PRESUMED SYMPATHETIC OPHTHALMIA AFTER SCLERAL BUCKLING SURGERY Mohammad Mehdi Parvaresh, MD, Khalil Ghasemi Falavarjani, MD
Purpose: To report an unusual case of sympathetic ophthalmia after successful scleral buckling surgery. Methods: The authors reported the clinical manifestation, ocular and systemic workup, and outcome of a 23-year-old woman who presented with reduced vision 3 weeks after successful scleral buckling surgery. Results: Slit-lamp examination showed a mild anterior chamber and vitreous reaction. Fundus examination showed extensive serous retinal detachment in both eyes. Systemic workup was negative for extraocular disease. The patient was treated with intensive systemic steroid and azathioprine. The inflammation was controlled and serous detachment resolved. Conclusion: Sympathetic ophthalmia can occur after successful scleral buckling surgery. RETINAL CASES & BRIEF REPORTS 7:331–333, 2013
ago. Again, 3 weeks before recent presentation, she underwent buckle revision surgery including subretinal fluid drainage and cryotherapy for redetachment associated with a new break. At the time of this surgery, a peripheral retinal tear in the right eye was treated by one cryotherapy spot. The patient reported headache and dizziness during the recent week. Visual acuity was counting fingers in the right eye and hand movement in the left eye. Ocular examination revealed mild bilateral cellular reaction in anterior chamber and anterior vitreous cavity. Intraocular pressure was normal. In the posterior segment, extensive serous retinal detachment was noted in both eyes (Figure 1). Periocular examination was normal. Fluorescein angiography showed multiple leakages at the level of the retinal pigment epithelium (Figure 2). B-scan echography revealed diffuse thickening of the choroid. On systemic examination, no central nervous system, hearing, or skin disorder was found. No specific disorder was found in rheumatologic and neurologic consultation. Laboratory studies for syphilis, tuberculosis, and sarcoidosis were negative. Magnetic resonance imaging of the brain was normal and cerebrospinal fluid examination revealed normal glucose and protein concentrations and mild lymphocyte pleocytosis. Intravenous steroid therapy (methylprednisolone 1 g/day) was instituted and continued for 3 days. Oral steroid (prednisone 1 mg/kg/day) and azathioprine 1.5 mg/kg/day was started at the Day 4. Two weeks later, visual acuity improved to 20/60 and 20/120 in the right and left eyes, respectively. Intraocular inflammation subsided, and retinal detachment resolved (Figure 3). The medications were tapered during the next 4 months; however, the intraocular inflammation and serous detachment recurred when the corticosteroid was reduced to 10 mg/day and azathioprine was discontinued. The
From the Eye Research Center, Rasoul Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran.
S
ympathetic ophthalmia (SO) is a rare bilateral diffuse granulomatous inflammation that may occur after surgery or trauma to one eye. It has been reported after various ocular surgeries including vitrectomy, secondary intraocular lens (IOL) placement, trabeculectomy, cyclodestruction, and cataract extraction.1 We report a patient with bilateral serous retinal detachment associated with intraocular inflammation after successful scleral buckling (SB) surgery. Case Report A 23-year-old woman was referred with complaint of decreased vision in both eyes for 1 week. She had a history of successful SB surgery for rhegmatogenous retinal detachment in the left eye, 4 years None of the authors have any financial/conflicting interests to disclose. Presented orally in the Interactive Session on Challenging Intraocular Inflammations, WOC 2012, February 19, 2012, Abu Dhabi, United Arab Emirates. Reprint requests: Khalil Ghasemi Falavarjani, MD, Eye Research Center, Rasoul Akram Hospital, Tehran University of Medical Sciences, Sattarkhan-Niayesh Street, Tehran 14455-364, Iran; e-mail: [email protected]
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RETINAL CASES & BRIEF REPORTS´ 2013 VOLUME 7 NUMBER 4
Fig. 1. Fundus photography shows bilateral serous retinal detachment.
extent of retinal detachment was less than the initial presentation. Again, the disease was successfully treated with oral prednisone 1 mg/kg/day in tapering doses and methotrexate. Nine months after initial presentation, the patient was on prednisone 5 mg/day, and the eyes were free of intraocular inflammation.
