|Year : 2015 | Volume
| Issue : 1 | Page : 19-21
Cataract surgery in the exciting eye in sympathetic ophthalmia
Abhay A Lune1, Akash P Shah1, Sonali A Lune2
1 Department of Ophthalmology, Padmashree Dr. D.Y. Patil Medical College and Research Centre, Pune, Maharashtra, India
2 Lune Eye Clinic, 1641, Madhav Heritage, Tilak Road, Pune, Maharashtra, India
|Date of Web Publication||17-Jun-2015|
Abhay A Lune
Lune Eye Clinic, 1641, Madhav Heritage, Tilak Road, Pune - 411 030, Maharashtra
Source of Support: None, Conflict of Interest: None
Sympathetic ophthalmia (SO) is a rare, bilateral, non-necrotizing, granulomatous panuveitis that occurs following penetrating injury or a surgical procedure in one eye threatening sight in the fellow eye. Visual prognosis is reasonably good with prompt appropriate wound repair and corticosteroids pre and post-operatively. Only in a severely injured eye with no prognosis for vision is enucleation done within 2 weeks of injury to prevent the disease.
We report a case of sympathetic ophthalmia with traumatic cataract following penetrating injury in the exciting eye. Cataract surgery with posterior chamber lens implant was done in the exciting eye, with pre-operative and post-operative cover of steroids, yielding good postoperative vision.
If the injured eye has any vision, enucleation should be avoided as this may become the better eye if the fellow eye develops severe inflammation. We present this as a rare case report because after a thorough literature search in Pubmed, to the best of our knowledge, such a case has been rarely reported.
Keywords: Enucleation, panuveitis, penetrating injury, sympathetic ophthalmia
|How to cite this article:|
Lune AA, Shah AP, Lune SA. Cataract surgery in the exciting eye in sympathetic ophthalmia. Sudanese J Ophthalmol 2015;7:19-21
| Introduction|| |
Sympathetic ophthalmia (SO) is a rare, bilateral, non-necrotizing, granulomatous panuveitis that occurs following penetrating injury or surgical procedures in one eye threatening sight in the fellow eye. An incidence of 0.19% following penetrating injuries and 0.007% following intraocular surgery has been reported.  The time from ocular injury to onset of SO varies from a few days to decades, with 80% of the cases occurring within 3 months after injury to the exciting eye and 90% within 1 year.  The treatment recommended is wound repair under cover of corticosteroids or enucleation of the injured eye within 2 weeks, based on the visual prognosis.
| Case report|| |
We report a case of a 25 year old female presenting to us with pain and dimness of vision in the left eye following trauma to that eye with a wooden stick 12 days back. She had complaints of watering and mild pain in the right eye since two days. On examination visual acuity was perception of light with accurate projection of rays in the left eye and 20/30 in the right eye. Slit-lamp examination of the left eye revealed ciliary congestion, a full thickness 2.0 mm sealed corneal tear with iris incarceration at the inferior pupillary margin at five o'clock position and formed but irregular depth of anterior chamber with fluffy free floating cortical matter obscuring the view of the pupil. Hence, pupillary reaction could not be noted. Traumatic cataract with rupture of anterior lens capsule and leakage of cortex into the anterior chamber was seen in the left eye [Figure 1]. The right eye revealed mild ciliary congestion, few fresh mutton-fat keratic precipitates with grade 1 cells and flare in the anterior chamber [Figure 2]. Siedel's test was negative in the left eye. The left eye was firm digitally and intraocular pressure in the right eye was 12 mmHg on applanation tonometry. Fundus examination and Fluorescein angiography of the right eye revealed no abnormality and was not visualized in the left eye. B Scan ultrasonography of both eyes was normal. A diagnosis of sympathetic ophthalmia was made based on the history and clinical findings.
