Sympathetic Ophthalmitis Annie Mathai, Rajeev K Reddy, Hemant S Trehan, Ritesh Narula Smt.Kanuri Santhamma Retina Vitreous Centre, Kallam Anji Reddy Campus, L V Prasad Eye Institute, Hyderabad

Ocular History  48 year old man  : decreased vision OS following injury with stone 17 days earlier  Diagnosed as globe rupture with uveal prolapse  Underwent excision of prolapsed uveal tissue and corneo-scleral tear repair

28 th July 2007: First Presentation  VA: OD - 20/20, OS - no PL  OD - normal  OS - red eye  Corneo-scleral sutures  Irregular AC  AC details not clear  Soft eye  No fundus view OS

Ultrasonography OS  Funnel RD  Choroidal thickening  Peripheral choroidal detachment

Diagnosis & management  OD - normal  OS - status post corneo-scleral tear repair, RD, pre-phthisical eye  Treatment OS:  Prednisolone acetate eye drops 2 hourly  Ofloxacin eye drops 4 hourly  Atropine eye drops 3times/day

9 th September 2007: Second Presentation  Pain, redness, decreased vision OD x 3 days  Seen elsewhere with shallow AC, raised IOP  Diagnosed as angle closure glaucoma OD  Underwent OD:YAG peripheral iridectomy  Started on topical and systemic steroids (20mg)

9 th September 2007: Second Presentation  VA: OD - 2/60, OS - no PL  Anterior segment OD  AC: 1-2+ cells, 1+ flare  Sluggishly reacting pupil  3 attempted PIs  IOP - 10 mm Hg  OS findings same as before

9 th September 2007: Second Presentation  Fundus examination OD  No vitreous cells  Shallow serous detachment at macula  Diagnosed as CSCR

9 th September 2007: B-scan & OCT  Localised RD on B-scan & OCT  No choroidal thickening on B-scan

9 th September 2007: Diagnosis  Acute central serous chorioretinopathy precipitated by steroids  Anterior uveitis secondary to PI  Systemic steroids discontinued  Topical steroids continued  Called for review after 3 days

12 th September 2007: 3 days later  Visual acuity OD - 6/18  AC - 2+ cells, 1+ flare  No vitreous cells  Fundus - shallow serous RD  Topical steroids continued  Called for review after 2 weeks

19 th September 2007: 1 week later  Seen in emergency  Sudden decrease of vision OD  Visual acuity - 1/60  Fresh kps, 2+ cells, 2+ flare  Fundus - serous RD  Yellow subretinal lesions

Clinical diagnosis  Symathetic ophthalmitis  B-scan to look for choroidal thickness  Fluorescein angiography

Ultrasonography  Echo free vitreous cavity  Localised shallow RD  No choroidal thickening

27 sec 4 min 40 sec2 min 10 sec1min 9 sec Fluorescein angiography

 Pin-point hyperfluorescence  Hyperfluorescence increases in late phase

Final diagnosis & management  Sympathetic ophthalmitis  IV Methyl prednisolone 1 gm daily x 3 days  Followed by oral prednisolone  OU: Pred acetate eye drops 2 hourly  OU: Homatropine eye drops 3 times/day

Response to treatment (OD)  On 4 th day visual acuity improved to 6/18  In 10 days visual acuity was 6/6  Serous RD completely resolved  Topical and oral steroids continued  Also started on Azothioprine 50 mg BD

Response to treatment - serous RD Prior to treatment Following treatment

Last follow-up Visual acuity - 6/6

Conclusions  Bilateral ocular involvement following open-globe injuries  High alert for sympathetic ophthalmitis  Fluorescein angiography is a crucial investigation to confirm sympathetic ophthalmitis