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   Table of Contents      
ARTICLE
Year : 1970  |  Volume : 18  |  Issue : 1  |  Page : 29-32

Sympathetic ophthalmitis with total deafness- a case report


India

Correspondence Address:
M S Nirankari
India

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How to cite this article:
Nirankari M S, Khanna K K, Chawla G D, Mathur R. Sympathetic ophthalmitis with total deafness- a case report . Indian J Ophthalmol 1970;18:29-32

How to cite this URL:
Nirankari M S, Khanna K K, Chawla G D, Mathur R. Sympathetic ophthalmitis with total deafness- a case report . Indian J Ophthalmol [serial online] 1970 [cited 2020 May 28];18:29-32. Available from: http://www.ijo.in/text.asp?1970/18/1/29/35057


  Introduction Top


Despite persistent efforts to discover the true cause of sympathetic ophthal­mitis, the problem remains still an enigma. Amongst the many fascinating theories regarding its possible aetiology, two main theories at present hold the field. It is now suggested (Greer, 1963) that the disease is the result of a two-stage process in which the development of auto-allergy to the uveal pigment sets the stage while the actual onset of the disease process is initiated by some unknown factor­possibly a virus. In this regard it very much resembles the Vogt Koyanagi Harada Syndrome, clinically as well as histologically. Histologically bilateral granulomatous uveitis with the presence of characteristic Dalen Fuch's nodules and development of detachment of retina (detachment of retina is not uncommon and at times an initial symptom of sympathetic ophthalmitis -Duke Elder) are found iii both of these conditions. Clini­cally Vogt Koyanagi Harada Syndrome is characterised by poliosis, vitiligo, alopoeacia, and disacousis and signs of meningeal involvement. Sympathetic ophthalmitis is often unaccompanied by any clinical syndrome; but occasionally accompanied by bleaching of eye-lashes, eyebrows and deafness. There may occasionally be found systemic symptoms of meningeal involvement, (Duke Elder) [3] .

Positive phagocytic reaction to the intradermal injection of uveal pigment can also be observed in both of these conditions. Presently, a case of sympathetic ophthalmitis accompanied only with total deafness is being described. The disacousis might be related to a disturbance of pigment in auditory labyrinth. The function of this pigment is unknown; but both the labyrinth pigment and ocular pigment arise from the same embryonic structure of the neural crests.


  Case History Top


S. S, 55 M.

Chief complaints and duration


Complete loss of vision in left eye-1½ months. Gradual diminution of vision in right eye - 20 days. Development of total deafness of both the ears-20 days. Mild headache - 20 days.

Past history : As narrated by his attendants, the patient had accidentally injured his left eye with a nail 3 months ago. He availed himself of the treatment of his irritable, congested, painful and sightless left eye at a nearby civil hospital for one month without any relief.

Present history : For the last 20 days, the vision of his right eye and the hearing power of both of his ears have progressively deteriorated to the point of nearly complete loss of vision of his right eye and hearing power, respectively. On interrogation, there was no history of any deteriora­tion or improvement of the condition of his left eye (injured eye) during this period. There was no history of his having taken streptomycin injections for the treatment of his injured eye. Also there was no history of ear discharge of pain in the ear. No other relevant point could be obtained in the history.

Physical examination : He was well built and well nourished man. There were no evidences of patches of vitiligo or poliosis over the body. Some of the hairs of his scalp were grey; but there was no history of its turning grey in the near future.

E. N. T. examination : No abnorma­lity detected in the drum membrane and the external ear. Audiometry and tuning fork tests could not be done due to total deafness.

Other systems of the body : No abnormality detected.

Examination of eyes

1. Left eye :- Early phthisis bulbi noted. Mild circumcorneal congestion observed. There was a tear at 1 o' clock position through the limbus extending 3 mm. on either side in the sclera and cornea. Uveal tissue was seen incarcerated in the wound. The cornea was misty and flattened. Anterior chamber was irregular and shallow. Iris patterns were disturbed with marked depigmentation noted at places. There was no evidence of nodules or neovascularization over the surface of the iris. Pupil was drawn up and invisible. Lens and fundus examination could not be done due to opaque media. The tension of the eye was low. There was no light perception in the eye.

2. Right eye:- Mild circumcorneal congestion noted. Cornea and sclera were found normal. A. C. and iris were also normal. The pupil was dilated and non-reactive (Atropinised).

Examination of the lens showed immature posterior subcortical opaci­ties. The tension of the eye was normal. Only perception and projection of light was present. The fundus examination findings revealed hazy media (heavy veil like opacities in vitreous) through which the details of the fundus could not be seen except the hyperaemic and hazy disc margins along with generalised oedema of the retina noted. On slit lamp examina­tion, mutton fat K. P.'s and aqueous flare were marked. Iris pattern was distrubed and it was thickened at places. Nodules on the iris, synechiae and capsular exudates were not seen.

Investigations

Blood examination: Hb. 13.0 gm%. E.S.R. 8 mm. 1st hour (Westergreen), total leucoeytes 5,500/cmm, no special feature was present in the differential count and bleeding and clotting times. Nothing abnormal was revealed in the examination of the urine, stool, X-ray of the skull, chest and orbit Examination of the cerebro spinal fluid was refused. Wasserrnann's and Kahn tests were negative. Mantoux reaction was positive in 1.10000.

Diagnosis : Sympathetic ophthalmitis with total deafness.

Treatment : He was put on the following therapy­

  1. Atropin ointment 1% localty, B. D., both eyes.
  2. Cambisone eye ointment (Predni­solone, Neomycin and Surfen) locally, B. D., both eyes.
  3. Injection Decadron, 1/4 cc., retro­bulbar, daily right eye.
  4. Tablet Decadron, 1 tablet, 6 hourly.
  5. Injection B1, 100 mg., and B12, 500 mcgm., intramuscularly; once daily.
  6. Capsule chloromycetin, 1 capsule, 6 hourly.


