2, Apr – Jun, 2015 Pakistan Journal of Ophthalmology Case Report Sympathetic Ophthalmitis Tanvir Abbas, AsadAslam Khan,Mohammad Ali AyazSadiq Pak J Ophthalmol 2015, Vol. 31 No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Mohammad Ali A Sadiq Institute of Ophthalmology Mayo Hospital Lahore, King Edward Medical University, Lahore Email: sadiq.maa@gmail.com …..……………………….. Sympathetic ophthalmitis is a rare bilateral granulomatous panuveitisoccurring after ocular penetrating trauma most frequently associated with uveal tissue prolapse. It can also occur following ocular surgery like cataract, vitrectomy, trabeculectomy, retinal detachment surgery and even after laser photocoagulation. Incidence varies between 0.05% to 0.2% following penetrating trauma and 0.01% following ocular surgery. Key words: Sympathetic Ophthalmitis, Granulomatous panuveitis. Sympatheticophthalmitis is a rare bilateral granulomatous panuveitisrarely occurring after ocular penetrating trauma most frequently associated with uveal tissue prolapse1. It can also occur following ocular surgery like cataract, vitrectomy, trabeculectomy, retinal detachment surgery and even after laser photocoagulation. Incidence varies between 0.05% to 0.2% following penetrating trauma and 0.01% following ocular surgery2. With the improvement of microsurgical technique and early enucleation the incidence of the sympathetic Ophthalmitis has decreased. It is very important to diagnose this blinding condition early to avoid visual threatening complication. CASE REPORT Forteen year old young boy presented in theOut patient Clinic with the complaint of right painful gradual and progressive decrease in vision for two weeks. Past ocular history is significant for trauma in the left eye with a fire cracker 3 months back. He underwent open globe repair within 24 hours of injury. On examination patient had counting fingers at 3 feet in the right eye and no perception of light in the left. Right eye showed sluggish pupillary response. The pupil of the left eye was not appreciable. The patient also had a positive reverse Marcus gun. Slit lamp examination showed mutton fat keratitic precipitates mainly involving the inferior part along with grade 3 cells and flare in the right eye (Figure 1) and a repaired corneoscleral tear in the left (Figure 2). Right eye intraocular pressure was 14 mmHg and the left eye was phthiscal.The posterior segment in either eye was not visible. Complete blood picture, Erythrocyte sedimentation rate, Chest X-ray, venereal disease research laboratory (VDRL), Toxoplasmosis Ig G and M, Montoux test and serum Angiotensin converting enzyme level, were ordered and found to be within normal limits. Sympathetic ophthalmitis was diagnosed. The patient was started on oral Prednisolone in divided doses (weight adjusted) under cover of antacid, Predforte eye drops every 4 hourly and 1% Atropine eye drops twice a day. On the 2nd week follow up the best corrected visual acuity improved to 6/18 with quite and maintained anterior chamber and no keratic precipitates. Intra-ocular pressure was 16 mmHg. The posterior segment showed disc edema and a dull foveal reflex (Figure 3). The treatment was continued. s mailto:sadiq.maa@gmail.com SYMPATHETIC OPHTHALMITIS Pakistan Journal of Ophthalmology Vol. 31, No. 2, Apr – Jun, 2015 109 Fig. 1: Right eye showing mutton fat keratitic precipitates more inferiorly. Fig. 2: Left eye shows a pthysical eye with a corneoscleral tear repair. At 1 month follow up visit, the best corrected visual acuity improved to 6/9 and anterior segment was quite with resolving disc and macular edema. Topical steroids were reduced to four times a day and atropine was stopped. Systemic steroids were, however kept on maintaining dose. At two months visit, the best corrected visual acuity was 