Penetrating trauma associated with findings of multiple evanescent white dot syndrome in the second eye: coincidence or an atypical case of sympathetic ophthalmia?

PURPOSE: To report a case of sympathetic ophthalmia (SO) resembling multiple evanescent white dot syndrome (MEWDS). METHODS: Retrospective chart review. RESULTS: A 17-year-old girl with a ruptured globe in the right eye underwent prompt primary repair and vitrectomy, scleral buckling, and silicone oil infusion 3 weeks later. Eight weeks after injury, she presented with visual loss in the left eye. Fundus examination in the left eye disclosed optic disk swelling and well-circumscribed, 100 to 500 microm diameter gray-white lesions at the level of the retinal pigment epithelium (RPE) posterior to the equator, sparing the fovea. On fluorescein angiography, the lesions appeared as areas of blocked choroidal fluorescence in the arterial phase and were associated with dye leakage in a wreathlike pattern during venous filling. Dye leakage occurred at the optic disk. Visual field testing showed depressed central sensitivity and an enlarged blind spot in the left eye. The patient was treated with prednisone and underwent diagnostic enucleation of the right eye. Histopathology showed rare choroidal granulomata and pigment phagocytosis. Vision improved to 20/20 in the left eye, and the window defects persisted. Visual field testing 6 months later was normal. One month after discontinuing prednisone, new areas of RPE hypopigmentation developed. Two weeks later, choroidal inflammation recurred and periphlebitis developed. CONCLUSION: This case indicates that SO can mimic MEWDS.

Macular holes.

Spontaneous closure of macular holes occurs in 3% to 9% of patients over 6 years [3,58]. Visual acuity can recover dramatically once the hole closes. The risk for hole development in the fellow eye in the absence of PVD is approximately 29%. The presence of vitreomacular separation reduces the risk to less than 5%. Most of the fellow eyes that develop macular holes do so within 2 years [59]. Macular hole surgery has been evolving. ILM peeling is a recent, widely accepted innovation. Meta-analysis of 12 published case series indicates anatomic success in 77% and functional success in 55% of patients with the traditional technique of epiretinal peeling and no adjuvant use. Meta-analysis of 22 series with techniques using adjuvants indicates an anatomic success rate of 81% and a functional success rate of 60%. Meta-analysis of 4 studies involving 221 cases indicates an anatomic success rate of 96% and a functional success rate of 81% [5]. True superiority of one approach versus another cannot be determined without a randomized, prospective clinical trial, which is unlikely to be conducted. In the meantime, surgeons must choose an approach based on individual features of a given patient and their own surgical experience.