Indian Journal of Ophthalmology

ARTICLE
Year
: 1968  |  Volume : 16  |  Issue : 3  |  Page : 134--138

Sympathetic ophthalmia


SP Das 
 Eye Infirmary, Medical College Hospitals, Calcutta, India

Correspondence Address:
S P Das
Eye Infirmary, Medical College Hospitals, Calcutta
India




How to cite this article:
Das S P. Sympathetic ophthalmia.Indian J Ophthalmol 1968;16:134-138


How to cite this URL:
Das S P. Sympathetic ophthalmia. Indian J Ophthalmol [serial online] 1968 [cited 2020 Aug 7 ];16:134-138
Available from: http://www.ijo.in/text.asp?1968/16/3/134/37536


Full Text

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.