6/6 and disc edema had resolved with a good foveal reflex. The intraocular pressure was 18mmHg. The patient complained of weight gain due to systemic steroid. DISCUSSION The condition was first recognized by Hippocrates and described and named by Mackenzie in the mid- 1800s.4Fuch's provided the first histopathologic details in 19052. Fig. 3: Colour fundus photograph and Fundus fluoroceine angiography showing disc edemaand abnormal foveal reflex. It is a rare condition with no gender or racial correlation. It can occur in any age group following penetrating trauma or surgical intervention. Cases have been reported after cataract3 and vitreoretinal surgeries4 and even after ocular laser.5 The etiology of this is poorly understood with immunological reaction mediated by T cells against photoreceptor and uveal tissue antigen being the most important factor. While the particular antigen is yet to be determined, putative retinal antigens include retinal soluble antigen (S-antigen), rhodopsin, interphotoreceptor retinoid-binding protein, and recoverin6,7. The retinal S - antigen has been the most extensively studied. The first symptom of Sympathetic Ophthalmia is photophobia and the decrease of near vision followed by far vision. Signs such as mutton fat keratitic precipitates, anterior chamber reaction, disc edema with late leakage on fundus fluorescein angiography and exudative retinal detachment with dalenfuchs nodules are pathognomic.8It is important to rule out other causes of granulomatous inflammation before making a final diagnosis as the diagnosis is that of exclusion. Sympathetic Ophthalmitis can be prevented by doing enucleation of sympathizing blind eye within 10 days of trauma, especially in those cases having exposed cillary body. TANVIR ABBAS, et al 110 Vol. 31, No. 2, Apr – Jun, 2015 Pakistan Journal of Ophthalmology Treatment includes topical and systemic steroids. Antimetabolites are used in case of steroid intolerance. Systemic steroid should be continued for six months and then tapered off as Sympathetic Ophthalmitis has a relapsing and remitting course. Author’s Affliliation Dr. Tanvir Abbas Medical Officer, Institute of Ophthalmology Mayo Hospital Lahore Prof. AsadAslam Khan Professor, Institute of Ophthalmology Mayo Hospital Lahore, King Edward Medical University Lahore Dr. Mohammad Ali Ayaz Sadiq Assitant Professor, Institute of Ophthalmology Mayo Hospital Lahore, King Edward Medical University, Lahore REFRENCES 1. Jack J kanski, Brad bowling, etal. Degenrative disorder of conjunctiva. 7th edition.China:Elseveir; 2011: 162-65. 2. Albert DM, Diaz – Rohena. A historical review of sympathetic ophthalmia and its epidemiology SurvOphthalmol. 1989; 34 (1): 1-14. 3. El-Asrar AM1, Al-Obeidan SA. Sympathetic ophthalmia after complicated cataract surgery and intraocular lens implantation.Eur J Ophthalmol. 2001 Apr-Jun; 11 (2): 193-6. 4. Masatoshi Haruta,1Hirokazu Mukuno,2 Kazuaki Nishijima, etal. Sympathetic ophthalmia after 23 – gauge transconjunctival sutureless vitrectomy. Clin Ophthalmol. 2010; 4: 1347–1349. 5. Albahlal A1, Al Dhibi H1, Al Shahwan S, et al. Sympathetic ophthalmia following diode laser cyclo- photocoagulation. Br J Ophthalmol. 2014 Aug; 98 (8): 1101-6. 6. Schalken JJ, Winkens HJ, Van Vugt AH, De Grip WJ, Broekhuyse RM. Rhodopsin – induced experimental autoimmune uveoretinitis in the monkeys. Br J Ophthalmol.1989; 73 (3):168-172. 7. Grey I, Wiggert B, Redmond TM, Kuwabara T, Crawford MA, Vistica BP, Chader GJ. Uveoretinitis and pinealitis induced by immunization with interphoto- receptor retinoid – binding protein. Invest Ophth Vis Sci. 1986; 27 (8): 1296-1300. 8. Sharp DC, Bell RA, Patterson E, Pinkerton RM. Sympathetic ophthalmia. Histopathologic and fluorescein angiographic correlation. Arch Ophthalmol. 1984 Feb; 102 (2): 232-5.