We read with great interest the editorial written by Sen and Nussenblatt, which discussed current knowledge of the risk of sympathetic ophthalmia (SO). The authors reviewed historical data on the incidence, prevalence, primary causes, and visual outcomes of this condition. They comment on the recently published retrospective review of 85 patients with SO at 3 tertiary centers, including our own. In this study, ocular trauma was the most common inciting event for SO, and bilateral ocular inflammation developed more rapidly in patients with traumatically induced SO than in patients with other causes, such as surgically induced SO.

As part of this discussion, the authors comment on a retrospective case series of perforating injury and outcomes in Operation Iraqi Freedom. In this report, 65 eyes of 61 soldiers sustained perforating ocular injury. Twenty-five patients underwent primary enucleation, 1 underwent evisceration, and 12 underwent secondary enucleation within 2 weeks of the initial injury. SO was not a reported complication in any of these patients. The lack of SO in patients sustaining perforating trauma was attributed to early primary and secondary enucleation and timely medical care.

However, we would like to draw attention to the fact that one case of SO has been reported in the literature secondary to battlefield injuries sustained during Operation Iraqi Freedom. In this case, the patient sustained shrapnel wounds and underwent evisceration of the left eye on the day of the trauma. SO developed 3 weeks later, and examination of the left orbit revealed dehiscence of the scleral shell and a pigmented lesion in the subconjunctival space.

We believe that mention of this case is appropriate for two reasons. First, SO is still a concern in patients who sustain ocular trauma on the battlefield. Second, we wish to highlight the theoretical increased risk of SO after evisceration versus enucleation. SO did not develop in any of the patients in the large series from Operation Iraqi Freedom, and the only reported case of SO developing after war injury since World War II occurred after evisceration. We suggest that evisceration after war injury may not be an ideal treatment option for severely traumatized eyes.