Sympathetic ophthalmia after surgical resection of iridociliary melanoma. A case report

Background: We report a case of sympathetic ophthalmia with systemic findings following resection of a malignant melanoma of the iris and ciliary body, and describe the treatment and clinical outcome. Methods: A 49-year-old man underwent sector iridocyclectomy of a malignant iridociliary melanoma of the right eye. Five weeks later, he was diagnosed with sympathetic ophthalmia. Snellen's best-corrected visual acuity, fluorescein angiography, electroretinography, cerebrospinal fluid analysis and audiometry were performed. High-dose systemic steroid and immunosuppressive (cyclosporine and azathioprine) therapy was prescribed. Two months later chorioretinitis and macular edema persisted, and intravitreous triamcinolone was injected into the right eye. Results: Five weeks after resection of an iridociliary melanoma, our patient had reported acute bilateral vision loss. Visual acuity was hand motion in both eyes. Examination showed bilateral granulomatous uveitis, diffuse choroiditis with Dalen-Fuchs nodules, papillitis and vitritis. On fluorescein angiography multiple hyperfluorescent dots, which coalesced in areas of exudative retinal detachment, were evident. The patient presented meningismus with pleocytosis on cerebrospinal fluid analysis, and sensorineural deafness. Sympathetic ophthalmia was diagnosed. High-dose intravenous steroids followed by oral prednisone at a tapering dose and immunosuppressive agents (cyclosporine and azathioprine), topical steroids in both eyes and intravitreal steroids in the right eye were administered. Phacoemulsification and intraocular lens implantation were performed to treat a dense cataract of the right eye. After 24 months of follow-up, best-corrected visual acuity was 20/200 in the right eye and 20/25 in the left; no signs of intraocular inflammation were observed and neurological signs had resolved. Low maintenance doses of systemic steroids and immunosuppressive agents were administered up to month 18 of follow-up to avoid recurrence. Conclusions: Sympathetic ophthalmia is a rare, but severe disease that can occur after resection of iridociliary melanoma. High-dose steroid therapy and supplementation with immunosuppressive agents early in the course of the disease was effective in resolving the condition.