A 30-year-old man comes to the office for follow-up after traumatic injury to his left eye. Two months ago, there was an explosion at the factory where he worked. A large piece of shrapnel penetrated his left eye. Surgical removal of the shrapnel was performed, and vision in the left eye recovered to 20/200. Today, the patient reports that vision in his right eye is becoming blurry. On examination, there is bilateral conjunctival erythema. The right eye visual acuity is 20/160, which was normal 2 months ago. Which of the following is most likely involved in the pathogenesis of this patient's current ocular condition?

Question

A 30-year-old man comes to the office for follow-up after traumatic injury to his left eye.  Two months ago, there was an explosion at the factory where he worked.  A large piece of shrapnel penetrated his left eye.  Surgical removal of the shrapnel was performed, and vision in the left eye recovered to 20/200.  Today, the patient reports that vision in his right eye is becoming blurry.  On examination, there is bilateral conjunctival erythema.  The right eye visual acuity is 20/160, which was normal 2 months ago.  Which of the following is most likely involved in the pathogenesis of this patient's current ocular condition?

Quizplus · Accepted Answer

This patient with a traumatic injury to the left eye has developed inflammation (eg, conjunctival erythema) and decreased vision in the uninjured right eye. This is most consistent with sympathetic ophthalmia, an autoimmune condition that can occur when T cells become sensitized to previously sequestered eye antigens. Certain anatomic sites (eg, eyes, testes) have inherent immune privilege, in which inflammation is inhibited to limit potential organ damage. However, if self-antigens from these sites are released through trauma into the lymphatic system, T cells may recognize these antigens as foreign and mount an inflammatory response against both the injured eye and the uninjured eye. Introduction of bacteria during trauma may also upregulate the inflammatory process, increasing the chances that these autoreactive T cells will develop. The potential for sympathetic ophthalmia is considered in the management of severe eye injuries. If an injured eye has no expected recovery of vision, it is surgically removed (ie, enucleated) to prevent blindness in the uninjured eye. However, if some recovery is anticipated (as occurred in this patient), close follow-up is performed. If the condition develops, treatment focuses on decreasing inflammation (eg, corticosteroids, monoclonal biologics). (Choice A) Hematogenous fungal spread can cause fungal endophthalmitis resulting in eye pain and progressive vision loss. However, it is unlikely in the absence of risk factors (eg, intravenous drug use, indwelling catheter) or current symptoms/signs of fungemia. (Choice B) Allergic conjunctivitis is caused by an IgE-mediated hypersensitivity response. Although it can cause conjunctival erythema, it also typically causes significant itching. In addition, it does not usually cause vision loss. (Choice C) A narrow anterior chamber angle can predispose to acute angle-closure glaucoma, which can cause decreased visual acuity and conjunctival injection. However, it also typically causes ocular pain, headache, and nausea, and examination usually reveals palpable firmness of the eyeball and a fixed, mid-dilated pupil. (Choice D) Immune complex deposition due to systemic disease (eg, systemic lupus erythematosus, rheumatoid arthritis) can lead to occlusive vasculitis of the retina and visual loss. However, other symptoms of autoimmune disease are typically present, and this patient's history of ocular trauma makes sympathetic ophthalmia more likely. Educational objective: Traumatic injury to the eye can lead to the release of previously sequestered self-antigens that T cells recognize as foreign. This can lead to inflammation and blindness in both the injured and uninjured eye.

A 30-Year-Old Man Comes to the Office for Follow-Up After