Sympathetic ophthalmia is a non-suppurative uveitis that occurs in one eye after penetrating ocular trauma. The uvea of the healthy eye also develops an acute diffuse inflammation of the same nature. The injured eye is referred to as the exciting eye, while the uninjured eye is called the sympathizing eye, with sympathetic ophthalmia being the general term for this condition.

bubble_chart Etiology

The cause of the disease is unknown, and it is currently believed to be related to immune factors. There are two theories: infection and autoimmunity.

Infection theory: includes bacterial infection and viral infection theories.

After perforating trauma, bacterial infection spreads from one eye to the other via the bloodstream or optic chiasm cerebrospinal fluid, but no definitive pathogen has been identified.

Viruses may play an adjuvant role in triggering immune responses.

Immune theory: Penetrating eye injury provides an opportunity for intraocular antigens to reach local lymph nodes, allowing intraocular tissue antigens to contact the lymphatic system and induce an autoimmune reaction.

bubble_chart Clinical Manifestations

Sympathetic ophthalmia has a latent period after trauma, ranging from a few hours to as long as 40 years, with 90% of cases occurring within 1 year. The most dangerous period is 4 to 8 weeks after the injury. It is particularly prone to occur when the ciliary body is injured, when there is incarceration of uveal tissue in the wound, or when there is a foreign body in the eye.

1. Stimulating eye: After ocular injury, poor wound healing or persistent inflammation post-healing, stubborn ciliary congestion, accompanied by acute irritative symptoms, edema in the posterior pole of the fundus, optic disc hyperemia, suet-like deposits behind the cornea, turbid aqueous humor, and thickened, darkened iris.
2. Sympathizing eye: Initially, there are mild subjective symptoms such as eye pain, photophobia, tearing, and blurred vision. Irritative symptoms gradually become more pronounced, with grade I ciliary congestion, turbid aqueous humor, and fine deposits. As the condition progresses, plastic inflammatory reactions appear, with indistinct iris texture, pupil constriction and posterior synechiae, nodules at the pupillary margin, pupillary seclusion, vitreous opacity, and optic disc hyperemia and edema. Small yellowish-white lesions resembling drusen can be seen in the peripheral choroid, gradually merging and expanding, spreading throughout the choroid. During the convalescence stage, the fundus may exhibit residual pigmentation, depigmentation, and pigmentary disturbances, and a "sunset glow" appearance may appear in the fundus.

bubble_chart Diagnosis

1. History of penetrating ocular injury and bilateral inflammatory response.
2. When deposits appear in the sympathetic eye, along with floaters and flare in the anterior chamber and anterior vitreous, sympathetic ophthalmia should be considered.
3. Pathological examination of the enucleated, blind exciting eye can further confirm the diagnosis.

bubble_chart Treatment Measures

1. Treatment Principles: Once diagnosed, promptly dilate the pupils, control inflammation, and implement comprehensive treatment.
2. First, administer large doses of corticosteroids, such as oral prednisone 60–80 mg every morning. Subsequently, adjust the dosage to every other day based on the condition. After the inflammation subsides, continue maintenance doses for several months. Do not discontinue or reduce the dosage prematurely.
3. For patients who cannot continue hormone therapy, use immunosuppressants such as cyclophosphamide or cyclosporine.
4. Apply antibiotics locally and systemically, along with adjuvant therapy.
5. For the affected eye, if vision is completely lost despite early aggressive treatment, perform early enucleation. If there is potential for vision recovery, continue active treatment for both eyes.
6. Generally, follow-up should last for more than 3 years, with annual check-ups during this period.

bubble_chart Differentiation

1. For a patient with a history of trauma in one eye and symptoms of irritation in the other eye, every effort should be made to rule out the primary lesion.
2. Exclude lens-induced uveitis and uveoencephalitis (VKH): they share indistinguishable commonalities but also have distinct characteristics.
3. Differentiate from Behcet's syndrome (Behcet's disease).