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Chichao Chan - One of the best experts on this subject based on the ideXlab platform.
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Open Access Classical Pathology of Sympathetic Ophthalmia Presented in a Unique
2016Co-Authors: Shida Chen, Mary E Aronow, Defen Shen, Charles Wang, Chichao ChanAbstract:Abstract: The ocular pathology of Sympathetic Ophthalmia is demonstrated in a 10 year-old boy who sustained a penetrating left globe injury and subsequently developed Sympathetic Ophthalmia in the right eye two months later. Two and a half weeks following extensive surgical repair of the left ruptured globe, he developed endophthalmitis and was treated with oral and topical fortified antibiotics. One month after the initial injury, a progressive corneal ulcer of the left eye led to perforation and the need for emergent corneal transplantation. The surgical specimen revealed fungus, Scedosporium dehoogii. The boy received systemic and topical anti-fungal therapy. Two months following the penetrating globe injury of the left eye, a granulomatous uveitis developed in the right eye. Sympathetic Ophthalmia was suspected and the patient began treatment with topical and oral corticosteroids. Given the concern of vision loss secondary to Sympathetic Ophthalmia in the right eye, as well as poor vision and hypotony in the injured eye, the left eye was enucleated. Microscopically, granulomatous inflammation with giant cells was noted within a cyclitic membrane which filled the anterior and posterior chamber of the left globe. Other classic features including Dalen-Fuchs nodules were identified. Small, choroidal, ill-defined granulomas and relative sparing of the choriocapillaris were present. Molecular analysis did not identify evidence of remaining fungal infection. The pathology findings were consistent with previously described features of Sympathetic Ophthalmia. The present case is unique in that co-existing fungal infection may have potentiated the risk for developing Sympathetic Ophthalmia in the fellow eye
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classical pathology of Sympathetic Ophthalmia presented in a unique case
The Open Ophthalmology Journal, 2014Co-Authors: Shida Chen, Mary E Aronow, Defen Shen, Charles Wang, Chichao ChanAbstract:The ocular pathology of Sympathetic Ophthalmia is demonstrated in a 10 year-old boy who sustained a penetrating left globe injury and subsequently developed Sympathetic Ophthalmia in the right eye two months later. Two and a half weeks following extensive surgical repair of the left ruptured globe, he developed endophthalmitis and was treated with oral and topical fortified antibiotics. One month after the initial injury, a progressive corneal ulcer of the left eye led to perforation and the need for emergent corneal transplantation. The surgical specimen revealed fungus, Scedosporium dehoogii. The boy received systemic and topical anti-fungal therapy. Two months following the penetrating globe injury of the left eye, a granulomatous uveitis developed in the right eye. Sympathetic Ophthalmia was suspected and the patient began treatment with topical and oral corticosteroids. Given the concern of vision loss secondary to Sympathetic Ophthalmia in the right eye, as well as poor vision and hypotony in the injured eye, the left eye was enucleated. Microscopically, granulomatous inflammation with giant cells was noted within a cyclitic membrane which filled the anterior and posterior chamber of the left globe. Other classic features including Dalen-Fuchs nodules were identified. Small, choroidal, ill-defined granulomas and relative sparing of the choriocapillaris were present. Molecular analysis did not identify evidence of remaining fungal infection. The pathology findings were consistent with previously described features of Sympathetic Ophthalmia. The present case is unique in that co-existing fungal infection may have potentiated the risk for developing Sympathetic Ophthalmia in the fellow eye.
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gender differences in vogt koyanagi harada disease and Sympathetic Ophthalmia
Journal of Ophthalmology, 2014Co-Authors: Yujuan Wang, Chichao ChanAbstract:Vogt-Koyanagi-Harada disease (VKH) and Sympathetic Ophthalmia (SO) are types of T-cell mediated autoimmune granulomatous uveitis. Although the two diseases share common clinical features, they have certain differences in gender predilections. VKH classically has been reported as more prevalent in females than males, yet some studies in Japan and China have not found differences in gender prevalence. Male patients have a higher risk of chorioretinal degeneration, vitiligo, and worse prognosis. Conversely, the changing levels of estrogen/progesterone during pregnancy and the menstrual cycle as well as higher levels of TGF- show a protective role in females. Potential causes of female predilection for VKH are associated with HLA-DR and HLA-DQ alleles. SO, a bilateral granulomatous uveitis, occurs in the context of one eye after a penetrating injury due to trauma or surgery. In contrast to the female dominance in VKH, males are more frequently affected by SO due to a higher incidence of ocular injury, especially during wartime. However, no gender predilection of SO has been reported in postsurgical cases. No clinically different manifestations are revealed between males and females in SO secondary to either ocular trauma or surgery. The potential causes of the gender difference may provide hints on future treatment and disease evaluation.
