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Haemophilus influenzae is an occasional cause of ophthalmia neonatorum. Recently, this organism has exhibited a change in its epidemiology and has been identified as a cause of severe neonatal infections. Ophthalmologists should be aware of the changing susceptibility of neonates to severe infections with H influenzae and the possibility that H influenzae ophthalmia neonatorum can be associated with these infections.
Sympathetic ophthalmia was found 15 months after cataract extraction in a previously traumatized eye. Histopathologic examination disclosed numerous Dalen-Fuchs nodules with underlying choroidal granulomas causing obliteration of the choriocapillaris and disruption of Bruch's membrane. Prominent Dalen-Fuchs nodules were also observed clinically in the sympathizing eye, and the angiographic findings of initial hypofluorescence followed by late hyperfluorescence correlated with the pathologic findings in the sympathogenic eye. Only ten cases of sympathetic ophthalmia with fluorescein angiography have been reported previously. This is the fifth case accompanied by a histopathologic description of the exciting eye. The finding of breaks in Bruch's membrane has not been previously reported, to the best of our knowledge. This article compares the angiographic and pathologic appearances with those described in previous reports.
Sympathetic uveitis developed in a 64-year-old woman 11 weeks after posttraumatic vitrectomy accompanied by vitreous hemorrhage. After removal of the exciting eye three weeks later, the sympathetic inflammation in the second eye subsided. Histologic examination revealed typical signs of an early stage of sympathetic ophthalmia characterized by a focally pronounced infiltration of lymphoid and T cells exclusively in the choroid. These T cells consisted of Leu 2a+ suppressor-cytotoxic T cells and a few Leu 3a+ inducer T cells situated near HLA-DR+ cells of the uvea. The latter contained electron-lucent cytoplasm without pigment granules and may represent the accessory cells for the initiation of the T-cell reaction. The findings suggest that sympathetic ophthalmia represents a T-cell-mediated cytotoxic reaction (similar to allograft rejection and graft-v-host disease) toward antigens on or near the pigment epithelium or the uveal melanocytes.
The inflammatory cell reaction within the vitreous and uvea of a human eye with atypical sympathetic ophthalmia was studied immunohistologically and with the fluorescence-activated cell sorter. The uveal infiltrate consisted predominantly of T cells of the helper/inducer subset, with less than 5% of the cells characterized as B cells, plasma cells, or monocytes. These results suggest that T cells perform an important role in atypical human sympathetic ophthalmia. A similar population of mononuclear cells was observed in the vitreous inflammatory infiltrate, in marked contrast to the peripheral blood, where there was a significant depression of circulating T cells. The similarity between the inflammatory cell populations within the vitreous cavity and uvea, in contrast to the peripheral blood, underlines the importance of studying the intraocular inflammatory reaction in uveitis to gain further insight into the mechanism of this disease.
Sympathetic ophthalmia was diagnosed 49 months after helium ion irradiation of a left choroidal melanoma. The patient maintained good vision until 18 months after therapy, when she developed neovascular glaucoma. This complication required multiple therapeutic procedures, including topical anti-inflammatory and antiglaucomatous drops, 360 degrees peripheral panretinal cryoblation, and a single 180 degrees application of inferior cyclocryotherapy over a 2 1/2-year period. Four weeks after the cyclocryotherapy, inflammation was noted in both eyes, and, one month later, enucleation of the left sympathogenic eye was performed. Serial histopathologic sections showed a full-thickness, fibrovascular, scleral scar and tantalum marker ring suture without uveal incarceration. Penetrating surgical trauma, a uveal melanoma, and multiple nonpenetrating treatments resulted in the development of sympathetic ophthalmia.
