Case of Sympathetic Ophthalmia

1. CASE PRESENTATION Dr. PRABHA

2. 22yr old male presented with sudden loss of vision left eye of 12 days duration associated with photophobia , watering and metamorphopsia Past history of penetrating injury with uveal tissue prolapse RE eye 2 months back for which emergency wound repair done & treated with systemic & topical steroids & antibiotics

3. GENERAL EXAMINTION Moderately built & nourished No pallor , cyanosis , jaundice , clubbing , lymphadenopathy No vitiligo , alopecia PR – 82/mt BP – 140 / 60 mmHg

4. SYSTEMIC EXAMINATION CNS – no convulsions , no FND CVS – Loud S2 GIT – no organomegaly RESP – NAD MSK – NAD

5. OCULAR EXAMINATION Vision - RE CF ½ m LE 6/36

6. RIGHT EYE Lid & adnexa no poliosis , vitiligo Conjuctival congestion Sutured full thickness corneoscleral wound from limbus at 9 o’clock to 6o’clock and is extended 2mm to the sclera AC cells 2+ Flare 2+ Pupil dilated pharmacologically Iris deficient at 6 o’clock

7. RIGHT EYE Lens phacodonesis+ Rosette cataract AVF– no cells FUNDUS – media hazy due to cataractous lens & coarse vitreous floaters Disc & vessels normal FR dull Organized vitreous hge inferiorly

8. LEFT EYE Conjuctival congestion Cornea clear AC cells 1+ Flare 1+ Pupil dilated pharmacologically Lens clear AVF– no cells

9. LEFT EYE FUNDUS – media clear Disc & vessels normal CDR – 0.3 , NRR pink & even Macular edema with ILM folds + 3 to 4 small yellowish white subretinal lesion seen just superior to macula Serous detachment of retina of 3DD seen between IT & IN arcade starting from the inferior disc margin

11. INVESTIGATIONS Hb – 14.8 gm% TC – 12600 ccmm DC – N81 , L 18 . E2 ESR- 3mm/hr RBS – 110 BUN – 39mg% S creatinine – 0.7% S.biliribin – 1mg5 ALP – 202 IU SGOT – 42 IU SGPT-24IU Platelet – 3L PS- mild neutrophilia

12. FFA – hyperfluorescent , pin point leaks in peripapillary area which persists in late phase Hypofluorescent area with late staining seen superior to macula

14. B scan RE – vitreous floaters LE – serous RD WITH CHOROIDAL THICKENING

15. LEFT EYE

16. RIGHT EYE

17. DIAGNOSIS OLD OPEN GLOBE INJURY TYPE B GRADE D PUPIL B ZONE 2 WITH VITREOUS HEMORRHAGE WITH ANTERIOR UVEITIS RE POSTERIOR UVEITIS WITH SPILL OVER ANTERIOR UVEITIS LE – SYMPATHETIC OPHTHALMIA

18. TREATMENT Gatiquin P eye Drops QID BE Homide eye drops BD BE Inj Methyl prtednisolone 500mg IV BD – 7D followed by Inj Dexamethasone 2cc IM OD T. Azoran 50mg BD

19. On discharge Vision CF 1m RE ,NIG NIP 6/12 LE ,NIG NIP BE – AC no cells & flare LE – serous detchment & macular edema reduced

20. SYMPATHETIC OPHTHALMIA It is a rare bilateral diffuse granulamatous non necrotizing panuveitis that may develop after either surgical or accidental trauma to one eye ( exciting eye ) followed by latent period and the appearance of uveitis in uninjured fellow eye ( sympathizing eye)

21. Incidence recently estimated is 0.03 per 1 lakh population Key features are Bilateral anterior or posterior uveitis of variable severity with uniform choroiditis Associated features Dalen-Fuch spots, papillitis , dysacousis , tinnitus , alopecia , poliosis , vitiligo , headache.

23. TREATMENT Enucleation of the inciting eye as a treatment modality is still controversy Treatment should address the T cell mediated nature of the disease Large doses of topical & systemic corticosteroids should be given early in he course of the disease Other immunosuppressive therapies may be considered isolated or in association with steroids

24. PROGNOSIS visual prognosis is good with 50% of patient achieving a final visual acuity of 20/40 or better in at least one eye The cause of sympathetic ophthalmia is chronic with frequent exacerbations and if left untreated leads to loss of vision & phthisis bulbi Long term follow up is essential