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Sympathetic Ophthalmia to the twenty first century and beyond
Journal of Ophthalmic Inflammation and Infection, 2013Co-Authors: Chichao ChanAbstract:Sympathetic Ophthalmia is a rare bilateral granulomatous inflammation that follows accidental or surgical insult to the uvea of one eye. Onset of Sympathetic Ophthalmia can be insidious or acute, with recurrent periods of exacerbation. Clinical presentation shows mutton-fat keratic precipitates, choroidal infiltrations, and Dalen-Fuchs nodules. Histopathology reveals diffuse or nodular granulomatous inflammation of the uvea. Prevention and treatment strategies for Sympathetic Ophthalmia are currently limited to two modalities, enucleation of the injured eye and immunosuppressive therapy, aimed at controlling inflammation. The etiology and pathophysiology of the disease is still unclear but is largely thought to be autoimmune in nature. Recent insight on the molecular pathology of the disease as well as developments in imaging technology have furthered both the understanding on the autoimmune process in Sympathetic Ophthalmia and the targeting of prevention and treatment strategies for the future.
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inflammatory cytokine and chemokine expression in Sympathetic Ophthalmia a pilot study
Histology and Histopathology, 2011Co-Authors: Emiko Furusato, Robert B Nussenblatt, Defen Shen, Bungo Furusato, Elisabeth J Rushing, Chichao ChanAbstract:Sympathetic Ophthalmia is a bilateral uveitis that develops after penetrating injury to one eye. This study aimed to identify the inflammatory cellular sub-phenotypes and expression of pertinent inflammatory cytokines/chemokines in Sympathetic Ophthalmia (SO). Dalen-Fuchs nodules (DFN), granulomas, and non-granulomatous foci of inflammation were micro-dissected from 15 cases. RNA was extracted, and quantitative PCR was performed to measure IL-17, IL-18, IL-23, IFN-?, CCL19, CXCL11, CCL17, and CCL22 transcripts. Immunohistochemical methods were used to characterize CD3, CD4, CD8, CD20, CD68, and CD163 expression. Non-granulomatous lymphocytes were predominantly CD3-positive and expressed more IFN-? than cells within granulomas, consistent with Th1 cells. In contrast, granulomas and DFN contained mainly CD68+, CD163+/- and expressed more IL-17, IL-18, IL-23, CCL19, and CXCL11 than non-granulomatous cells. Our data indicate for the first time that M1 macrophages are the predominant inflammatory cells within granulomas and DFN of SO. We further observed high levels of IL-17 within granulomas and the presence of Th1 and M1 cells.
Mihori Kita - One of the best experts on this subject based on the ideXlab platform.
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Sympathetic Ophthalmia after 23 gauge transconjunctival sutureless vitrectomy
Clinical Ophthalmology, 2010Co-Authors: Masatoshi Haruta, Hirokazu Mukuno, Kazuaki Nishijima, Hitoshi Takagi, Mihori KitaAbstract:Purpose We report a case of a Sympathetic Ophthalmia that occurred after 23-gauge transconjunctival sutureless vitrectomy for a retinal detachment.
Masatoshi Haruta - One of the best experts on this subject based on the ideXlab platform.
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Sympathetic Ophthalmia after 23 gauge transconjunctival sutureless vitrectomy
Clinical Ophthalmology, 2010Co-Authors: Masatoshi Haruta, Hirokazu Mukuno, Kazuaki Nishijima, Hitoshi Takagi, Mihori KitaAbstract:Purpose We report a case of a Sympathetic Ophthalmia that occurred after 23-gauge transconjunctival sutureless vitrectomy for a retinal detachment.
