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Year : 2020  |  Volume : 68  |  Issue : 9  |  Page : 2023-2024

Commentary: Optical coherence tomography in sympathetic ophthalmia

Medical and Vision Research Foundations, Sankara Nethralaya, Chennai, Tamil Nadu, India

Date of Web Publication20-Aug-2020

Correspondence Address:
Dr. Parthopratim Dutta Majumder
Senior Consultant, Medical and Vision Research Foundations, Sankara Nethralaya, 18, College Road, Sankara Nethralaya, Chennai - 600 006, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_886_20

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How to cite this article:
Dutta Majumder P. Commentary: Optical coherence tomography in sympathetic ophthalmia. Indian J Ophthalmol 2020;68:2023-4

How to cite this URL:
Dutta Majumder P. Commentary: Optical coherence tomography in sympathetic ophthalmia. Indian J Ophthalmol [serial online] 2020 [cited 2020 Sep 23];68:2023-4. Available from: http://www.ijo.in/text.asp?2020/68/9/2023/292594

Sympathetic ophthalmia (SO) is a rare, bilateral granulomatous uveitis that can develop after a variable time following a planned (such as surgical procedure) or accidental trauma.[1] SO is more of a clinical entity that may involve iris and ciliary body or choroid, to begin with, followed by panuveitis. However, clinical presentation and course of SO remain variable.[2] For our purposes, SO is a condition that could result in bilateral vision loss or significant ocular morbidity if not identified early or where treatment is significantly delayed. Diagnostic confusion leading to a delay in the diagnosis of SO and subsequent treatment is not uncommon.[3] In a study by Lubin et al.[4] a strong correlation between final visual acuity and severity of the inflammation was observed. The majority of the patients (93.3%) with mild inflammation retained 20/70 or better vision, whereas eyes with severe inflammation had visual acuity of less than 20/70.[4] Thus, it is crucial to initiate treatment at the preliminary stage of SO. In this issue of the Indian Journal of Ophthalmology, Rogaczewska et al.[5] reported a case of SO where spectral-domain optical coherence tomography (SD-OCT) was helpful in identifying early manifestation of the disease.

Histopathologically, the early stage of SO is characterized by minimal cellular infiltration of choroid along with exudative retinal detachment, and Dalen–Fuchs nodules.[6] Dalen–Fuchs nodules are composed of groups of epithelioid cells or macrophages, located between Bruch's membrane and the retinal pigment epithelium layer.[4] These nodules can be considered characteristic of SO, but not pathognomonic and are present in only 25% to 36% of cases of SO.[4] Dalen–Fuchs nodules can also occur in Vogt–Koyanagi–Harada disease and sarcoidosis. These nodules are usually 60 to 700 μm in diameter and most commonly seen in the midperiphery of the fundus.[7] Dalen–Fuchs nodules can occur both in the early and late phase of SO.[8]

Being a noninvasive, noncontact method, OCT can be used not only for timely diagnosis but also as a follow-up tool in patients with SO. Using SD-OCT, Gupta et al.[9] demonstrated reversible retinal changes with photoreceptor involvement in the early stage of SO. Serous retinal detachment with disruption to the continuity of the two inner hyper-reflective bands was observed in a cohort of six patients with SO.[9] Treatment with systemic corticosteroid led to resolution of the serous detachment with normal photoreceptor layer and restoration of a third hyper-reflective band (inner and outer segment photoreceptor junction) in these eyes. Dalen–Fuchs nodules were described as hyperreflective lesions at the level of the retinal pigment epithelium with associated disruptions of the IS/OS junction on SD-OCT in an 84-year-old patient with SO.[10] Morphological appearance of Dalen–Fuchs nodule may resemble similar to that observed in the histopathological section.[11],[12] Using enhanced depth imaging (EDI-OCT), the thickening of choroid in acute phase of SO was described in a young male by Behdad et al.[13] that reduced with systemic corticosteroid therapy. A similar observation was reported by a recent study that noted a significantly higher choroidal thickness in SO patients when compared to normal controls.[14] Although the increased choroidal thickness is an important marker for the degree of choroidal inflammation, it can be seen in various other inflammatory conditions.[15],[16] SD-OCT was found to be helpful in picking up a small serous retinal detachment with retinal pigment epithelium (RPE) irregularities in a 23-year old asymptomatic male who sustained a penetrating injury in the other eye.[17] Thus, OCT can play a crucial role in the early diagnosis of SO in patients with a suggestive history. One must not forget to perform fundus fluorescein angiography and rule out central serous retinopathy before instituting systemic corticosteroid in patients with serous retinal detachment in such a scenario.[18]

High index of suspicion and regular monitoring of such patients may facilitate timely recognition of SO and help to reduce visual morbidity.