|Figure 1: Traumatic cataract with rupture of anterior lens capsule and leakage of fluffy white cortex into the anterior chamber in the left eye|
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|Figure 2: Right eye showing few fresh mutton-fat keratic precipitates with grade 1 cells and flare in the anterior chamber|
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She was treated with oral ciprofloxacin 500 mg twice a day, acetazolamide 250 mg three times a day & prednisolone 80 mg gradually tapered over 6 months after resolution of inflammation. Topically eye drops prednisolone 1% two hourly, eye drop cyclopentolate 1% twice a day and eye drop nepafenac three times a day were instilled in both the eyes. The left eye underwent cataract surgery with phaco-aspiration of the lens matter, synechiolysis of the incarcerated iris and posterior synechiae and implantation of a sulcus-fixated posterior chamber intraocular lens as the posterior capsule was found to be intact. The edges of the corneal tear were well-opposed without any leakage and with well-formed anterior chamber, hence did not require any suturing. The post-operative period was uneventful with a best corrected vision of 20/30 and a well-centered implant [Figure 3]. Her symptoms in the right eye improved with disappearance of the ciliary congestion and the flare and cells and with vision of 20/20. At 1 year follow-up the patient was asymptomatic.
|Figure 3: Post-operative photograph of the left eye showing pseudophakia with corneal opacity following penetrating injury|
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| Discussion|| |
After the inciting event, traumatic or surgical, bilateral intraocular inflammation has been reported between 1 week and 66 years.  Surgical procedures that may lead to sympathetic ophthalmia include cataract extraction, iridectomy, paracentesis, cyclodialysis, retinal detachment repair, keratectomy, evisceration, laser cyclocoagulation, vitrectomy, after perforated corneal ulcer, radiation for choroidal melanoma and external beam radiation. 
On literature search we came across the only similar case reported by Ganesh et al. They reported a case of cataract extraction in the exciting eye in sympathetic ophthalmia and observed that it can be safely and successfully performed with vigilant preoperative and postoperative control of inflammation, careful surgical planning and meticulous surgical technique. 
Some have suggested early enucleation of the injured eye to improve visual prognosis of the sympathizing eye.  while a review of sympathetic ophthalmia cases noted that from a histology standpoint there was no benefit from enucleation of the exciting eye.  Kilmartin et al. found that once sympathetic ophthalmia develops, enucleation of the exciting eye to reduce inflammation in the sympathizing eye does not necessarily lead to a better visual outcome or to a reduced need for medical therapy. 
In conclusion, cataract removal with posterior chamber implant can be safely attempted along with pre and postoperative steroids to control inflammation and to achieve a good visual outcome in the exciting eye. If the injured eye has any vision, enucleation must be avoided as this may become the better eye in case the fellow eye develops severe inflammation.
We present this as a rare case report because after a thorough literature search in Pubmed, to the best of our knowledge such a case has been rarely reported.
| References|| |
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Arevalo JF, Garcia RA, Al-Dhibi HA, Sanchez JG, Suarez-Tata L. Update on Sympathetic Ophthalmia. Middle East Afr J Ophthalmol 2012; 19:13-21.
Zaharia MA, Lamarche J, Laurin M. Sympathetic uveitis 66 years after injury. Can J Ophthalmol 1984;19:240-3.
Ganesh SK, Sundaram PM, Biswas J, Babu K. Cataract surgery in sympathetic ophthalmia. J Cataract Refract Surg 2004; 30:2371-6.
Lubin JR, Albert DM, Weinstein M. Sixty-five years of sympathetic ophthalmia. A clinicopathologic review of 105 cases (1913-1978). Ophthalmology 1980;3:109-121.
Chu XK, Chan CC. Sympathetic ophthalmia: To the twenty-first century and beyond. J Ophthalmic Inflamm Infect 2013;3:49.
Kilmartin DJ, Dick AD, Forrester JV. Prospective surveillance of sympathetic ophthalmia in the UK and Republic of Ireland. Br J Ophthalmol 2000;84:259-63.
[Figure 1], [Figure 2], [Figure 3]