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Sympathetic Ophthalmia after 23-gauge transconjunctival sutureless vitrectomy
Dove Medical Press, 2010Co-Authors: Masatoshi Haruta, Hirokazu Mukuno, Kazuaki NishijimaAbstract:Masatoshi Haruta1, Hirokazu Mukuno2, Kazuaki Nishijima3, Hitoshi Takagi4, Mihori Kita51Department of Ophthalmology, Kurume University School of Medicine, Kurume, Fukuoka, Japan; 2Department of Ophthalmology, Konan Hospital, Kobe, Hyogo, Japan; 3Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Kyoto, Japan; 4Department of Ophthalmology, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan; 5Department of Ophthalmology, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Hyogo, JapanPurpose: We report a case of a Sympathetic Ophthalmia that occurred after 23-gauge transconjunctival sutureless vitrectomy for a retinal detachment.Case report: A 41-year-old Japanese woman underwent combined phacoemulsification with intraocular lens implantation and 23-gauge transconjunctival sutureless vitrectomy for a rhegmatogenous retinal detachment in the right eye. Endolaser photocoagulation and silicone oil tamponade were used to manage inferior retinal holes. Four weeks after the surgery, she returned with a 5-day history of reduced vision and metamorphopsia in her left eye. Slit-lamp examination showed a shallow anterior chamber in the right eye and moderate anterior uveitis bilaterally. Silicone oil bubbles and pigment dispersion were observed in the subconjunctival space adjacent to the right eye’s superonasal sclerotomy site. Fundus examination showed multifocal serous retinal detachments in both eyes. A diagnosis of Sympathetic Ophthalmia was made and the patient was treated with intensive topical and systemic steroids. The subretinal fluid cleared in both eyes following treatment. Twelve months after the onset of inflammation, the patient’s condition was stable on a combination of oral cyclosporine and topical steroids. Sunset glow retinal changes remain, but there has been no evidence of recurrent inflammation.Conclusion: Sympathetic Ophthalmia can develop after 23-gauge transconjunctival sutureless vitrectomy despite its smaller sclerotomy size. We recommend that special care should be taken to inspect for adequate closure of sclerotomy sites at the end of this operation.Keywords: fluorescein angiography, hypotony, optical coherence tomography, retinal detachment, shallow anterior chambe
Jyotirmay Biswas - One of the best experts on this subject based on the ideXlab platform.
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choroidal structural changes in Sympathetic Ophthalmia on swept source optical coherence tomography
Ocular Immunology and Inflammation, 2019Co-Authors: Rupesh Agrawal, Mukesh K Jain, Rehana Khan, Durgasri Jaisankar, Jianbin Ding, Ilaria Testi, Rajiv Raman, Jyotirmay BiswasAbstract:ABSTRACTPurpose: To analyze choroidal angioarchitecture in Sympathetic Ophthalmia (SO) using swept-source optical coherence tomography (SS-OCT) images.Methods: Case–control study of six patients wi...
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analysis of 130 cases of Sympathetic Ophthalmia a retrospective multicenter case series
Ocular Immunology and Inflammation, 2019Co-Authors: Sophia Seen, Vishali Gupta, Jyotirmay Biswas, Parthopratim Dutta Majumder, Sudha K Ganesh, Mamta Agarwal, Aniruddh Soni, Kanika Aggarwal, Padmamalini Mahendradas, Ho Su LingAbstract:ABSTRACTObjective: To analyze the demographic profile, treatment, and visual outcome of the patients with Sympathetic Ophthalmia (SO) in a multicenter collaborative retrospective cohort study.Metho...
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postsurgical Sympathetic Ophthalmia retrospective analysis of a rare entity
International Ophthalmology, 2018Co-Authors: Parthopratim Dutta Majumder, Eliza Anthony, A E George, Sudha K Ganesh, Jyotirmay BiswasAbstract:PURPOSE: To describe clinical manifestations, management and visual outcome in postsurgical Sympathetic Ophthalmia (SO). METHODS: Retrospective study. RESULTS: Mean age of the patients was 41.1 years, and males were affected 1.8 times than the female. Vitrectomy and scleral buckling were the most common inciting surgeries followed by cataract surgery. Among 10 eyes with anterior uveitis, mutton-fat keratic precipitate was seen in only two eyes. Mean follow-up duration was 1556.50 ± 1470.75 days. Vision significantly improved in 11 patients (78.6%; p = 0.005). CONCLUSION: Postsurgical SO is a rare entity, but it is a bilateral blinding disease and SO following surgical intervention can have variable presentations. Rapid, effective management of postsurgical Sympathetic Ophthalmia can give improved visual outcomes.