Discussion Sympathetic ophthalmia should be suspected in the presence of bilateral uveitis after any ocular trauma or surgery. There is no specific laboratory study for definitive diagnosis of SO. Differential diagnostic considerations include other causes of panuveitis, including tuberculosis, sarcoidosis, syphilis, and fungi, as well as traumatic or postoperative endophthalmitis;
Fig. 2. Fluorescein angiography shows multiple hyperfluorescent sites of leakage at the level of the retinal pigment epithelium.
however, the most important disease mimicking SO is Vogt—Koyanagi—Harada (VKH).1 The clinical presentation of SO and VKH is similar. The main differentiating clue is the history of the surgery or trauma, which is typically absent in patients with VKH.1 Sympathetic ophthalmia has been reported after a wide variety of ocular surgeries. Gass,2 in a survey of retinal surgeons, reported an incidence of 0.01% after vitrectomy. More reports indicate a higher prevalence of SO after vitrectomy.3,4 Sympathetic ophthalmia rarely occurs after SB surgery. In a survey of the UK and Ireland ophthalmic surgeon, Kilmartin et al3 reported three cases of SO after SB surgery; however, two patients had additional intraocular surgeries. Lyons et al5 reported a patient with rhegmatogenous
333
SYMPATHETIC OPHTHALMIA AFTER SCLERAL BUCKLING
Fig. 3. Two weeks after starting medications, retinal detachment resolved.
retinal detachment planned for nondrainage SB surgery, the globe inadvertently perforated during suture placement, resulting in subretinal fluid drainage. Four months later, the patient returned back with bilateral granulomatous uveitis and treated as SO. Ozbek et al6 reported a patient with SO 2 years after placement of an encircling band, subretinal fluid drainage, SF6 injection, and indirect laser photocoagulation. Our patient had neurologic symptoms and signs, including headache and lymphocyte pleocytosis. Although extraocular findings are typical for VKH disease, they may be observed in SO as well. We considered our patient as a case of SO based on the history of surgery. Although incomplete VKH disease cannot be definitely ruled out, based on the revised diagnostic criteria for VKH disease, the absence of the history of penetrating ocular surgery is a prerequisite for VKH diagnosis.7 The treatment of choice of SO is immunomodulatory therapy, and prompt and aggressive treatment is necessary.1 Systemic corticosteroids are the first step with the frequent addition of corticosteroid-sparing agents. It is important to recognize the significance of
bilateral uveitis after intraocular surgery including SB surgery. Key words: sympathetic ophthalmia, uveitis, scleral buckling. References 1. Arevalo FJ, Garcia RA, Al-Dhibi HA, et al. Update on sympathetic ophthalmia. Middle East Afr J Ophthalmol 2012;19:13–21. 2. Gass JDM. Sympathetic ophthalmia following vitrectomy. Am J Ophthalmol 1982;93:552–558. 3. Kilmartin D, Dick A, Forrester J. Prospective surveillance of sympathetic ophthalmia in the UK and Republic of Ireland. Br J Ophthalmol 2000;84:259–263. 4. Kilmartin D, Dick A, Forrester J. Sympathetic ophthalmia risk following vitrectomy: should we counsel patients? Br J Ophthalmol 2000;84:448–449. 5. Lyons C, Tuft S, Lightman S. Sympathetic ophthalmia from inadvertent ocular perforation during conventional retinal detachment surgery. Br J Ophthalmol 1997;81:608–613. 6. Ozbek Z, Arikan G, Yaman A, et al. Sympathetic ophthalmia following vitreoretinal surgery. Int Ophthalmol 2010;30:221–227. 7. Read RW, Holland GN, Rao NA, et al. Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: report of an international committee on nomenclature. Am J Ophthalmol 2001;131:647–652.