There are various theories as to the origin of epithelioid cells in the choroid with sympathetic ophthalmia. Some investigators propose a transformation of choroidal melanocytes as the origin, and others suggest a histiomonocytic derivation. One reason this controversy exists may be the relative lack of investigations into necrotic changes of choroidal melanocytes. The structural alterations in the choroidal melanocytes of an injured eye with sympathetic ophthalmia were studied, and the sequence of events involved in degeneration and necrotic changes were elucidated. The damaged melanocytes developed vacuolation, and the melanin granules were gathered into autophagosomes or had disappeared. The nuclei of the severely damaged melanocytes became pyknotic. Degenerated cell nuclei were phagocytized by macrophages. It is concluded that choroidal melanocytes may not transform into epithelioid cells and that they disappear from the choroid following degeneration.
We describe a 49-year-old white man with sympathetic ophthalmia following contact neodymium-YAG laser cyclotherapy. There was no invasive surgery, and no perforating injuries preceded cyclodestructive therapy. The eye had hemorrhagic secondary glaucoma due to Coats' disease. It was treated three times with contact cyclophotocoagulation after cyclocryotherapy failed to lower intraocular pressure. Subsequently, the intraocular pressure slowly decreased and the eye became phthisical 15 months after the last surgery. Intraocular inflammation developed in the fellow eye and sympathetic ophthalmia was suspected. Histologic and immunohistologic study of the enucleated blind eye confirmed this diagnosis.
PURPOSE: To analyze indocyanine green angiography (ICGA) features in two cases of sympathetic ophthalmia using a standard angiography protocol for posterior uveitis. METHODS: Report on two patients who suffered from penetrating ocular injuries 45 and 8 years before sympathetic ophthalmia was diagnosed and confirmed by histopathological examination of the enucleated eye. In addition to routine examination and fluorescein angiography, initial and follow-up ICGAs were performed. RESULTS: The first patient, with a phthisic right eye following s shotgun injury, consulted 6 months after cataract extraction in his good left eye for progressive visual loss due to a neovascular membrane in a moderately inflamed eye. The second patient consulted 8 years after a perforating injury of his right eye by a metallic foreign body because of recent visual loss and inflammation in his good left eye. ICGA of both patients showed numerous hypofluorescent dark dots visible at the intermediate phase, some becoming isofluorescent at the late phase and resolving after long-term corticosteroid therapy, others remaining hypofluorescent until the late phase. CONCLUSION: The two patterns of hypofluorescent areas, either persisting throughout angiography or fading in the late phase, were interpreted respectively as cicatricial and active lesions. ICGA gave determining additional information on choroidal involvement and on subsequent evolution of lesions.
A 71-year-old woman developed an endogenous bacterial endophthalmitis in her right eye. Because of the rapid progression she was treated by para plana vitrectomy-lensectomy and with antibiotics and corticosteroids. The patient improved after the antibiotic therapy. One month later she had a recurrence of the inflammatory signs in the same eye. Examination disclosed lens remnants in the vitreous. Because of the possibility of phacoallergic uveitis, she underwent a second vitrectomy. The corticosteroid dosage was increased. She did well until three months later when, while still taking corticosteroids, she noted loss of visual acuity in the left eye, accompanied by bilateral inflammatory signs. Sympathetic ophthalmia was suspected and the blind right eye was enucleated. The choroid was grossly unremarkable; the routine sections disclosed many inconspicuous foci of mononuclear infiltration. Tangential sections of flat-embedded choroid, however, showed ill-defined nests of epithelioid cells containing phagocytosed melanin, supporting the diagnosis of sympathetic ophthalmia. To our knowledge, this is the first published report of this complication after pars plana vitrectomy-lensectomy in the absence of nonsurgical trauma or other surgical procedures.
The incidence and aetiology of ophthalmia neonatorum have been estimated over a 7-month period in Franceville, a semi-rural community in south-eastern Gabon. Chlamydia trachomatis was the most frequently observed pathogen, being isolated from 17 babies (2.7% of births), and Neisseria gonorrhoeae was recovered from 12 (1.6% of births). 5 of 17 cases of chlamydial conjunctivitis were in infants less than 5 d old as opposed to 9 in the typical 5 to 10-days-old group. As expected, most cases of gonococcal ophthalmia neonatorum occurred in the first 5 d of life with cases in older infants often not accompanied by a granulocytic response. Chlamydial conjunctivitis was usually unilateral whereas other cases were most frequently bilateral.
