|Year : 1968 | Volume
| Issue : 3 | Page : 134-138
Eye Infirmary, Medical College Hospitals, Calcutta, India
|Date of Web Publication||24-Dec-2007|
S P Das
Eye Infirmary, Medical College Hospitals, Calcutta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das S P. Sympathetic ophthalmia. Indian J Ophthalmol 1968;16:134-8
Sympathetic ophthalmia has been known since many years. In 1840, the disease was fully recognised and described by McKENZIE and he gave the name of the disease that it bears to-day. He described that sympathetic ophthalmia is a bilateral disease following penetrating injury of the eye, especially that involving the ciliary region. He thought that the route of involvement of the second eye was by way of optic nerve and chiasma, but he also considered the possibility of transmission through ciliary nerves and blood stream. Even today the actual cause of sympathetic ophthalmia is obscure.
| Material|| |
9 cases of sympathetic ophthalmia, all proved by histological examination of the exciting eyes were studied in the Eye Infirmary, Medical College Hospitals, Calcutta, over a period of 11 years from 1953 to 1963.
| Clinical data|| |
Of these nine cases of sympathetic ophthalmia, four were males and five females. Four of these 9 were between the ages of 31 to 40, indicating a higher incidence in an age group that faced the maximum of industrial hazards. Penetrating wounds were the cause of the disease in 8 of the present 9 cases.
By far the most common form of perforating injury was by flying pieces of iron penetrating the eye ball (4 cases). The other forms of penetrating injury were with a stick (1 case), a pen (1 case) and a cow's horn (1 case). In one case, aged 19, the condition had followed three weeks after a cataract extraction, of a traumatic dislocation of the lens.
Non-penetrating wounds may also cause sympathetic ophthalmia. In one case the disease developed following phthisis bulbi after small-pox, though in this case also the phthisis bulbi had resulted from perforation of a small-pox ulcer of the cornea.
In panophthalmitis, though not uncommon following intra-ocular operations or injuries, sympathetic ophthalmia was not observed in such cases in the present series.
The clinical picture in the exciting eye of sympathetic ophthalmia was one of iridocyclitis without any special characteristic. Usually the iritis ran a prolonged indolent course with occasional exacerbations but sometimes it occured even after the exciting eye became quiet soon after the injury as in the case, where the perforation had taken place from an injury with a cow's horn. The injured eye had presented no difficulty in treatment but had no perception of light. The patient was allowed to go home, since a prophylactic enucleation of the blind eye was refused. She returned to the hospital after 5 weeks when the vision in the opposite eye got reduced to perception of light from sympathetic inflammation. In the case of the phthisical eye after small-pox, the ophthalmia, developed after repeated ciliary pain and congestion.
The conditions of exciting and sympathizing eyes are shown in [Table - 1].
Except in case 1 where there was no history of injury, the interval between the injury to onset of sympathetic ophthalmia was almost uniform. The shorest time was 24 days and the longest time was 70 days . In case 1, the patient had six repeated exacerbation of inflammation in the phthisis bulbi during the 4 years period. The patient came for medical help in the last attack of inflammation when the vision in the second eye had fallen.
The treatment adopted in all cases was uniform. Enuclcation of the exciting eye was performed in every case and the usual classical treatment of uveitis in the form of atropine, cortisone, antibiotic was given for the sympathizing eye. The results of the 9 cases are shown in the end column of [Table - 1].
| Pathology|| |
Since enucleation of the exciting eye was taken as a routine procedure in the present observation, the materials for study of pathology of sympathetic ophthalmia were the enucleated exciting eyes in all the 9 cases.
The inflammation in all the cases was granulomatous and the essential feature was panuveitis, particularly the marked involvement of the choroid, which became much thickened. The infiltration of the uvea was characterised by lmphocytes, epitheleoid cells and giant cells. The disease was marked in the outer layers of the choroid around the larger -veins whereas its inner layers especially the chorio - capillaries though involved, remained relatively free. The retina and the sclera remained relatively free. Dalen-Fucks nodule, one of the characteristic features in the pathology of sympathetic ophthalmia was observed in 5 cases. In the iris, cellular infiltration occured in the posterior layers whereas the anterior layers remained almost free.
| Comment|| |
Sympathetic ophthalmia is an infrequent condition and sufficient cases do not occur in any single institution to draw a clear-cut conclusion. So different workers gave different views about some of the features of the disease.
