Sympathetic ophthalmia is a rare, bilateral inflammatory process with an incidence of 0.03/100 000 in the UK and Ireland.1 It usually follows either penetrating eye injury or intraocular surgery. Although sympathetic ophthalmia has previously been described after irradiation of ocular melanoma,2,3 it has never been reported after simple 106Ru plaque brachytherapy. We present a case which confirms that there is a risk of developing sympathetic ophthalmia after charged‐particle therapy in the absence of a penetrating injury of the uveal tract.
Case report
A 41‐year‐old lady was referred by her optician for a slow‐growing iris lesion. Fine needle aspiration biopsy confirmed the diagnosis of ciliary body malignant melanoma. Systemic investigations for metastatic disease were negative. The patient underwent routine surgery for the insertion and subsequent removal of a 106Ru plaque. Postoperative recovery was uneventful.
At 6 months after surgery, the patient presented with a 1‐week history of reduced vision in both eyes to 6/24 OD and 6/36 OS. This was accompanied by photophobia, soreness and redness of both eyes.
Examination showed moderate anterior uveitis with mutton fat keratic precipitates in the left eye. There was no vitritis. Both fundi showed macular neuroretinal detachments with faint yellowish subretinal spots. Fluorescein angiography showed multiple hypofluorescent spots in the fundus with neuroretinal detachments, which was also confirmed on optical coherence tomography (figs 1 and 2).
Figure 1 Colour fundus photographs and fluoroscein angiography showing yellowish sub retinal spots at the pasterior pole along with nellro sensory detachments at the macula giving rise to retinal state. FFA shows early hypofluoresence followed by late staining of the yellow spots.
Figure 2 Sequential OCT scans of the right (top) and left (bottom) eyes shaving extensive neurosensory retinal detachments and the resolution of SRF over a 3 week period of treatment with steroids.
A diagnosis of sympathetic ophthalmia was made, and the patient was treated with intensive topical and systemic steroids. She responded well to treatment and was discharged on a tapering dose of systemic steroids. After 6 months, her vision had improved to 6/5 OU, with no evidence of recurrent inflammation.
Comment
The pathogenesis of sympathetic ophthalmia consists of an autoimmune hypersensitivity response directed against exposed uveal tissue in the traumatised (exciting) eye, which is followed by a similar response against the fellow (sympathising) eye. If left untreated, it follows a chronic, relapsing and progressive course. Various surgical causes previously reported include complicated cataract surgery,4 cyclocryotherapy,5 laser cyclophotocoagulation,6,7,8 proton beam and helium ion irradiation,2,3 and vitrectomy.9,10
The disruption of uveal tissue that set off the chain of events in this case is thought to have resulted from the radioactive effect of the treatment. Fine needle aspiration biopsy is unlikely to have caused sympathetic ophthalmia, as the biopsy was taken through clear cornea under direct visualisation and avoiding choroidal tissue. Perforation at the time of suturing during surgery was not noted peroperatively, and is unlikely given the very anterior location of the tumour, which made surgery technically easy at an area with relatively thick sclera.
This case shows a rare delayed complication of Ruthenium brachytherapy that has never been reported previously. The most likely differential diagnosis is Vogt Koyanagi Harada syndrome, which may present in a similar manner. However, Vogt Koyanagi Harada syndrome follows a relapsing remitting course, often with systemic symptoms despite treatment with immune suppression, unlike sympathetic ophthalmia, which is a potentially curable disease if managed properly in acute stages. An absence of recurrence of disease process on stoppage of therapy, as well as the clinical history of our patient, makes the diagnosis of sympathetic ophthalmia more likely.
Footnotes
Competing interests: None.
Informed consent was obtained for publication of the person's details in this report.
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