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ARTICLE
Year : 1963  |  Volume : 11  |  Issue : 1  |  Page : 4-8

Sympathetic ophthalmia in relation to panophthalmitis and evisceration


Muslim University Institute of Ophthalmology amid Gandhi Eye hospital, Aligarh, India

Date of Web Publication28-Jan-2008

Correspondence Address:
Suresh Kumar
Muslim University Institute of Ophthalmology amid Gandhi Eye hospital, Aligarh
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Kumar S, Nath K. Sympathetic ophthalmia in relation to panophthalmitis and evisceration. Indian J Ophthalmol 1963;11:4-8

How to cite this URL:
Kumar S, Nath K. Sympathetic ophthalmia in relation to panophthalmitis and evisceration. Indian J Ophthalmol [serial online] 1963 [cited 2019 Oct 17];11:4-8. Available from: http://www.ijo.in/text.asp?1963/11/1/4/38824

Table 1.

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Table 1.

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It has been stressed in the past that sympathetic ophthalmia, rarely, if ever occurs when the injury in the exciting eye has been complicated by a purulent infection or panophthalmitis. Text-books usually state that the purulent process by destroying much of the uveal tract, offers a certain degree of protection against the disease. So strongly was this belief held that older ophthalmologists were tempted to induce pus formation in the injured eye as a prophylactic :Measure against sympathetic ophthalmia. However, while this protection afforded by the suppurative process is generally true, it is not absolute.

There are numerous reports in the literature where the purulent process has failed to prevent the disease. Schirmer (1905) reported two cases of sympathetic - ophthalmia that followed injury and panophthalmitis in the exciting eye, and Wood (1936) reports having seen one similar case. Shahan (1927) performed evisceration of the contents of the globe in a man aged 31 years, two weeks after a perforating injury by a nail and seventeen days previous to the outbreak in the opposite eye. Enucleation of the remainder of the exciting eye was performed on the day following the outbreak and the subsequent course was favourable. Reynolds and Ginsberg (1937) presented two cases of sympathetic ophthalmia, in one, a man aged 33 years, an evisceration was performed 2 weeks after rupture of the sclera and collapse of the eyeball. Sympathetic ophthalmia developed one month later. Fuchs (1940) also mentions about possibility of the disease developing in the uninjured eye and he warns against evisceration, as great many cases have been reported in which sympathetic ophthalmia followed this procedure.

The following case of a child aged To years who developed sympathetic ophthalmia 2 days after evisceration of the grossly infected injured eye illustrated the above point.


  Case History Top


A. K., a male child aged 10 years was brought to the out-patients department of Gandhi Eye Hospital on 9th July, 1960. The history was that a week before, the child slipped while playing and struck his right eye against the sharp edge of a wall cupboard.

(i) First Examination

Right Eye Eye: The lids were swollen with marked conjunctival chemosis and limitation of movements. A sloughing corneo-scleral wound was present in the three O'clock meridian involving the ciliary region and extending for 3 mm. on either side of the limbus. The anterior chamber was shallow with hypopyon extending unto the lower pupillary margin. Pupil was irregular, iris periphery was entangled in the wound, but there was no prolapse. A yellow reflex was observed in the pupillary area, tension of the eyeball was raised and the vision reduced to doubtful perception of light.

Left Eye: Vision was 6/5. Eye was not subjected to slit lamp examination but, oblique illumination with loupe and lens did not reveal any abnormality. Fundus was normal.

The injured right eye was eviscerated on the day following admission. Contents of the globe were scooped cut and all the uveal tissue was evacuated by thorough curetting of the interior of the eyeball. Only the optic nerve surrounded by the rim of sclera was left behind.

Two days after the operation, i.e., 10 days after the injury the patient complained of photophobia and fogginess of vision in the left eye. Vision was 6/9. Optic disc was hyperaemic, there was muscular edema and also some haze in the posterior vitreous. Neither chamber flare nor keratic precipitates could be demonstrated on the slit lamp. Atropine sulph. 1% ointment was applied and the eye bandaged.

Four days after the evisceration the left eye vision got reduced to 6/18. Hyperemia of disc increased and vitreous became more hazy. Inflammatory exudates of recent origin were observed in the fundus periphery. From these signs of uveo-papilitis there arose a grave suspicion of sympathetic ophthalmia. On this premise the stump of the eviscerated right eye was excised and sent for histopathological examination.

Six days after evisceration, (14 clays after the injury) intense photophobia, pain and ciliary congestion developed in the' left eve. Vision was reduced to 2/60. Fundus reflex was poor and details could not be made out. Slit lamp examination showed pronounced aqueous flare and mutton fat type of precipitates were noticed at the back of the cornea. These findings confirmed our previous suspicion and a diagnosis of sympathetic ophthalmia was established.


  Treatment Top


After the third examination intensive cortico-steroid therapy was instituted with hourly instillations of 1.50 hydrocortisone acetate drops in the conjunctival sac and dexamethasone 1.5 mgm. orally daily in divided doses. In addition, sodium salicylate 10 grs. t.i.d., and intravenous calcium injections with vitamin 'C' 500 mgm. were also given. After the appearance of precipitates the administration of dexamethasone was raised to 2.5 mgm. daily and with the treatment rigidly regulated it took nearly 2 months to control the condition. At the time of discharge from the hospital on 20th October, io6o, the L.E. was quiet and fundus clear with visual acuity of 6/12.

Histopathological Findings: [Figure - 1],[Figure - 2],[Figure - 3] and [Figure - 4] of the excised stump from the right eye showed focal collections of epitheloid cells, lymphocytes, foreign body type of giant cells and few neutrophils embedded in fibrous issue stroma. There was no evidence of necrosis. The anatomical diagnosis was sympathetic ophthalmia.