Purpose: To report an unusual case of sympathetic ophthalmia after successful scleral buckling surgery. Methods: The authors reported the clinical manifestation, ocular and systemic workup, and outcome of a 23-year-old woman who presented with reduced vision 3 weeks after successful scleral buckling surgery. Results: Slit-lamp examination showed a mild anterior chamber and vitreous reaction. Fundus examination showed extensive serous retinal detachment in both eyes. Systemic workup was negative for extraocular disease. The patient was treated with intensive systemic steroid and azathioprine. The inflammation was controlled and serous detachment resolved. Conclusion: Sympathetic ophthalmia can occur after successful scleral buckling surgery. RETINAL CASES & BRIEF REPORTS 7:331–333, 2013
ago. Again, 3 weeks before recent presentation, she underwent buckle revision surgery including subretinal fluid drainage and cryotherapy for redetachment associated with a new break. At the time of this surgery, a peripheral retinal tear in the right eye was treated by one cryotherapy spot. The patient reported headache and dizziness during the recent week. Visual acuity was counting fingers in the right eye and hand movement in the left eye. Ocular examination revealed mild bilateral cellular reaction in anterior chamber and anterior vitreous cavity. Intraocular pressure was normal. In the posterior segment, extensive serous retinal detachment was noted in both eyes (Figure 1). Periocular examination was normal. Fluorescein angiography showed multiple leakages at the level of the retinal pigment epithelium (Figure 2). B-scan echography revealed diffuse thickening of the choroid. On systemic examination, no central nervous system, hearing, or skin disorder was found. No specific disorder was found in rheumatologic and neurologic consultation. Laboratory studies for syphilis, tuberculosis, and sarcoidosis were negative. Magnetic resonance imaging of the brain was normal and cerebrospinal fluid examination revealed normal glucose and protein concentrations and mild lymphocyte pleocytosis. Intravenous steroid therapy (methylprednisolone 1 g/day) was instituted and continued for 3 days. Oral steroid (prednisone 1 mg/kg/day) and azathioprine 1.5 mg/kg/day was started at the Day 4. Two weeks later, visual acuity improved to 20/60 and 20/120 in the right and left eyes, respectively. Intraocular inflammation subsided, and retinal detachment resolved (Figure 3). The medications were tapered during the next 4 months; however, the intraocular inflammation and serous detachment recurred when the corticosteroid was reduced to 10 mg/day and azathioprine was discontinued. The
From the Eye Research Center, Rasoul Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran.
S
ympathetic ophthalmia (SO) is a rare bilateral diffuse granulomatous inflammation that may occur after surgery or trauma to one eye. It has been reported after various ocular surgeries including vitrectomy, secondary intraocular lens (IOL) placement, trabeculectomy, cyclodestruction, and cataract extraction.1 We report a patient with bilateral serous retinal detachment associated with intraocular inflammation after successful scleral buckling (SB) surgery. Case Report A 23-year-old woman was referred with complaint of decreased vision in both eyes for 1 week. She had a history of successful SB surgery for rhegmatogenous retinal detachment in the left eye, 4 years None of the authors have any financial/conflicting interests to disclose. Presented orally in the Interactive Session on Challenging Intraocular Inflammations, WOC 2012, February 19, 2012, Abu Dhabi, United Arab Emirates. Reprint requests: Khalil Ghasemi Falavarjani, MD, Eye Research Center, Rasoul Akram Hospital, Tehran University of Medical Sciences, Sattarkhan-Niayesh Street, Tehran 14455-364, Iran; e-mail: [email protected]
331
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RETINAL CASES & BRIEF REPORTS´ 2013 VOLUME 7 NUMBER 4
Fig. 1. Fundus photography shows bilateral serous retinal detachment.
extent of retinal detachment was less than the initial presentation. Again, the disease was successfully treated with oral prednisone 1 mg/kg/day in tapering doses and methotrexate. Nine months after initial presentation, the patient was on prednisone 5 mg/day, and the eyes were free of intraocular inflammation.