The older group of patients are more subject to operative wounds, whereas the younger individuals are more susceptible to accidental wounds. For this reason it is believed that young individuals are more susceptible to sympathetic ophthalmia from penetrating wounds. In the present observation 6 of the 9 cases were between the age group of 30 and 50 years of age.
Regarding sex, males are more exposed to accidental and industrial injuries of the eye. But the present series show that females were slightly more affected than males.
In 1840 McKENZIE stated that the most common cause of sympathetic ophthalmia is a penetrating wound involving the iris and ciliary body. This view is now firmly established. PARSONS 5 says that sympathetic ophthalmia almost always results from a penetrating wound. IRVINE 4 in his analysis of 63 cases of sympathetic ophthalmia found that no instance of the disease developed without perforation of the globe. All workers are of the opinion that perforating wound is the exciting cause of the disease in a majority of cases of sympathetic ophthalmia.
In this series seven of the nine cases resulted from penetrating injuries. JOY 4 and WOOD7 have reported sympathetic ophthalmia following cataract operation. In one of the present cases, the disease followed cataract operation. Non-penetrating wound may also cause sympathetic ophthalmia. In one case of the present series, the disease developed following phthisis bulbi after small pox.
In connection with the clinical picture in the sympathizing eye, WOODS 7 classified the disease as having two different forms the anterior and posterior forms of the disease depending whether the anterior or posterior uvea is primarily affected. The anterior form is characterised by lowgrade iritis with K.P.'s, posterior synechia and vitreous opacities. Due to posterior synechia the tension of the eye rises leading to secondary glaucoma. If the process is allowed to continue, the eve passes into low tension leading to phthisis bulbi. The posterior form is characterised by marked fall in vision due to papillitis and vitreous opacities. Then the process advances to anterior uvea with characteristic changes in the iris already described. In the present series the anterior form of the disease was observed in 6 cases and the posterior form was seen in the other three cases.
Sympathetic ophthalmia is a chronic, low-grade uveitis with remissions and exacerbations (DUKE-ELDER 1 ). In the present series the disease was not allowed to run long and enucleation was undertaken at the shortest possible time, except in one case where the patient came a long time later with resulting bad prognosis.
FUCHS 2 has left little to be improved upon on his classical description of the pathology of the disease. On the other hand, the pathogenesis has remained a matter of speculation through the age. A propos to the disease has taken a strong hold of our imagination.
In the present observations, no corelation between the severity of the pathology of the exiciting eye and visual end-result in the sympathizing eye was found.
In sympathetic ophthalmia, if the injured eye is so badly injured that it has no useful vision, it is better to excise the exciting eye as soon as possible. This rule was followed in 7 out of 9 of the persent series and good results were obtained. In one of the present cases the patient came to this institution after two months of injury with occlusio pupillae of both eyes and enucleation did not improve the vision in the sympathizing eye. In another case where the patient refused enucleation as the injured eye became quiet, he was given a drop of atropine 1 per cent in the sound eye. The patient came back after two weeks, the vision having dropped to perception of light in the sound eye with pupillary dilatation. Enucleation of the injured eye even at this late stage gave 6/9 vision in the sympathizing eye.
| Summary and conclusions|| |
The following conclusions are made on a study of 9 cases of Symphathetic Ophthalmia over a period of 11 years.
(1) The disease is uncommon and occurs mostly in connection with a penetrating injury of the eye involving the uvea.
(2) The severity of the histopathological picture of the exciting eye does not correlate with the visual end result in the sympathizing eye.
(3) Prompt enucleation of the exciting eye markedly improves the vision in the sympathizing eye.
(4) If expectant treatment is to be continued, the patient should be always kept under observation for the appearance of K. P. or papillitis in the sympathizing eye. It is better to instil a drop of atropine 1 percent in the sympathizing eye with the idea of dilating the pupil to prevent pupillary occlusion.
| Acknowledgement|| |
This work was carried out under the guidance of Dr. M. Sen Gupta, Professor of Ophthalmology, Eye Infirmary, Medical College Hospitals, Calcutta.
[Table - 1]