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Editor,—Sympathetic ophthalmia is a rare complication of intraocular surgery. We report a patient in whom inadvertent scleral perforation at the time of buckle placement was complicated by sympathetic ophthalmia.
A 58-year-old myope with a 4 day history of floaters in the right eye was found on examination to have a temporal retinal detachment involving the macula. The visual acuity at presentation was 6/24 R and 6/6 L. There was no history of ocular trauma or inflammation. A superotemporal retinal tear was identified and, since this was very peripheral, non-drainage surgery was planned. Cryotherapy was applied and a 5 mm radial sponge, positioned under the tear, was secured with two 5/0 Ethibond sutures.
The globe was inadvertently perforated with the posterior suture, resulting in subretinal fluid drainage. At the end of surgery, the retina was flat, with no incarceration, and the break was closed on the indenting buckle. There was no haemorrhage. At discharge, the right visual acuity was 6/12, but 3 months later it had decreased to 6/18 due to macular pucker.
He returned 4 months postoperatively with a 5 day history of worsening right vision. The visual acuities were 6/60 R and 6/9 L. There was a bilateral granulomatous anterior uveitis. No posterior segment inflammation was noted. He was started on topical steroids and mydriatics. Five days later both visual acuities were reduced to 6/60. There were cells in the anterior vitreous and inferotemporal serous retinal detachments with a generalised ‘blotchy’ white retinal appearance. Mottled choroidal hyperfluorescence and disc leakage were evident on fluorescein angiography (Fig 1A and B) and patchy choroidal thickening with retinal surface irregularities were reported on ultrasound. He was referred to the uveitis clinic where sympathetic ophthalmia was diagnosed clinically. He was treated with prednisolone 80 mg daily. Within 48 hours, the subretinal fluid had cleared and the steroid dose was gradually reduced. Three months after the onset of inflammation, retinal pigment epithelial depigmentation was noted around the site of perforation and the right macula. Two years later, his visual acuities are 6/18 and 6/6, he is on prednisolone 5 mg orally and prednisolone eyedrops 0.3% to both eyes. These doses were briefly increased to treat two inflammatory episodes. A right trabeculectomy was performed for glaucoma.
Sympathetic ophthalmia following intraocular surgery is rare. Liddy and Stuart estimated its incidence to be 0.007%.1 Retinal detachment surgery was first implicated by Kornblueth and Stein2 who reported a case following multiple scleral perforations in the management of giant tear. Pusin et al3 described it in a patient with concurrent bacterial endophthalmitis and Wang4 in a patient with globe rupture. In this patient, no known risk factors were identified; human leucocyte antigen (HLA) typing was A24(9) A30(19) B41 B51(5) Bw4 Bw6 Cw4 Dr4 Dr17(3) Dr52 Dr53. The latter can be associated with Vogt–Koyanagi–Harada disease, a possible differential diagnosis in this case. Gass, in a survey of retinal surgeons, reported an incidence of 0.01% after vitrectomy5 and found drainage during a scleral buckling procedure to be the initial penetrating wound in three of 53 eyes enucleated for sympathetic ophthalmia.
The risk of sympathetic ophthalmia is rarely a consideration when deciding on the management of retinal detachment. Nevertheless, along with the commoner complications of subretinal fluid drainage (subretinal haemorrhage and retinal incarceration), its occurrence is a further argument for non-drainage surgery wherever possible. Clearly, however, closure of the retinal break is of paramount importance since failure to do so will entail reoperation, with an increased risk of proliferative vitreoretinopathy and, potentially, sympathetic ophthalmia.
It is important to recognise the significance of bilateral uveitis following even the smallest ocular perforation since early diagnosis and vigorous treatment of sympathetic ophthalmia are commonly associated with a good visual prognosis.6
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