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Sympathetic Ophthalmia presenting with signs of frosted branch angiitis: Report of a case
Wolters Kluwer Medknow Publications, 2018Co-Authors: Radha Annamalai, Jyotirmay BiswasAbstract:Sympathetic Ophthalmia is an ocular inflammatory disease commonly associated with penetrating trauma. We report a case of Sympathetic Ophthalmia who had Dalen-Fuchs nodules on presentation and developed a frosted branch angiitis (FBA)-like picture which is not a known feature of this disease. A 25-year-old male patient was seen 8 months following penetrating trauma to the left eye. He was treated with oral steroids and immunosuppressives. Fundus fluorescein angiography confirmed the presence of perivascular retinitis; optical coherence tomography showed retinal thickening and ultrasonography showed peripapillary choroidal thickening. Atypical features such as FBA in cases of Sympathetic Ophthalmia can be present and can indicate an ongoing active inflammation. Early aggressive management is required to prevent visual morbidity
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multimodal imaging in Sympathetic Ophthalmia
Ocular Immunology and Inflammation, 2017Co-Authors: Sarakshi Mahajan, Rupesh Agrawal, Alessandro Invernizzi, Jyotirmay Biswas, Vishali GuptaAbstract:ABSTRACTPurpose: To show the current status of multimodal imaging and its role in supporting an early diagnosis of Sympathetic Ophthalmia.Methods: The diagnosis is mainly clinical supported with ancillary investigations; mainly fluorescein angiography and others, including indocyanine angiography optical coherence tomography (OCT), OCT enhanced depth imaging, autofluorescence imaging, and ultrasonography.Results: Various imaging modalities such as OCT, autofluorescence imaging and angiography are critical in the diagnosis and management of Sympathetic Ophthalmia. The clinician must make adequate use of such ancillary investigations in the management of the patients. Conclusions: Sympathetic Ophthalmia is a rare, bilateral inflammation of the uveal tract following penetrating trauma or surgery in one eye. The intraocular inflammation requires a prompt diagnosis so that the treatment can be initiated as early as possible.
Robert B Nussenblatt - One of the best experts on this subject based on the ideXlab platform.
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Sympathetic Ophthalmia: WHAT HAVE WE LEARNED?
2015Co-Authors: Nida H. Sen, Robert B NussenblattAbstract:Sympathetic Ophthalmia (SO) is a rare bilateral granulomatous uveitis following ocular trauma or surgery to one eye. The eye sustaining the injury is referred to as the inciting eye and the fellow eye is called the sympathizing eye. The etiology of SO has not been completely understood but the underlying pathophysiology is believed to be an autoimmune reaction against the exposed ocular antigens from the inciting eye. The time to development of SO varies from 2 weeks to 50 years with approximately 90 % of patients developing the disease within 1 year of injury (1,2,3,4). Since MacKenzie and Fuchs ’ clinical description of the disease about a century ago enucleation of the inciting eye in an attempt to influence the course of the disease in the sympathizing eye has been a controversial issue. Most cases are diagnosed based on history and presentation, and some are confirmed by the histology (3). SO represents approximately 1-2 % of all uveitis cases; the true incidence and prevalence of SO has been hard to establish however a recent prospective study in England and Ireland by Kilmartin et al estimated that SO affects 0.03/100,000 persons per year. Although earlier studies found traumatic SO to be more common Kilmartin et al demonstrated ocular surgery as the most common cause (3,5,6,7,8)
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inflammatory cytokine and chemokine expression in Sympathetic Ophthalmia a pilot study
Histology and Histopathology, 2011Co-Authors: Emiko Furusato, Robert B Nussenblatt, Defen Shen, Bungo Furusato, Elisabeth J Rushing, Chichao ChanAbstract:Sympathetic Ophthalmia is a bilateral uveitis that develops after penetrating injury to one eye. This study aimed to identify the inflammatory cellular sub-phenotypes and expression of pertinent inflammatory cytokines/chemokines in Sympathetic Ophthalmia (SO). Dalen-Fuchs nodules (DFN), granulomas, and non-granulomatous foci of inflammation were micro-dissected from 15 cases. RNA was extracted, and quantitative PCR was performed to measure IL-17, IL-18, IL-23, IFN-?, CCL19, CXCL11, CCL17, and CCL22 transcripts. Immunohistochemical methods were used to characterize CD3, CD4, CD8, CD20, CD68, and CD163 expression. Non-granulomatous lymphocytes were predominantly CD3-positive and expressed more IFN-? than cells within granulomas, consistent with Th1 cells. In contrast, granulomas and DFN contained mainly CD68+, CD163+/- and expressed more IL-17, IL-18, IL-23, CCL19, and CXCL11 than non-granulomatous cells. Our data indicate for the first time that M1 macrophages are the predominant inflammatory cells within granulomas and DFN of SO. We further observed high levels of IL-17 within granulomas and the presence of Th1 and M1 cells.
