Common Symptoms
Clinical symptoms are typically consistent with uveitis, including blurry vision, conjunctival injection, and ocular irritation. Other symptoms of sympathetic ophthalmia (SO) include photophobia in the sympathizing (nontraumatic) eye, epiphora, floaters, loss of accommodation, bilateral eye pain, and decreased vision. On rare occasions, patients may report extraocular symptoms such as hearing loss, headache, vitiligo, and meningeal irritation.
73.1.2 Exam Findings
Anterior segment exam may demonstrate mutton-fat keratic precipitates on the corneal endothelium (▶ Fig. 73.1), conjunctival injection, and thickened iris due to anterior inflammation possibly leading to posterior synechiae. Intraocular pressure can be increased due to blockage of trabecular meshwork or decreased due to impaired ciliary body function. The extent of inflammation in the posterior segment varies. Patients may present with vitritis, retinal vasculitis, and choroiditis. Serous retinal detachments, papilledema, and classic Dalen-Fuchs nodules, characterized as yellowish white choroidal lesions, may also be present on posterior examination (▶ Fig. 73.2).
Fig. 73.1 Mutton-fat keratic precipitates on the corneal endothelium may be noted in the setting of sympathetic ophthalmia.
(Courtesy of Derek Kunimoto.)
Fig. 73.2 Fundus examination of sympathetic ophthalmia may reveal multifocal serous retinal detachments.
(Courtesy of Michael Dollin and Rajiv Shah.)
73.2 Key Diagnostic Tests and Findings
73.2.1 Optical Coherence Tomography
Optical coherence tomography (OCT) frequently demonstrates choroidal and retinal pigment epithelium (RPE) thickening; may also reveal retinal detachment, intraretinal edema, disintegration of RPE and choriocapillaris, and thinning and disorganization of the inner retina (▶ Fig. 73.3).
Fig. 73.3 Optical coherence tomography may demonstrate multifocal retinal detachment with thickening of the outer retina and intraretinal fluid. Increased hyperreflectivity is also noted in the outer retina.
(Courtesy of Michael Dollin and Rajiv Shah.)
73.2.2 Fluorescein Angiography or Ultra-Widefield Fluorescein Angiography
Angiography often reveals multiple hyperfluorescent sites of leakage at the level of the RPE during the venous phase (▶ Fig. 73.4). Possible hypofluorescent areas may correspond to Dalen-Fuchs nodules. In the chronic phase, the nodules become atrophic and appear as window defects. Retinal vasculitis may also be visualized in late staining.
Fig. 73.4 In active sympathetic ophthalmia, early-phase (a) fluorescein angiography may show multifocal points of hyperfluorescence with larger areas of hypofluorescence. (b) Late fluorescein angiography phases may reveal leakage and pooling.
(Courtesy of Michael Dollin and Rajiv Shah.)
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