An Overview of Sympathetic Ophthalmia
Symptoms, Causes, Diagnosis, and Treatment
Medically reviewed by Johnstone M. Kim, MD
Sympathetic ophthalmia (SO) is a rare eye condition that can develop after an eye injury or within days or weeks after eye surgery. This condition presents itself as a type of uveitis (eye inflammation), and it occurs because the body’s immune system attacks the healthy eye. The healthy eye is called the "sympathizing eye” because it shows sympathy to the injured one and becomes inflamed. Sympathetic ophthalmia is vision-threatening if not treated quickly.
Prevalence
Research shows sympathetic ophthalmia incidences to range from 0.2 to 0.5% following an eye injury and .01% following intraocular surgery (surgery inside of the eye). Research reported in the Journal of Ophthalmic Inflammation and Infection suggests these are lower incidences than previously thought, citing increased knowledge on SO and other inflammatory eye conditions making it easier to diagnose.
Symptoms
Eye floaters and loss of accommodation are the earliest signs of sympathetic ophthalmia.
Eye floaters appear as small spots that drift through a person’s field of vision. Floaters stand out when you look at something bright or blank (such as a blue sky). They generally don’t interfere with sight.
Accommodation is a process where the eye changes its optical power to see an image more clearly or focus on an object at a distance. Accommodation is usually a reflex, but a person can consciously control it.
Additional symptoms of sympathetic ophthalmia may include:
Pain and redness in the sympathizing eye
Headache
Decreases in visual acuity
Increased sensitivity to light
Vision loss
Retinal detachment in severe cases
Causes
Injury to the eye or eye surgery are the only known causes of sympathetic ophthalmia. Some studies have found SO affects more men than women, but these studies are few. One 2018 report reported in the journal International Ophthalmology found post-eye surgery, men are affected 1.8 times more than women by SO.
As for age, SO is normally distributed among adults and children. Higher incidences of SO are common in older populations due to an increased need for intraocular surgeries, such as cataract surgery.
There are no racial differences related to sympathetic ophthalmia. There have been no studies showing that sympathetic ophthalmia is associated with any medical health conditions, such as diabetes or high blood pressure.
Diagnosis
Diagnosis of sympathetic ophthalmia is clinical and includes looking at the history of eye injury and trauma and testing to look for eye inflammation and other eye abnormalities.
One important part of diagnosis involves ruling out Vogt–Koyanagi–Harada disease (VKH), another inflammatory eye disease presenting with similar symptoms to SO. VKH usually has no known cause.
Uveal eye tissue (tissue beneath the white of the eye) can be sampled and examined under a microscope for certain antigens. These antigens are found in people with long-standing uveitis (eye inflammation) and common in many eye inflammatory conditions, including SO and VKH.
A slit lamp can help look at the inside of the eye. Without it, inflammation is only shown as red eyes. A slit lamp can see collections of inflammatory cells sitting in the back part of the cornea. The cornea is the transparent part of the eye, covering the iris, pupil and anterior chamber. It helps to alter light and improve optical power.
A slit lamp may also reveal optic disc swelling and white patches on the retina, the innermost, light-sensitive layer of the eye. There may be peripheral anterior synechiae where the rim of the iris is stuck towards the lens.
A diagnosis of sympathetic ophthalmia can be made when eye testing finds specific eye abnormalities, eye inflammation, and if a person has recently had an eye injury or eye surgery.
Treatment
Once sympathetic ophthalmia is diagnosed, immunosuppressive therapy is the main treatment. Immunosuppressive drugs are effective for preventing the over-activity of the immune system and may offer a positive prognosis. These drugs include corticosteroids, biologics, and Janus kinase (JAK) inhibitors, and medications typically used to treat autoimmune diseases, (conditions where the immune system attacks its own healthy tissues).
Takeaway
Mild cases of SO are also treated with corticosteroids and pupillary dilator drugs (mydriatics).
Corticosteroids for inflammatory eye disease are given in eyedrop form. Eyedrops treat ocular surface inflammation and inflammation on the front of the eye. When inflammation is deeper, corticosteroid injections around the eye or directly in the eye may be given. More severe and more progressive cases of SO will require high-dose systemic corticosteroids, such prednisone in oral form, in the short term (spanning two months). But beyond that, immune modulatory treatment with steroid sparing medication is ideal.
Doctors try to avoid long-term use of corticosteroids because long-term use has adverse effects including mental status changes, joint pain problems, and increased risk for osteoporosis, a bone-weakening disease.
Pupillary dilator drugs make the pupil of the eye dilate (open up). The pupil of the eye is the black center of the eye. Pupillary dilators relax the eye muscles and improve eye focus. They are typically topical medicines and a common side effect is blurred vision.
Sometimes, doctors will decide to remove a severely injured eye within two weeks of vision loss to reduce a person’s risk for developing sympathetic ophthalmia in the healthy eye. Removal is only done when there is complete vision loss in the injured eye and there is no chance vision will return.
Summary
The prognosis for sympathetic ophthalmia is positive with correct diagnosis and prompt and aggressive therapies. Since eye professionals are aware of the potential for SO to develop after an eye injury or eye surgery, diagnosis and early treatment intervention have reduced the potential for permanent vision loss and increased the potential for treatment success.
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