Discussion Sympathetic ophthalmia should be suspected in the presence of bilateral uveitis after any ocular trauma or surgery. There is no specific laboratory study for definitive diagnosis of SO. Differential diagnostic considerations include other causes of panuveitis, including tuberculosis, sarcoidosis, syphilis, and fungi, as well as traumatic or postoperative endophthalmitis;
Fig. 2. Fluorescein angiography shows multiple hyperfluorescent sites of leakage at the level of the retinal pigment epithelium.
however, the most important disease mimicking SO is Vogt—Koyanagi—Harada (VKH).1 The clinical presentation of SO and VKH is similar. The main differentiating clue is the history of the surgery or trauma, which is typically absent in patients with VKH.1 Sympathetic ophthalmia has been reported after a wide variety of ocular surgeries. Gass,2 in a survey of retinal surgeons, reported an incidence of 0.01% after vitrectomy. More reports indicate a higher prevalence of SO after vitrectomy.3,4 Sympathetic ophthalmia rarely occurs after SB surgery. In a survey of the UK and Ireland ophthalmic surgeon, Kilmartin et al3 reported three cases of SO after SB surgery; however, two patients had additional intraocular surgeries. Lyons et al5 reported a patient with rhegmatogenous
333
SYMPATHETIC OPHTHALMIA AFTER SCLERAL BUCKLING
Fig. 3. Two weeks after starting medications, retinal detachment resolved.
retinal detachment planned for nondrainage SB surgery, the globe inadvertently perforated during suture placement, resulting in subretinal fluid drainage. Four months later, the patient returned back with bilateral granulomatous uveitis and treated as SO. Ozbek et al6 reported a patient with SO 2 years after placement of an encircling band, subretinal fluid drainage, SF6 injection, and indirect laser photocoagulation. Our patient had neurologic symptoms and signs, including headache and lymphocyte pleocytosis. Although extraocular findings are typical for VKH disease, they may be observed in SO as well. We considered our patient as a case of SO based on the history of surgery. Although incomplete VKH disease cannot be definitely ruled out, based on the revised diagnostic criteria for VKH disease, the absence of the history of penetrating ocular surgery is a prerequisite for VKH diagnosis.7 The treatment of choice of SO is immunomodulatory therapy, and prompt and aggressive treatment is necessary.1 Systemic corticosteroids are the first step with the frequent addition of corticosteroid-sparing agents. It is important to recognize the significance of
bilateral uveitis after intraocular surgery including SB surgery. Key words: sympathetic ophthalmia, uveitis, scleral buckling. References 1. Arevalo FJ, Garcia RA, Al-Dhibi HA, et al. Update on sympathetic ophthalmia. Middle East Afr J Ophthalmol 2012;19:13–21. 2. Gass JDM. Sympathetic ophthalmia following vitrectomy. Am J Ophthalmol 1982;93:552–558. 3. Kilmartin D, Dick A, Forrester J. Prospective surveillance of sympathetic ophthalmia in the UK and Republic of Ireland. Br J Ophthalmol 2000;84:259–263. 4. Kilmartin D, Dick A, Forrester J. Sympathetic ophthalmia risk following vitrectomy: should we counsel patients? Br J Ophthalmol 2000;84:448–449. 5. Lyons C, Tuft S, Lightman S. Sympathetic ophthalmia from inadvertent ocular perforation during conventional retinal detachment surgery. Br J Ophthalmol 1997;81:608–613. 6. Ozbek Z, Arikan G, Yaman A, et al. Sympathetic ophthalmia following vitreoretinal surgery. Int Ophthalmol 2010;30:221–227. 7. Read RW, Holland GN, Rao NA, et al. Revised diagnostic criteria for Vogt-Koyanagi-Harada disease: report of an international committee on nomenclature. Am J Ophthalmol 2001;131:647–652.