Recent advances in understanding the pathogenesis of sympathetic ophthalmia are helping to remove the pigmented cloud which has obstructed the view of researchers on this disease for many years. Clinical features, diagnostic testing, histopathologic variations and principles of treatment are evaluated in the context of our increasing understanding of the pathogenesis of this disease. The relationship of sympathetic ophthalmia to Harada's disease and phacoantigenic uveitis are reviewed.
PURPOSE: The agents currently used to prevent ophthalmia neonatorum are less than optimal, with reports indicating evidence of bacterial resistance, ineffectiveness, and toxicity. Povidone-iodine ophthalmic solution, which has been shown to be effective in the preoperative preparation of the eye, generates no resistance, is an effective antimicrobial agent, and has low toxicity. We evaluated the effectiveness and safety of povidone-iodine for ophthalmia neonatorum prophylaxis. METHODS: A bacterial culture was taken from the conjunctiva of each eye of 100 infants within 30 minutes of birth. A drop of 2.5% povidone-iodine solution was then placed on one eye, while the other eye received either one drop of silver nitrate 1% ophthalmic solution or 0.5% erythromycin ointment. Conjunctival bacterial cultures were again taken two to four hours after birth. At each culture and at 24 hours after birth, the eyes were examined for toxic changes. To measure the effectiveness of the medications, the number of bacterial colony-forming units and species from each culture was compared. RESULTS: All three agents significantly reduced the number of colony-forming units, but povidone-iodine caused the most significant decrease. The number of species was reduced significantly by povidone-iodine (P = .00051) and silver nitrate (P = .007), with povidone-iodine yielding the most significant decrease. Erythromycin did not significantly reduce the number of species. Silver nitrate demonstrated more ocular toxicity at the 24-hour determination point than did either of the other two medications (P < .001). CONCLUSIONS: Povidone-iodine 2.5% ophthalmic solution is an effective antibacterial agent on the conjunctiva of newborns and causes less toxicity than silver nitrate.
A 29-year-old woman developed severe ocular manifestations of sympathetic ophthalmia on the day after enucleation of a blind, painful eye, and four weeks after a penetrating ocular injury. She was observed for one year with fundus photography, fluorescein angiography, and electrophysiologic tests. Nystagmus, a rare systemic manifestation of sympathetic ophthalmia, was noted early in the course of her disease and was accompanied by vertigo, truncal ataxia, and cerebrospinal fluid pleocytosis. Enucleation and intensive corticosteroid treatment resolved the process; however, she has experienced recurrences in the two-year follow-up period.
OBJECTIVE: To report a case of bilateral progressive subretinal fibrosis and blindness with multifocal granulomatous chorioretinitis occurring after intraocular surgery. We propose that this is a variant of sympathetic ophthalmia. DESIGN: Clinicopathologic case report. METHODS: The left enucleated globe was examined by histopathologic methods. The patient's sera were subjected to immunohistochemical studies against retinal antigens, and collagen 2 types in areas of fibrosis were identified. Polymerase chain reaction was used to test for herpes virus DNA in microdissected, formalin-fixed, paraffin-embedded tissue. RESULTS: The enucleated globe demonstrated histopathologic features similar to an entity previously described as progressive subretinal fibrosis with multifocal granulomatous chorioretinitis. The patient's sera demonstrated antibodies directed against retinal photoreceptors and pigment epithelium. Polymerase chain reaction for herpes virus was negative. Immunohistochemical studies demonstrated types III, IV, V, and VI collagen in areas of fibrosis. CONCLUSIONS: The clinical history along with the histopathologic and immunohistochemical findings suggest that progressive subretinal fibrosis with multifocal granulomatous chorioretinitis may represent a variant of sympathetic ophthalmia and that retinal autoimmunity may play a role in its pathogenesis.
