Clinical Research And Analysis Of Cases Of Sympathetic Ophthalmia

Purpose:To investigate the epidemiologic characteristics,clinical features,treatment methods and prognosis of sympathetic ophthalmia(SO),and provide reference for clinical diagnosis and treatment of sympathetic ophthalmia.Methods:1.We conducted a review of 8 cases of SO diagnosed in our institution between January 2013 and March 2017.2.A retrospective and noncomparative review was performed on these 8patients.3.Thirty-five previously published cases of SO were identified through documentation retrieval between 2006 and 2016.4.Forty-three casesof SO,which were diagnosed in our institution and identified through documentation retrieval,were analyzed,to make the results more reliable by expanding the sample size through documentation retrieval.5.The data were processed with statistical methods.Results:1.Epidemiologic characteristics: Between January 2013 and March 2017,in the department of uveitis and ocular immune service,the percentage of patients with SO in all patients with uveitis is 0.6%(8/1414),which is quite low.The clinical documents of 8 patients were analyzed,including 7 males and one female.The mean(±SD)age was 57(±17)years(range33–85).Three patients(3/8)are beyongd 65 years old.The first symptoms of 5 patients(5/8)appeared more than one year later after the inciting event.Four patiments(4/8)had been performed transscleral cyclophotocoagulation(TCP).Then we enlarge the sample size to 43 patients,including 30 males and 13 females.The mean(±SD)age was 44.6(±20.8)years(range 2.5–85).The ages of 9 patients(20.9%)range from 41 to 50,and 10 patients(23.3%)are beyond sixty-five years old.According to the injury,there were 25patients(58.1%)who underwent ocular surgeries,and 18 patients(50%)had history of trauma.Among the patients that had history of surgery,6 patients(14.0%) underwent vitreoretinal surgeries and 6 patients(14.0%)underwent TCP.In patients with trauma,13 patients(30.2%)had the history of penetrating corneal trauma.The time between the initial injuryand the first symptoms of uveitis ranged from one week to 40 years,and the latent period of 29 patients(67.4%)were within one year.2.Clinical features: 6 patients(6/8)experienced vision decrease in sympathizing eyes in our institution.6 patients(6/8)had signs of aqueous cells and/or flares,and vitreous inflammation.5 patients(5/8)esperienced exudative retinal detachment.4patient(4/8)had intraocular pressure(IOP)increased.Only 2 patients(2/8)had Dalen-Fuchs nodules and sunset glow fundus occurred in all patients.Then we enlarge the sample size to 43 patients.Thirty-six patients(83.7%)experienced vision decrease of sympathizing eyes.The most common sign is vitreous inflammation,which occurred in 23 patients(53.5%).The second is aqueous cells and/or flares with21 patients(48.8%).Eleven patients(25.6%)had Dalen-Fuchs nodules and 8 patients(18.6%)had mutton-fat keratin precipitates.Fundus fluorescein angiography(FFA)almost shows that multiple dot fluorescent in the level of retina pigment epithelium(RPE)and choroid at early stage,then expanding and fusing,and fluorescent accumulated under the retinal by fluorescent leakage at late stage.Indocyanine green angiography(ICGA)often shows the expansion of the choroid blood vessels and leakage of fluorescence at early stage,and shows hypofluorescence in the pole of the retina and around the optic disk at late stage.Optical coherence tomography(OCT)mainly shows an exudative retinal detachment and B ultrasonography often shows the incrassated choroid.3.Treatment: Seven patients(7/8)received treatment with steroids and 4(4/8)patients with combined therapy of steroids and immunosuppressants.After the sample size was enlarged,40 patients(93.0%)received treatment with steroids,and 27(62.8%)patients with steroids and immunosuppressants.Cyclosporine A is the most common used immunosuppressant,and had been used in 13 patients(48.1%).Six patients(22.2%)had taken azathioprine.4.Treatment effect: One of the 8 cases(Patient 8)haven't finish his follow-up and is not included in the observation.At the final visit of the 7 patients,the best corrected vision acuity(BCVA)of sympathizing eyes improved in 4 patients(4/7),unchanged in 3 patients(3/7).The treatment effect can be divided into cured,improved and deteriorated according to the ocular inflammation at final visit.Six patients(6/7)have been cured and one patients(1/7)has been improved.Then we enlarge the sample size to 43 patients.The average time of follow-up was 10.0months.The BCVA of 21 eyes(50%)had low vision(better than or equal to 0.05 and lower than 0.3)and blind(lower than 0.05)at initialvisit,and the number declined to 19 cases(21.4%)at the last follow-up.Comparing the initial BCVA and BCVA at final visit,the vision improved in 27 cases(64%).Conclusion :1.Sympathetic ophthalmia mainly occurs following ocular surgery or penetrating injury,and the morbidity is relatively low.2.Surgical injures have replaced penetrating trauma as the main pathogenesis,and the latent period become longer compared with what reported before.3.Sympathetic ophthalmia is a rarely complication of non-invasive surgery such as TCP and TSCPC,which has become a common inciting event.Such ympathetic ophthalmia is also known as iatrogenic sympathetic ophthalmia..4.Vision decrease of sympathizing eye is the most common symptom.The clinical course of sympathetic ophthalmia is similar as Vogt Koyanagi-Harada Disease.The signs of the eye are diverse in different phases of the disease.The signs of posterior segment often occur at the early stage of the disease,including vitreous inflammation and exudative retinal detachment,while sunset glow fundus and Dalen-Fuchs nodules appear at the later stage.Anterior segment inflammation commonly occurs in severe and/or recurrent cases.The inflammation is non-granulomatous at early stage,and the recurrent cases show signs of granulomatous inflammation,including mutton-fat keratin precipitates and iris nodules.5.The clinical features of Sympathetic ophthalmia are diverse,and the diagnosis of the diseaserequires detailed medical history inquery,ocular examinations,including a variety of auxiliary examinations(B ultrasonography,OCT and FFA and ICGA,etc.),and exclusion of VKH,glaucoma and other eye diseases.6.Systemic corticosteroids is the first-line drug for the treatment of sympathetic ophthalmia.Combination with immunosuppressants can enhance treatment effect and reduce the side effects.7.Sympathetic ophthalmia will be recurrent and chronic afte inappropriated treatment or delayed diagnosis.Early diagnosis and treatment can improve the visual prognosis,improve the cure rate and reduce the rate of blindness.