Follow-up

1st week:- There was marked subjective and objective improvement after the first week of therapy. The visual acuity in the right eye improved to finger counting at meter distance; slit lamp examination revealed a few K. P. s and weak aqueous Rare. Fundus reflex was still hazy. The vitreous was much clear; but the details of fundus were still not clear.

2nd week:- The patient could recognise persons or objects at a distance of 6 meters. Slit lamp examination revealed no aqueous flare. The K. P. s were very few. The vitreous was still hazy. The disc was slightly hyperaemic; but its margins were clear. Two small greyish yollow spots were seen in the periphery close to the equator in the lower outer quadrant. There was mild pigmentary disturbance seen around the patches.

3rd week :- The changes remained practically the same, as described in the previous week.

4th week :- The patient could recognize his attendant at a distance of 3 meters. The objective findings remained the same. Capsule chloro­mycetin were omitted after ten days. Steroids were used locally and parente­rally for about two months and gradually its doses tapered off.

8th week : At the time of his leaving the hospital, his vision of the right eye was 6/36. Fundus examina­tion revealed hazy media (vitreous degenerated and had opacities). The disc was normal. Two small patches of healed chorioretinitis noted in lower and outer quadrant near the equator. There were no signs of haemorrhages or exudates or retinal oedema. The patient did not permit enucleation of his left eye. The hearing loss remained the same.


  Discussion Top


As already described sympathetic ophthalmitis and Vogt Koyanagi Harada Syndromes can resemble histologically and clinically. Though the exciting cause of granulomatous uveitis in both these conditions may be common auto - allergy to uveal pigment initiated possibly by a virus infection, the course and severity of uveitis may differ in each condition. It may be possible that dependingi upon the type and severity of the virus infection and pigment allergy, the clinical and histological course may at times differ in either of these conditions. The similarity in clinical picture in these diseases further establishes the hypothesis that these two conditions are derived from the same common cause as mentioned above. The case under study has a clear cut picture of granulomatous uveitis accompanied with dysacousis. This combination of granulomatous uveitis accompanied only with deafness seems to be a connecting link between these two conditions and further establishes the probable hypothesis regarding the common aetiology and pathogenesis in these two conditions.


  Summary Top


An unusual case of sympathetic ophthalmitis accompanied with total deafness has been described which helps in bringing nearer the relationship of sympathetic ophthalmitis and Vogt Koyanagi Harada Syndrome which may develop from the same common aetiology[16].

 
  References Top

1.
Aronson, S. B; Yamamoto, E; Goodner, K. E. and O'Connor, R. G.: the occurence of an auto anti uveal antibody in human uveitis, Arch. Ophthal (Chicago) 72: 621, 1964.  Back to cited text no. 1
    
2.
Bhatnagar, B. S. and Nahar, S: Vogt Koyanagi Syndrome, J. All India Ophth. Soc. 14: 128, 1966.  Back to cited text no. 2
    
3.
Duke Elder, W. S.: Text Book of Ophthalmology. Vol. III, P. Henry Kimpton, London (1940).  Back to cited text no. 3
    
4.
Easom, H. A. and Zimmerman, L. E. Sympathetic Ophthalmia and bilateral phacoanaphylaxis, Arch. Ophthal. (Chicago) 72:91, 1964.  Back to cited text no. 4
    
5.
Greers, C.H.: Text Book of Ocular Pathology, Blackwell Scientific Publica­tions, Oxford. 1963.  Back to cited text no. 5
    
6.
Jaffe,N.S.: Syndrome of Vogt Koyanagi, Amer. J. Ophth. 33: 571, 1960.  Back to cited text no. 6
    
7.
Jou, H. H.: Sympathetic Ophthalmia, Amer. J. Ophth. 36: 1100, 1953.  Back to cited text no. 7
    
8.
Kaufman, H. E. : The uvea, Arch. Ophthal. (Chicago) 75: 407, 1966.  Back to cited text no. 8
    
9.
Kimura, J. S.: Annual Reviews-The uveal tract, Arch. Ophthal. (Chicago) 63: 571, 1960.  Back to cited text no. 9
    
10.
Maumenee, A.E.: The contributions of immunology to clinical ophthalmology, Amer. J. Ophth. 58: 230, 1964.  Back to cited text no. 10
    
11.
Mills, P. V. and Shedden, W. I. H.: Serological study in sypathetic ophthal­mic, Brit. J. Ophth. 49: 29, 1965.  Back to cited text no. 11
    
12.
Paul, S. D., Ahuja, O. P. and Shukla, B.R.: Viral Uveitis, J. All India Ophth. Soc. 12: 147, 1964.  Back to cited text no. 12
    
13.
Rones, B.: Uveitis with dysacousia, alopecia and Poliosis, Arch. Ophthal. (Chicago) 7: 847, 1932.  Back to cited text no. 13
    
14.
Schnellmann, D. C. and Aronson, S. B.: The relationship between auto antibody and sympathetic uveitis, Arch. Ophthal. (Chicago) 75: 213, 1966.  Back to cited text no. 14
    
15.
Stafford, W. R.: Sympathetic Oph­thalmia, Arch. Ophthal. (Chicago) 74: 521, 1965.  Back to cited text no. 15
    
16.
Woods, A. C.: Endogenous Uveitis, Williams and Wilkins Company. Baltimore, 1969.  Back to cited text no. 16
    




 

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Case History
Discussion
Summary
References

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