Less vision loss due to inflammation associated with sympathetic ophthalmia was seen following long-term treatment with immunomodulatory therapy (IMT), particularly alkylating agents, than with corticosteroid therapy.
Study design
This was a retrospective review of 35 patients with sympathetic ophthalmia seen at a single center between March 2005 and October 2022. Only patients with at least 12 months of follow-up were included. Drug-free remission was defined as inactive uveitis for at least 3 months after stopping all ophthalmic medications, while IMT remission was defined as inactive uveitis for at least 3 months after stopping IMT.
Outcomes
During the follow-up period (median 10.2 years), 24 patients achieved IMT remission and 14 patients achieved drug-free remission; 3 patients had drug-free remission without the prior use of IMT. At the final follow-up visit, 3 patients had a relapse of acute uveitis, which was treated with corticosteroids. Seventeen patients needed enucleation of the inciting eye during the study period: 6 enucleations were performed within 2 weeks of the inciting injury and 11 were performed for pain in eyes with no functional vision (including blind painful eyes). However, enucleation was not associated with a higher rate of vision loss in the sympathetic eye. Longer durations of both IMT and drug-free remission corresponded with lower rates of vision loss in the sympathetic eye and better visual outcomes. Alkylating agents had the highest success rates of inflammation control.
Limitations
This was a retrospective study. Different routes of corticosteroid administration (oral, topical, injectable) were used in the cohort; therefore, while corticosteroid duration could be studied, it was hard to compare medication potency/strength. In addition, different IMT agents, classes, and doses were used, making it difficult to compare their effects as well. Stepwise therapy was not always followed, with certain medications being bypassed for certain patients for various reasons.
Clinical significance
Long-term therapy with IMT for sympathetic ophthalmia was associated with improved visual outcomes in the involved eye compared with corticosteroid therapy. Control of inflammation in sympathetic ophthalmia may vary by IMT choice. Despite risks seen with alkylating agents, cyclophosphamide and chlorambucil were found to be highly effective at inducing uveitis remission when other treatment options had failed.
Financial Disclosures: Dr. Ashleigh Laurin Levison discloses relationships with AbbVie (Lecture Fees/Speakers Bureau), Clearside Biomedical, and Santen (Consultant).