Dr. Mary O’Hara; MD is the Director of Pediatric Ophthalmology and Adult Strabismus at the Eye Center of University of California, Davis where she is a professor of ophthalmology and pediatrics. She completed her residency training at Brooke Army Medical Center in San Antonio, Texas and her fellowship in pediatric ophthalmology at the Wills Eye Institute in Philadelphia.

I had a similar case of sympathetic ophthalmia. My patient was treated with argon laser photocoagulation for Coat’s disease of the right eye at age 14 months. The right eye went on to total retinal detachment and then elevated intraocular pressure that was addressed with trans-scleral diode laser CPC after which the eye became phthisical. At age 27 months, he presented to our clinic with a blind painful right eye and an intermittently red left eye. The left eye had a shallow anterior chamber and 360 degrees posterior synechiae with elevated intraocular pressure (48 mm Hg). B scan showed thickened choroid and the retina was similar to your patient. The diagnosis of sympathetic ophthalmia of the left eye was entertained and the patient was placed on high-dose oral steroids and a trabeculectomy was done emergently. The right eye was enucleated in an attempt to control the sympathetic response. The child was then placed on infliximab and methotrexate which controlled the inflammation and the choroidal thickening but the intraocular pressure was uncontrolled and so a glaucoma drainange device and cataract extraction were performed. We elected not to place an intraocular lens because of concerns about inflammation and he has done well in aphakic spectacles with corrected visual acuity of 20/40 in his remaining eye.

A penetrating keratoplasty (PK) was done when the cornea decompensated. He subsequently ruptured the PK when he fell, despite wearing RecSpecs at the time! The original graft was salvaged. At the mother’s request, we considered discontinuation of infliximab and methotrexate as he had been quiet for several years. However, he broke through with uveitis during a growth spurt, so we realized that continued immunosuppression therapy was necessary. Recently, his intraocular pressure has been rising again and we are treating it medically. We are considering a second glaucoma drainage device if medication fails to control the intraocular pressure.From our experiences with our patient, we would recommend a glaucoma drainage device for control of his intraocular pressures. Also, the child needs to be followed carefully for recurrence of sympathetic ophthalmia. Although sympathetic ophthalmia in a child is a rare condition, several reports have documented recurrence, either soon after or years after, cessation of immunomodulating therapy. In the above case, growth of the child spurred a recurrence that was relieved with increasing therapy dose to reflect the child’s increased size.