A spontaneous corneal perforation followed by granulomatous uveitis occurred in a 10-month-old female infant with bilateral anterior segment anomalies. The histopathologic findings in the enucleated right eye and the 30-year course of intraocular inflammation in her left eye are consistent with sympathetic ophthalmia. This case illustrates that sympathetic ophthalmia can be overlooked for years unless the diagnosis is considered and periodic anterior segment biomicroscopy and indirect ophthalmoscopy are performed in patients who have had perforating ocular injuries. A lensectomy-vitrectomy procedure was successful in restoring ambulatory vision in this patient.
Sera of patients diagnosed as having the active Vogt-Koyanagi-Harada (VKH) syndrome, Behcet's syndrome or sympathetic ophthalmia as well as normal controls were evaluated by ELISA and by staining of normal human retinal tissue using the avidin-biotin-peroxidase complex (ABC) technique for anti-retinal antibodies. No anti-retinal S-antigen antibodies were detected by ELISA. However, autoimmune antibodies were found against the outer segments of photoreceptors and Müller cells in patients with the VKH syndrome, with lower titers in some patients with Behcet's syndrome, and in a few patients with sympathetic ophthalmia. These results suggested anti-retinal antibodies were present and that retinal autoimmunity may play a role in pathogenesis in varieties of posterior uveitis. In addition, the indirect immunoperoxidase staining technique may facilitate the diagnosis of VKH in uncertain cases.
Silver nitrate prophylaxis against ophthalmia neonatorum due to Neissera Gonorrhoeae was introduced by Crédé in 1884, when he instilled a drop of 2% silver nitrate into the cul-de-sac of a newborn. Today, the prime cause of ophthalmia neonatorum is infection by Chlamydia trachomatis. The high incidence of this type of conjunctivitis is due to the frequent exposure of the newborn during delivery and to the ineffectiveness of silver nitrate as a prophylaxis against Chlamydia. In the study reported here, 198 infants less than one month old were examined because of severe bilateral conjunctivitis. In the first week of life a chemical irritation caused by Crédé's prophylaxis was found in the majority (59.7%), but in the second and third weeks infections with Chlamydia trachomatis were found in 27% of all cases. Bacteria were responsible for the infection in 52% of the cases. No gonococci were found in any of the patients examined in the course of the study.
BACKGROUND: Neonatal conjunctivitis (ophthalmia neonatorum) continues to cause blindness because the agents used prophylactically to prevent this condition are not completely effective and are not widely available in many parts of the world. Povidone-iodine ophthalmic solution is an effective antibacterial agent with broad antibacterial and antiviral activity to which no bacteria are known to be resistant, and it is far less expensive and less toxic than the agents currently used to prevent neonatal conjunctivitis. METHODS: We conducted a masked, prospective trial involving 3117 infants born over a period of 30 months in a hospital in Kenya. Shortly after birth each infant received a 2.5 percent solution of povidone-iodine (n = 1076), a 1 percent solution of silver nitrate (n = 929), or 0.5 percent erythromycin ointment (n = 1112) in both eyes. Randomization was achieved by rotating the three medications after each was used for a week. RESULTS: Of the neonates treated with povidone-iodine, 13.1 percent had infectious conjunctivitis, as compared with 17.5 percent of those treated with silver nitrate (P < 0.001) and 15.2 percent of those treated with erythromycin (P = 0.01). Povidone-iodine was more effective against Chlamydia trachomatis than was silver nitrate (P < 0.001) or erythromycin (P = 0.008). There were 104 cases of noninfectious conjunctivitis (9.7 percent) in the povidone-iodine group, as compared with 129 in the silver nitrate group (13.9 percent, P < 0.001) and 148 in the erythromycin group (13.3 percent, P = 0.004). Many cases of noninfectious conjunctivitis were probably due to a toxic reaction to the treatment itself. The incidence of Neisseria gonorrhoeae and Staphylococcus aureus infections was similar in the three groups. CONCLUSIONS: A 2.5 percent ophthalmic solution of povidone-iodine as prophylaxis against ophthalmia neonatorum is more effective than treatment with silver nitrate or erythromycin, and it is less toxic and costs less.