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Sympathetic Ophthalmia what have we learned
American Journal of Ophthalmology, 2009Co-Authors: Robert B NussenblattAbstract:Sympathetic Ophthalmia (SO) is a rare bilateral granulomatous uveitis following ocular trauma or surgery to one eye. The eye sustaining the injury is referred to as the inciting eye and the fellow eye is called the sympathizing eye. The etiology of SO has not been completely understood but the underlying pathophysiology is believed to be an autoimmune reaction against the exposed ocular antigens from the inciting eye. The time to development of SO varies from 2 weeks to 50 years with approximately 90% of patients developing the disease within 1 year of injury (1, 2, 3, 4). Since MacKenzie and Fuchs’ clinical description of the disease about a century ago enucleation of the inciting eye in an attempt to influence the course of the disease in the sympathizing eye has been a controversial issue. Most cases are diagnosed based on history and presentation, and some are confirmed by the histology (3). SO represents approximately 1-2% of all uveitis cases; the true incidence and prevalence of SO has been hard to establish however a recent prospective study in England and Ireland by Kilmartin et al estimated that SO affects 0.03/100,000 persons per year. Although earlier studies found traumatic SO to be more common Kilmartin et al demonstrated ocular surgery as the most common cause (3,5,6,7,8). Sympathetic Ophthalmia is in itself a sight-threatening disease with a high rate of visual loss; approximately half of patients experience 20/40 or worse vision and one third of patients become legally blind (3). Although improved immunosuppressive therapy may reduce chronic inflammation there is still a risk of visual loss from complications such as chorioretinal scars, macular edema and CNV (9). In this issue of the Journal, Galor and associates (10) report on the incidence of ocular complications and vision loss in the sympathizing eye of patients with SO. Eighty five patients with either a clinical or histopathologic diagnosis of SO seen at three academic tertiary care centers over the last 3 decades were included in this retrospective study. The median age was 45, there was a slight male predilection which is more in line with older reports. Historically SO was more prevalent in children and males however more recent reports indicated no racial or gender predilection and the age distribution appeared to be changing. This is likely due to injury prevention programs among children and increasing surgical procedures in the aging population. Among the military, where eye trauma is common, rates of SO have decreased. Recent review of ocular injury in military conflicts showed no SO. This may be attributable to timely medical attention, improved surgical techniques and fairly high rates of early enucleation of injured eyes; 39% primary enucleation and 19% secondary enucleation within 2 weeks of trauma (11). In the current study trauma was the most common cause and traumatically induced SO appeared to develop sooner after the inciting event compared to surgically induced SO. The length of follow-up was variable and those with any follow-up (74%) appeared to have presented sooner after the onset of SO which may have biased the results. As those who had follow-up are also those who presented early and presumably treated early this may have lead to overestimation of the favorable outcome. Median time to developing SO was 25 months and 41% developed SO within one year of trauma or surgery. Of the inciting eyes, 22% had enucleation and 35% had phthisis at presentation. Median time from SO to enucleation for those who had enucluation during follow-up was 1 month. Female sex was the only significantly associated factor with incident vision loss. It is hard to explain why female gender would be a poor prognostic indicator and the authors rightfully question this association. Given the small sample size and multiple comparisons it is not unreasonable to think this could be chance association. Traumatic etiology, exudative retinal detachment and active inflammation were associated with poor visual outcome. A more severe course with traumatic SO could theoretically be due to high doses of antigenic exposure (12). Patients started on prednisone immediately were more likely to achieve quiescence and appeared to do so quicker. This should not come as a surprise as SO is known to respond to steroids well, at least initially. (3, 8, 13, 14, 15, 16). The benefit of primary enucleation, early enucleation (within 2 weeks of injury) or enucleation after the onset of SO has been a long time debate (2, 5, 13, 17). The decision about enucleation needs to be made very carefully as the