Sympathetic Ophthalmia Clinical Guide PDF

Sympathetic Ophthalmia (look at pictures on ppt) ​ Happens in healthy eye; after trauma/open globe ​ Rare, bilateral diffuse granulomatous panuveitis due to trauma (more common) or surgery (less common) ​ Develop 2 weeks to many years after penetrating or perforating ocular injury (penetr...

Sympathetic Ophthalmia (look at pictures on ppt) ​ Happens in healthy eye; after trauma/open globe ​ Rare, bilateral diffuse granulomatous panuveitis due to trauma (more common) or surgery (less common) ​ Develop 2 weeks to many years after penetrating or perforating ocular injury (penetrating trauma) or rarely intraocular surgery on one eye ​ Uveitis may occur as early as 9 days and as late 50- 66 year ​ 90% of cases occur within three weeks to three months post-injury ​ Removal of the injured eye before sympathetic uveitis occurs protects against inflammation developing in the non-injured eye (enucleation within 2 weeks of the injury) ​ Once the inflammation start removal of the injured eye has little effect in it ​ Rarely sympathetic uveitis has been reported to be developed in the sympathizing eye after the injured eye has been enuclated ​ Etiology: ○​ Unknown ​ Delayed hypersensitivity response of an eye due to a trauma or surgery of the fellow eye Elschnig postulated that the injury to the exciting eye resulted in an absorption and dissemination of uveal pigment, which produced the hypersensitivity reaction in the injured eye The continued absorption resulted in an allergic reaction in the sensitized tissue of the sympathizing eye Predominantly a T-cell lymphocyte reaction in the injured and the sympathizing other eye Antiretinal antibodies (photoreceptor specifically the rod outer segment and Muller cells) have been found ​ ​ Risk factors ○​ Prior ocular trauma w/ delayed closure of the wound ○​ Prior ocular surgery ​ Symptoms ○​ External eyes not inflamed ○​ Severe bilateral ○​ Blurred vision and photophobia in the non-injured (sympathizing) eye usually is the first symptom ○​ Granulomatous lymphocytic infiltration to the uveal tracts ​ ○​ Acute anterior uveitis with keratic precipitates, posterior synechiae and fibrin on the anterior lens capsule in the right eye of a 25-year-old male, who had sustained a penetrating trauma to his left eye 3 months earlier ​ Histopathology ○​ Granulomatous inflammation throughout the uveal tissue, except for the choriocapillaris and retinal vessels ○​ The yellowish-white choroidal lesions (Dalen-Fuchs nodules) seen clinically correspond to collections of lymphocytes, histiocytes, and depigmented RPE cells lying beneath Bruch's membrane ○​ Retinal infiltrates have been reported in 18% of SO case ​ Signs: ○​ Bilateral severe anterior chamber reaction ○​ Large mutton-fat KP’s ○​ Depigmented nodules – disseminated yellow-white spots in the funds ​ Represent clusters of epithelial cells containing pigment lying between Bruch's membrane and the RPE (Dalen-Fuch’s nodules) ​ ○​ Papillitis, vitritis and choroiditis ​ Diagnosis ○​ Based on the history of injury or ocular surgery ○​ Clinical findings ○​ Fluorescein angiography ​ Indicate the severity of the disease ​ Guidance for therapeutic response ​ In the acute phase of SO, FA typically demonstrates multiple hyperfluorescent leakage sites at the RPE during the venous phase that persist into the late frames of the study  ​ ​ Factors that contribute to the development of sympathetic ophthalmia ○​ ​ DDx ○​ The most common ddx is Vogt-Koyanagi-Harada Syndrome ○​ ​ Preventative treatment in severe cases ○​ Enucleation of the blind traumatized eye before the sympathetic reaction develops ○​ Controversy about when to perform it, some propose 9 days after the injury or surgery (best in the first 2 weeks after trauma) ○​ Usually considered within 1-2 months of the trauma ​ Prognosis ○​ Is a serious vision-threatening disease ○​ 50% patients will have 20/40 or worse ○​ ⅓ will end up legally blind ​ Anti-inflammatory treatment in moderate to severe cases ○​ Atropine 1% qid – for pain and avoid synechia ○​ Prednisolone acetate 1% q 2h ○​ Prednisone 1.0 to 2.0 mg/kg/day tapered slowly over 3 to 4 months ○​ Severe cases IV