  Comments Top


It is a matter of common observation that either early enucleation or gross suppuration of the injured eye, or both, play an important role in the prevention of sympathetic ophthalmia. Trowbridge (1937) carried out a detailed study including the pathological aspect on 27 cases presented by Lawrence T. Post (1933) and five cases of his own, the total number thus being 32. In 3 cases sympathetic ophthalmia was found to occur in the presence of purulent infection, an incidence of 9.4%.

Bernard Samuels (19,38) states that once in a while panophthalmitis leads to sympathetic ophthalmia, whether or not the injured globe has been eviscerated. In his series of 101 cases of sympathetic ophthalmia he found panophthalmitis in three of them (an incidence of 3%). According to him panophthalmitis can be divided into two main groups, viz.: `closed' and 'open' panophthalmitis. In the closed variety the wound in the cornea or sclera is small and the purulent process within the globe goes on under high pressure resulting in complete or near complete destruction of the uveal tissue. The scleral or corneal opening being large in the open. type of panophthalmitis the uveal tissues escape complete destruction because of low tension within the globe and the absence of the damaging action of the bacterial toxins which escape to the exterior through the wound. Samuels argues that there is less likelihood of sympathetic infection in the closed type of panophthalmitis where little normal uveal tissue remains.

In recent years the occurrence of panophthalmitis has been much reduced by the use of antibiotics and other chemotherapeutic agents employed in the treatment of inflammatory conditions of the eye. In this hospital panophthalmitis comprises .5% of all out-door cases, the most common cause being perforation of a corneal ulcer and ocular injury. With this high incidence the treatment employed in this hospital is evisceration with complete evacuation of the contents of the globe followed by thorough curetting of the uveal tissue. Enucleation is not performed, not only because there is danger of subsequent septic meningitis, but also because the operation in presence of gross infection, marked conjunctival chemosis and swelling of the orbital tissues is beset with technical difficulties.

In the present case authors arc of the opinion that the causative organism was of very high virulence' and was able to survive in the presence of severe purulent infection under conditions of grossly raised intraocular tension. Having escaped through the emissaria of the infected globe the organism or its agent sensitized the uveal tissues of the other eye. The operation performed only precipitated the condition in so far as it helped to liberate the agent or its toxins into the general circulation thereby setting up an allergic reaction in the sympathizing eye.

In the present case the period between injury and onset of sympathetic ophthalmia being as short as 10 days, it lends support to our view that the causation agent was of very virulent nature and was not influenced by the infective process or the bacterial toxins.


  Conclusion Top


Problems of the pathogenesis of sympathetic ophthalmia in the presence of gross infection of the exciting eve is a baffling one. Difficulties are enhanced because the condition is rare and sufficient clinical material does not come under observation at one centre. We are of opinion that the factor of virulence of the organism plays an important role. The time interval between injury and occurrence of the disease in other eye, may give some indication regarding the virulence

Evisceration of the exciting eye can hardly be attributed to cause the disease, for in our experience the sympathetic ophthalmia has followed this procedure. Also, once in a while panophthalmitis leads to development of the disease whether or not the iii tired globe has been eviscerated, Samuels (1938) . The uveal tissue of the uninjured eye having been sensitized at an early stage, it is very hypothetical whether excision of the injured globe could have prevented the disease.


  Summary Top


A case of a child aged 1o years who developed sympathetic ophthalmia 2 days after evisceration and 10 days after injury and panophthalmitis of the exciting eye is presented.

Diagnosis of the disease was confirmed by clinical observation of the case and histopathological examination of the excised stump of the eviscerated eye.

The patient regained 6/12 vision in the sympathizing eye after intensive treatment with hormonal therapy.

The role of evisceration in development of the disease is discussed.

Virulence of the organism may play an important part in the pathogenesis of the condition.[11]

 
  References Top

1.
Fuchs, A., (1940). Klin. M.F. Augenh. 104 : 680.  Back to cited text no. 1
    
2.
Joy, H. H, (1935). Arch of Ophth., 14 : 733.  Back to cited text no. 2
    
3.
Post, L. T., (1934), South Med. Jour., 27 : 421.  Back to cited text no. 3
    
4.
Randolph, R. E., Norris, and Oliver, (1898). System of diseases of the eye. Philadelphia, J. B. Lippincott & Co., 3: 721.  Back to cited text no. 4
    
5.
Reynolds & Ginsberg, (1937), Soc. Proceed., Los Angeles Soc., Ophth. Otolar. Abst. Jour. Ophth., 20: 414.  Back to cited text no. 5
    
6.
Samuels, B., (1938). Arch. of Ophth., 20 : 804-811.  Back to cited text no. 6
    
7.
Schirmer, O. (1905). Graft-Saemisch Handbuch der Augenheilkunde. Leipzig, Chap. 8.  Back to cited text no. 7
    
8.
Shahan, W. E., (1927), Amer. Jour. Ophth., 10 : 120-123.  Back to cited text no. 8
    
9.
Trowbridge, Jr. D, H., (1937). Amer. Jour. Ophth., 20 : 135-148.  Back to cited text no. 9
    
10.
Verhoeff, E, H., and Irvine, S. R., (1935). Proc. New York State Med. Soc. Ophth., Albany, N.Y., (Quoted by Woods 2).  Back to cited text no. 10
    
11.
Woods, A. C., (1936) . Amer Jour. Opth., 19 : 9-15, 100-109  Back to cited text no. 11
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1]



 

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