vision in the inciting eye may eventually be better than the vision in the Sympathetic eye in some patients. No benefit of enucleation after the onset of SO has been noted in the study although limited power and the lack of detailed data on the timing of enucleation made it difficult, if not impossible, to make any conclusions to this end. Although the direct effect of treatment on visual outcomes could not be determined in this study because of limited power it would still be useful for the authors to provide more detailed information on the outcomes of and discuss about those patients who received other immunosuppressive medications. The factors most often associated with decreased vision were active intraocular inflammation, cataract, and optic nerve abnormality of which the former two can be reversible. And as expected majority of those with cataract associated vision loss showed improvement following cataract surgery. Taken together approximately 60% maintained 20/40 or better vision while 25% were legally blind in the sympathizing eye. Interestingly visual outcomes of this study are not much different than what has been reported more than a decade ago by our group. This is likely due to inclusion of patients from the past 3 decades going as far back as 1976 when the mainstay of treatment was steroids; while this increases the sample size it also masks any improved outcome associated with the use of modern immunosuppressive agents more recently. This study emphasizes the significant vision loss associated with SO, and highlights the importance of early diagnosis and prompt aggressive treatment. However important issues regarding early enucleation, the treatment of choice and whether modern immunosuppressives will lead to a better prognosis remain unanswered. Past reports have indicated that risk of SO is 1 in 1152 retinal surgical procedures and that multiple surgeries may have an “additive” effect in inducing SO (5, 14). It would be useful for the authors to mention the type of surgeries among surgically induced SO patients. The fact that SO has been reported following various surgical interventions including glaucoma surgery, cataract extraction, vitrectomy as well as “non-invasive” procedures such as cyclophotocoagulation is a stark reminder that as clinicians we need to weigh the benefits of each procedure against its risks every time. In the era of increasing intravitreal injections and intraocular surgeries one wonders if there will be an upward trend in the incidence of SO.
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immunopathology of progressive subretinal fibrosis a variant of Sympathetic Ophthalmia
American Journal of Ophthalmology, 2004Co-Authors: Robert B Nussenblatt, Soonphaik Chee, Chichao ChanAbstract:PURPOSE: We report the immunopathology of progressive subretinal fibrosis, a variant of Sympathetic Ophthalmia. DESIGN: Brief case report. METHOD: Review of medical record and immunopathology of a chorioretinal biopsy of a 40-year-old man who presented with left total retinal detachment (RD) following multiple vitrectomies in the right eye for RD. Small peripherally retinal holes, snow banks, and inflammatory nodules along the ora serrata were observed during left vitrectomy. Both eyes deteriorated rapidly to blindness with progressive subretinal fibrosis and inflammation over 3 months, and the patient was unresponsive to systemic prednisolone and azathioprine. RESULT: Immunopathology of the chorioretinal biopsy of the right eye revealed aggregates of CD20+ B cells, surrounded by CD3+ T cells. CD68+ macrophages were scattered throughout. CONCLUSION: The rapid clinical course described in this case may be related to the unique immunopathology of rapidly forming peudogerminal centers in the choroids and retina.
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visual prognosis and Sympathetic Ophthalmia
Current Opinion in Ophthalmology, 1996Co-Authors: Ali Ramadan, Robert B NussenblattAbstract:: Sympathetic Ophthalmia is probably the ocular disorder best known to practitioners outside of ophthalmology. It is characterized by a bilateral, nonnecrotizing granulomatous panuveitis that occurs after intentional or unintentional trauma to the exciting eye. So far, the identity of the inciting antigen has not been delineated with certainty. The sequelae from Sympathetic Ophthalmia have declined markedly in this century as a result of earlier diagnosis, use of corticosteroids, and better management of ocular injuries, in large part due to improved surgical techniques. Cases of Sympathetic Ophthalmia, however, still occur with their severe sight-threatening complications, which impose on ophthalmologists the importance of prompt diagnosis and aggressive treatment in order to achieve good visual outcome.