Methylprednisolone 1.0 g/day x 3 days  ○​ Immunosuppressive therapy – in patients steroid-resistant or have secondary effects: ​ Cyclosporine 5mg/kg/day increase until control after remission for at least 3 months slow taper 0.5 mg/kg/day 1-2 months Noninfectious Postoperative Uveitis ​ Normal inflammation ○​ Surgical manipulation causes breakdown of the blood-aqeuous barrier- protein leakage and cellular reaction (flare and cell) ​ Underlying iridocyclitis ○​ Intraocular surgery or cataract extraction ​ Intraocular lens-related inflammation ○​ Much less common now (IOL polishing and sterilization techniques) ​ Toxic inflammatory response Endophthalmitis ​ Inflammation of the intraocular tissues in response to insult from infection, trauma, immune reaction, physical or chemical changes, vasculitis or neoplasm ​ Most common: ○​ acute postoperative endophthalmitis ○​ Infectious ​ Bacterial (most common on eyelids; after surgery) ​ Fungal (after 2 weeks because not a lot of sx’s) ○​ Most present within 1-2 weeks, usually 3-5 days after the surgery ○​ More common in diabetic patients, immunosuppressive diseases or alcoholism Post-surgical Bacterial Endophthalmitis ​ Uveitis secondary to bacteria ​ Pathogenesis ○​ It has been postulated that the patient’s own flora is the most common source of infections ○​ 75% of cultures from samples taken on normal eyes are positive for ​ Staphylococcus epidermidis ​ Staph aureus ​ Various streptococci (Strep. Pyogenes) ​ Gram negative species ​ Pseudomona ​ Proteus ​ Escherichia coli ○​ This strongly suggest that the periocular microbiota serve as a potential causal agent for postoperative endophthalmitis ○​ Contamination of the lens (P. acnes commonly associated) can occur by contact with the ocular surface or can also be introduced into the eye by contaminated irrigation solutions  ○​ The most common organisms responsible for bacterial is Staph epidermidis ○​ Streptococci are diagnosed in 20% of infections after intraocular surgery, but account for 57% in late onset endophthalmitis after trabeculectomy ​ Symptoms ○​ Sudden onset (1-7 days postoperatively) ○​ Rapid progression ○​ Pain, red eye, blurred vision (HM vs LP), floaters, photophobia, and headache ○​ The patient is usally systemically unwell w/ fever and rigors ​ Signs ○​ Anterior segment ​ Proptosis, hyperemia, chemosis, swollen lids and corneal edema ​ Discrete iris nodules or plaques anterior fibrinous uveitis and hypopyon in severe cases ○​ Posterior segment ​ White or yellow retinal infiltrates ​ ​ Retinal necrosis in severe cases ​ Spread to the orbit may occur ○​ ​ ​ ○​ External photograph of a 65-years-old female who underwent uneventful cataract extraction along-with intraocular lens implantation in her left eye. Two weeks later, she presented with painful left eye and complete loss of vision (a). She was found to have necrosis of her left corneal wound and extrusion of the implanted intra-ocular lens ​ Vitritis ​ Hazy media w/ hypopyon ​ Work-up ○​ hospitalization* ○​ Cultures and smears ○​ Anterior chamber paracentesis (0.2 ml) for aqueous samples  ○​ Diagnostic vitrectomy for vitreous sample ​ Ultrasound evaluation ○​ Significant media opacification ○​ Findings endophthalmitis: ​ Dispersed vitreous opacities with vitritis ​ Chorioretinal thickening ○​ Rule out: RD or choroidal, dislocated lens material, retained foreign bodies ○​ Retinal or choroidal detachment are poor prognostic factors ○​ ○​ Ultrasonography in the diagnosis of postoperative endophthalmitis. (a) Classic appearance of vitreous stands and membranes on B-scan ultrasound. Variations in gain can alter the appearance of the vitreous opacities. (b) Capsular hyperreflectivity in a case of delayed onset endophthalmitis with dense intracapsular deposits. The vitreous contains some dense deposits but is not diffusely infiltrated. Absence of vitreous inflammation or opacities is suggestive that endophthalmitis is not present, except for limited anterior forms. ​ Treatment ○​ Broad-specturm therapy should be maintained until definitive culture reports are obtained ○​ Three therapy tx ​ Antibiotics ​ Intravitreal ​ Subtenon or subconjuctival injections ​ Systemic IV, IM or PO ​ Topical ​ Cycloplegic-mydriatics (atropine) ​ Corticoesteroids ​ Topical ​ Intravitreal ​ Oral ○​ Consider Pars Plana Vitrectomy ​ No improvement in 36-48 hrs or positive for Pseudomonas or fungus ○​ Intravitreal ​ Amikacin 0.4 mg or 2.25 mg Ceftazidime + 1.0 mg of Vancomycin for postoperative endophthalmitis  ​ 1.0 mg vancomycin + 2.25 g ceftazidime or 2.0 mg of ceftriaxone for postglaucoma filter belb infections ​ Dexamethasone 0.4 mg ​ Complications of Intravitreal Antibiotics ​ Corneal opacification and retinal toxicity ○​ Amikacin 0.4 mg/0.1 mL may be administered instead of ceftazidime in patients with beta-lactam allergy, but it should be used cautiously owing to the increased risk of retinal toxicities (gentamicin and tobramycin) ○​ Victrectomy also controvesial – risk of further spread ○​ Periocular injection ​ Gentamicin or tobramycin 40 mg (1 ml) ​ Covers most gram positive and gram negative organisms ​ Cefazolin 100 mg (1 ml) or Vancomycin 50 mg/ml ​ Covers pneumococcus and streptoccoci ○​ Systemic ​ Amikacin 15 mg/kg IV or IM q 8 hrs + Cefazolin 1g IV q 6 hrs for 2-5 days ○​ Topical ​ Fortified tobramycin or gentamicin 14 mg/ml and cefazolin 133 mg/ml 2 drops q 1 hr ○​ Steroids ​ If intravitreal are not given ​ Start 24 hrs after antibiotic therapy ​ Dexamethasone phosphate 4-12 mg (1ml) or Prednisolone succinate 25 mg (1ml) subconjunctival every other day 1-2 times ​ Oral Prednisolone 40mg PO qd for 10 days ​ *use remains controversial ​ May ameliorate the immune-driven destruction of ocular tissues Post-surgical Fungal Endophthalmitis ​ Over 20 species have been isolated, the most common being ○​ Candida species, in particular Candida albicans, Aspergillus, Cephalosporium and Fusarium ​ Usually presents between 2 and 4 weeks, or later, following surgery ​ Persistent iritis might be the only presenting sign ​ The full clinical presentation is that of chronic endophthalmitis with indolent inflammation associated with relatively mild symptoms, fibrinopurulent anterior chamber exudate and vitreous snowballs ​ Signs ○​ Some pain and redness ○​ Transient hypopyon ○​ Anterior vitreous gray-white patch ○​ Satellite lesions ○​ Good light perception ○​ Rare severe anterior chamber reaction  ​ Sometimes signs and symptoms are masked by the post-surgery use of topical corticosteroids and this can lead to a dramatic increase in intraocular inflammation and ocular discomfort ​ ​ ​ Cultures ​ Treatment ○​ Pars plana vitrectomy ○​ First choice - Intravenous amphotericin B associated with intravitreal injections of the drug following vitrectomy ​ Synergistic effect with oral Flucytosine PO 50-150 mg/kg/d ​ Not use Ketoconazole is antagonistic to amphotericin B ○​ Topical Natamycin q1h or amphotericin B q1-2 h should be give in addition Phacoanaphylactic Endophthalmitis ​ Also known as phacoanaphylactic uveitis ​ Granulomatous inflammatory process associated with a disrupted lens (inflammatory centered around lens material) ​ Cause: rare autoimmune response to lens protein ​ Usually occurs following traumatic rupture of the lens capsule or following cataract surgery when cortical material is retained within the eye ​ Ocular inflammation usually begins within 14 days of lens injury ​ Small amounts of circulating lens protein normally maintain T-cell tolerance, but if tolerance to lens protein abrogates, anti-lens antibodies are produced ​ Antibody-antigen reaction takes place ​ Incidence of endophthalmitis after cataract extraction is reported to be 0.04%–0.15% ​ Presentation is with abrupt reduction in visual acuity and pain, which is less severe than in bacterial endophthalmitis ​ Days to weeks after rupture of the lens capsule ​ Signs ○​ Unilateral (bilateral if the lens capsule is ruptured in each eye) ○​ Red, painful eye ○​ Severe uveitis – large KP’s ○​ Occasional Hyopion ○​ Anterior uveitis is granulomatous and of variable severity ○​ The IOP is frequently high ○​ The posterior segment is not involved ​ ​ Differential diagnosis is bacterial endophthalmitis ​ Treatment involves removal of all lens material in conjunction intensive steroid therapy ​ Topical Cycloplegics ○​ Cyclopentolate, atropine sulfate, homatropine, and scopolamine ​