Sympathetic Ophthalmia

This 30YO male suffered an open globe injury from an iron nail OD on 11/2/25. Three days later, the corneo-limbal laceration was repaired elsewhere. He presented to us on 11/25 with 1 week of bilateral vision loss. Vision was hand motion OD and 20/400 OS. Mild anterior chamber cells were noted OU.

Multicolor SLO imaging shows bilateral multifocal pockets of subretinal fluid (SRF) along with inferior exudate retinal detachments. OCT scanning shows bilateral bacillary layer detachments (BALADs), SRF, and choroidal thickening and undulation. Fluorescein angiography shows multifocal subretinal leakage with disc leakage.

Learning Points:
Sympathetic ophthalmia is a rare, bilateral granulomatous panuveitis that develops following penetrating trauma or intraocular surgery to one eye, with an incidence of approximately 0.19% after open-globe injury (He et al, AJO 2022;234:117-125). It typically presents within the first year after the inciting event but can occur days to years later, presenting with decreased vision, pain, and photophobia. Findings mirror those seen in Vogt-Koyanagi-Harada disease, including granulomatous anterior uveitis, vitritis, exudative retinal detachment with BALAD, choroidal thickening, and Dalen-Fuchs nodules. Systemic corticosteroids remain the first-line treatment, with most patients requiring long-term corticosteroid-sparing immunosuppressive agents to prevent recurrences. Visual prognosis is generally good with treatment. See Parchand et al for a recent comprehensive update (Ind J Ophthalmol 2022;70:1931-1944).

Our patient was started on intravenous methylprednisolone 1g for 5 days, followed by oral steroids and azathioprine. All fluid resolved 3 weeks after starting treatment (not shown). Vision improved to 20/63 OU. A slow steroid taper was planned.