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Last Month’s Blink

Sympathetic Ophthalmia

Written by A. Itzam Marin, MD, and Alan Palestine, MD. Photo by Pamela Rowlett, CRA. All are at the University of Colorado School of Medicine, Aurora, Colo.

A 59-year-old woman who had undergone two open-globe repair procedures in her left eye five months earlier was referred to our clinic because of a sudden-onset decrease in vision in her right eye over the past few days. At presentation, her VA was hand motion. Anterior exam of her right eye showed 3+ anteri­or chamber cells and large keratic precipitates, and IOP was elevated. A dilated exam revealed vitritis, diffuse ret­inal haze, and small yellow­ish-white lesions extensively throughout the retina (Fig. 1). The left eye had a phthisical appearance and marked band kera­topathy, with no view posteriorly. An infectious workup was largely unremarkable except for a positive QuantiFERON-TB Gold test, which was thought to be unrelated to her current process.

OCT of the right eye demonstrated subretinal nodules consistent with Dalen-Fuchs nodules (Fig. 2). Fluorescein angiography showed multi­ple hyperfluorescent sites of leakage at the level of the retinal pigment epithelium (RPE) during the venous phase as well as the above-mentioned nodules (Fig. 3). Normal choroidal vasculature and accentuation of the Dalen-Fuchs nodules can be appreciated by the diffuse areas of blocking from the RPE on indocyanine green angiography (Fig. 4).

Given her history and these findings, the patient was diagnosed with sympathetic ophthalmia in the right eye.

She was initially treated with systemic and intraocular steroids prior to tuberculosis treatment and was subsequently controlled on fluocino­lone acetonide intravitreal implant and adalimumab. Following treatment, her BCVA was 20/100.

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