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CHORIORETINAL INFLAMMATORY DISEASES - Noninfectious Causes

Sympathetic Ophthalmia

Sympathetic ophthalmia (SO) is a bilateral, diffuse, granulomatous, T-cell-mediated non-necrotizing panuveitis in one eye (sympathizing eye), following a surgical or accidental trauma of the other eye (exciting eye), after a variable latency period.

SO represents 2% of all uveitis cases. Incidence has been estimated to be up to 0.5% in eyes with nonsurgical trauma and 1/10000 cases after intraocular surgery.

The latency period can be as low as 5 days and as late as 50 years. 80% of cases occur 3 weeks to 3 months after injury and 90% up to 1 year.

It is associated with traumatic uveal incarceration or prolapse. This appears to cause a delayed type hypersensitivity to previously sequestered antigens localized on the retinal pigment epithelium or on uveal melanocytes. Certain types of human leukocyte...

Sympathetic ophthalmia (SO) is a bilateral, diffuse, granulomatous, T-cell-mediated non-necrotizing panuveitis in one eye (sympathizing eye), following a surgical or accidental trauma of the other eye (exciting eye), after a variable latency period.

SO represents 2% of all uveitis cases. Incidence has been estimated to be up to 0.5% in eyes with nonsurgical trauma and 1/10000 cases after intraocular surgery.

The latency period can be as low as 5 days and as late as 50 years. 80% of cases occur 3 weeks to 3 months after injury and 90% up to 1 year.

It is associated with traumatic uveal incarceration or prolapse. This appears to cause a delayed type hypersensitivity to previously sequestered antigens localized on the retinal pigment epithelium or on uveal melanocytes. Certain types of human leukocyte antigens (HLA-DR4, DRw53 and DQw3) are more frequently found in patients developing SO.

At presentation, patients may complain of decreased visual acuity and photophobia.

Clinically, a bilateral asymmetric panuveitis, with more severe inflammation in the exciting eye is generally present. Anterior segment findings include mutton-fat keratic precipitates, flare, cells, thickening of the iris and posterior synechia. IOP may be elevated (trabecular meshwork inflammation) or low (ciliary body shutdown). An examination of the posterior segment reveals vitritis, as well as multiple yellowish white choroidal lesions (called Dalen-Fuchs nodules – collection of epithelioid cells lying between Bruch’s membrane and the RPE). These lesions may become confluent. Exudative retinal detachment can also occur.

Complications of SO include: cataract, cystoid macular edema, CNV and optic atrophy.

FA can demonstrate multiple areas of hyperfluorescence, traducing leakage at the RPE level. This hyperfluorescence persists up to late stages and pooling can be observed in areas of serous retinal detachment. Dallen-Fuchs nodules are hypofluorescent in the earlier stages of angiography and become hyperfluorescent by late staining. Ultrasonography can reveal choroidal thickening.

The course of the panuveitis is chronic, with frequent exacerbations. When trauma is associated to loss of visual function, with a profoundly injured eye, enucleation can be pondered within 2 weeks of the initial trauma. Whenever there is a possibility of obtaining a reasonable visual function, the eye should be preserved. When timely and aggressive treatment is established the prognosis is good, with up to 60% of patients achieving a visual acuity of 20/40.

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Clinical Cases