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Management of Ophthalmic Injuries by the Forward Surgical Team
Published in Mansoor Khan, David Nott, Fundamentals of Frontline Surgery, 2021
Richard J. Blanch, Johno Breeze, William G. Gensheimer
Aside from the detrimental effect on visual outcome in the eye affected, the main risk of very delayed, absent, or incompetent repair is sympathetic ophthalmia. Sympathetic ophthalmia is an autoimmune granulomatous inflammatory disorder that occurs after open globe injury or intraocular surgery and affects the uninjured (as well as the injured or operated) eye. The risk of sympathetic ophthalmia after intraocular surgery is low, at between 1/1,000 and 1/10,000, but is higher after open globe injury. In a large series of 1,392 patients with open globe injury, 1,283 underwent primary repair (889 patients), evisceration (491 patients), or enucleation (3 patients) of whom none developed sympathetic ophthalmia. 109 patients did not have primary surgical management, and of these patients, two developed sympathetic ophthalmia (1.83%), suggesting that this risk is low except when primary repair or eye removal is not performed.
Posterior uveitis
Published in Gwyn Samuel Williams, Mark Westcott, Carlos Pavesio, Bushra Thajudeen, Practical Uveitis, 2017
Gwyn Samuel Williams, Mark Westcott
These two conditions are almost identical, with only the history separating them. They are both rare but do occur often enough to warrant more than an academic consideration in diagnosing posterior uveitis. The specific sign that differentiates these conditions is the exudative retinal detachment. Many causes of posterior uveitis, as well as non-uveitic conditions, can cause an exudative detachment, though these two conditions are so famous for it that should a striking exudative detachment be present then these conditions should be considered first. Sympathetic ophthalmia is a condition that occurs in the contralateral eye following trauma or multiple surgeries, which is a form of trauma, to an eye. The damaged eye is known as the exciting eye as the damage is thought to release some as yet unknown antigen into the blood that causes an immune response against it that then goes on to involve the other eye, called the sympathising eye. Perhaps it is easier to imagine twin brothers where one twin gets into trouble with the police who take his picture and then go on to harass the innocent twin purely because of the trouble the first one caused as they look so identical the police cannot tell the difference.
Laser Surgery in the Treatment of Glaucoma
Published in Neil T. Choplin, Carlo E. Traverso, Atlas of Glaucoma, 2014
Since then, electrolysis, beta-irradiation, cryotherapy, xenon arc, ultrasound, surgical excision, and various visible and infrared lasers have been tried in an attempt to improve on this type of glaucoma surgery. In current practice, laser-based cyclodestructive procedures are useful in the treatment of glaucomas with poor surgical prognosis in which trabeculectomy with antimetabolites or aqueous drainage devices have failed. In addition, these procedures may also be used to decrease pain and to lower pressure in cases with limited visual potential. The most frequently used techniques are laser-based contact and noncontact cyclophotocoagulation using Nd:YAG or diode-based laser systems. The use of these techniques causes considerable pain, inflammation, and visual loss; they should therefore be treatments of last recourse (Figure 15.28). Initial reports of sympathetic ophthalmia were in eyes with previous ocular surgery, creating controversy. Subsequently, there have been reports of sympathetic ophthalmia occurring in eyes after cyclophotocoagulation that were not previously operated upon. Laser–tissue interactions vary somewhat depending on the wavelength and the peak power delivered. High-power, pulsed lasers (20 μs), such as the Microrupter series, cause more tissue disruption. Continuous-wave lasers require a longer exposure time to deliver sufficient energy to cause cyclophotocoagulation; the effects are more coagulative in nature. Distinctive pops that are heard are steam bubbles disrupting uveal tissue. The reported rates of phthisis are in excess of the occurrence of choroidal hemorrhage or loss of fixation in eyes with advanced glaucoma undergoing trabeculectomy. This argument in favor of cyclophotocoagulation should perhaps be revisited by surgeons. Although laser-based treatments produce less pain than cyclocryotherapy, they should be performed under retrobulbar anesthesia and the patients given a 3- to 4-day supply of moderate strength analgesic, such as Vicodin.
COVID Vaccine-Associated Uveitis
Published in Ocular Immunology and Inflammation, 2023
Zohar Habot-Wilner, Piergiorgio Neri, Annabelle A. Okada, Rupesh Agrawal, Ng Xin Le, Shai Cohen, Naomi Fischer, Fionn Kilmartin, Amy Coman, Dara Kilmartin
Sympathetic ophthalmia is closely related to VKH disease, with similar bilateral intraocular inflammation developing months-to-years after intraocular surgery or penetrating trauma in the “exciting eye,” and often requires long-term immunosuppressive treatment to prevent recurrent inflammation and preserve vision in the “sympathizing eye.” As reported by Nakayama et al., COVID-19 vaccination was suspected of having triggered acute recurrence in one patient who had previously been stable on a regimen of adalimumab and cyclosporine.72 The inflammatory recurrence was treated with pulse doses of intravenous methylprednisolone followed by a slow taper of oral prednisolone, in addition to continuation of the adalimumab and cyclosporine. Visual acuity improved; however, progression of cataract and development of epiretinal membrane were noted (Table 1).
Changing Trends in Uveitis in the United Kingdom: 5000 Consecutive Referrals to a Tertiary Referral Centre
Published in Ocular Immunology and Inflammation, 2023
N. P. Jones, S. Pockar, L. R. Steeples
Sympathetic ophthalmia has significantly fallen in this study both in incidence and as a proportion of patients seen. In 2000, a UK surveillance study17 prospectively identified a minimum incidence of 0.03/100 000 per annum. The study was reliant upon active reporting and there may have been a significant underestimation of incidence nationwide. As the single uveitis centre in the GM and Lancashire/Cumbria area dealing with this disease, we can say with some confidence that the incidence was approximately 0.31/100 000 pa during quartile 1 and 0.23/100 000 pa in quartile 4. For trauma-induced SO, those figures were 0.20 and 0.08 and for surgery-induced, 0.03 and 0.15. Clearly, the main precipitator of SO has changed during the study period from trauma to intraocular surgery. A recent study18 identified a very low risk of SO following a single vitreoretinal procedure (0.008%) but rising exponentially to as high as 6.67% after 7 procedures. The modern tendency towards multiple vitreoretinal surgery should be tempered by knowledge of this risk.
Recurrent Sympathetic Ophthalmia with Annular Choroidal Detachment after Pembrolizumab Treatment: A Case Report
Published in Ocular Immunology and Inflammation, 2020
Junwon Lee, Joo Youn Shin, Jihei Sara Lee, Sung Chul Lee, Min Hee Hong, Christopher Seungkyu Lee
Sympathetic ophthalmia is a bilateral, granulomatous uveitis due to trauma or surgery in one eye. It is thought to occur secondary to the development of an autoimmune reaction to ocular antigens exposed during the traumatic or surgical event. Typically, T-cell predominance is seen in the choroidal infiltrate, which suggests the role of T-cells in the pathophysiology of this condition.12 In theory, eyes with previous sympathetic ophthalmia may be predisposed to aggravation/recurrence or an autoimmune reaction after anti-PD-1 therapy, which enhances the T-cell response. Posterior segment inflammation after pembrolizumab in the present case may be regarded as an unrelated autoimmune inflammation, rather than the recurrence of sympathetic ophthalmia, because severe annular choroidal detachment is a rare feature of sympathetic ophthalmia. However, annular choroidal detachment resembling uveal effusion syndrome can develop in a severe case of sympathetic ophthalmia.13 Further studies should evaluate the risk of ocular inflammation after immune checkpoint inhibitor treatment in patients with a history of uveitis.