  References Top

Dutta Majumder P, Anthony E, George AE, Ganesh SK, Biswas J. Postsurgical sympathetic ophthalmia: Retrospective analysis of a rare entity. Int Ophthalmol 2018;38:2487-93.  Back to cited text no. 1
Tan XL, Seen S, Dutta Majumder P, Ganesh SK, Agarwal M, Soni A, et al. Analysis of 130 cases of sympathetic ophthalmia - A retrospective multicenter case series. Ocul Immunol Inflamm 2019;27:1259-66.  Back to cited text no. 2
Chan CC, Roberge RG, Whitcup SM, Nussenblatt RB. 32 cases of sympathetic ophthalmia. A retrospective study at the National eye institute, Bethesda, Md., from 1982 to 1992. Arch Ophthalmol Chic Ill 1960 1995;113:597-600.  Back to cited text no. 3
Lubin JR, Albert DM, Weinstein M. Sixty-five years of sympathetic ophthalmia. A clinicopathologic review of 105 cases (1913--1978). Ophthalmology 1980;87:109-21.  Back to cited text no. 4
Rogaczewska M, Iwanik K, Stopa M. Early presentation of sympathetic ophthalmia in optical coherence tomography studies: A case report. Indian J Ophthalmol 2020;68:2019-22.  Back to cited text no. 5
  [Full text]  
Müller-Hermelink HK, Kraus-Mackiw E, Daus W. Early stage of human sympathetic ophthalmia. Histologic and immunopathologic findings. Arch Ophthalmol Chic Ill 1960 1984;102:1353-7.  Back to cited text no. 6
Gasch AT, Foster CS, Grosskreutz CL, Pasquale LR. Postoperative sympathetic ophthalmia. Int Ophthalmol Clin 2000;40:69-84.  Back to cited text no. 7
Cunningham ET, Kilmartin D, Agarwal M, Zierhut M. Sympathetic ophthalmia. Ocul Immunol Inflamm 2017;25:149-51.  Back to cited text no. 8
Gupta V, Gupta A, Dogra MR, Singh I. Reversible retinal changes in the acute stage of sympathetic ophthalmia seen on spectral domain optical coherence tomography. Int Ophthalmol 2011;31:105-10.  Back to cited text no. 9
Muakkassa NW, Witkin AJ. Spectral-domain optical coherence tomography of sympathetic ophthalmia with Dalen-Fuchs nodules. Ophthalmic Surg Lasers Imaging Retina 2014;45:610-2.  Back to cited text no. 10
Reynard M, Riffenburgh RS, Minckler DS. Morphological variation of Dalén-Fuchs nodules in sympathetic ophthalmia. Br J Ophthalmol 1985;69:197-201.  Back to cited text no. 11
Dell'Arti L, Barteselli G, Invernizzi A, Leone G, Benatti E, Viola F. Morphological appearance of type III Dalén-Fuchs nodules by SD-OCT. Retina Phila Pa 2017;37:e48-9.  Back to cited text no. 12
Behdad B, Rahmani S, Montahaei T, Soheilian R, Soheilian M. Enhanced depth imaging OCT (EDI-OCT) findings in acute phase of sympathetic ophthalmia. Int Ophthalmol 2015;35:433-9.  Back to cited text no. 13
Agrawal R, Jain M, Khan R, Jaisankar D, Xin W, Ding J, et al. Choroidal structural changes in sympathetic ophthalmia on swept-source optical coherence tomography. Ocul Immunol Inflamm 2019;1-6. doi: 10.1080/09273948.2019.1685110. [Epub ahead of print]  Back to cited text no. 14
Kim M, Choi SY, Park Y-H. Analysis of choroidal and central foveal thicknesses in acute anterior uveitis by enhanced-depth imaging optical coherence tomography. BMC Ophthalmol 2017;17:225.  Back to cited text no. 15
Hirooka K, Saito W, Namba K, Takemoto Y, Mizuuchi K, Uno T, et al. Relationship between choroidal blood flow velocity and choroidal thickness during systemic corticosteroid therapy for Vogt-Koyanagi-Harada disease. Graefes Arch Clin Exp Ophthalmol 2015;253:609-17.  Back to cited text no. 16
Khan Z, Bergeron S, Burnier M, Kalin-Hajdu E, Aubin M-J. Optical coherence tomography as a tool to detect early sympathetic ophthalmia in an asymptomatic patient. Can J Ophthalmol 2020;55:e9-13.  Back to cited text no. 17
Tandon R, Vanathi M, Verma L, Bharadwaj A. Central serous retinopathy masquerading as sympathetic ophthalmia. Eye Lond Engl 2003;17:666-7.  Back to cited text no. 18


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