Sympathetic Ophthalmia: Recognition, Treatment and the Enucleation Question

Last updated: November 2026

Sympathetic ophthalmia is a rare bilateral granulomatous panuveitis that follows penetrating injury or surgery to one eye. The injured eye is the "exciting" eye and the other is the "sympathising" eye. Early, strong immunosuppression saves sight.

How common, and when?

• After penetrating trauma: about 0.2–0.5%; after intraocular surgery much rarer (around 0.01%), with vitreoretinal surgery now an important cause.
• Half of cases start within 3 months and 90% within a year, but it can appear decades later.

Clinical features

• Both eyes: blurred vision, photophobia, reduced accommodation in the sympathising eye.
• Mutton-fat KPs, thickened iris, vitritis, choroiditis, exudative retinal detachment, optic disc swelling.
• Dalen-Fuchs nodules: small yellow-white deep lesions (seen in about a quarter to a third; not pathognomonic).
• Like Vogt-Koyanagi-Harada disease, it can cause poliosis, vitiligo and hearing loss, but VKH has no history of injury.

Investigations

• FFA: multiple pinpoint leaks in the acute phase; ICG: hypofluorescent dark dots.
• OCT: serous detachment, choroidal thickening; B-scan: choroidal thickening.
• Exclude infection (syphilis, TB) before high-dose immunosuppression.

Treatment

• High-dose systemic steroids (oral prednisolone 1–2 mg/kg/day, or IV methylprednisolone 1 g/day for 3 days in severe disease), tapered slowly over at least 3 months.
• Most patients need a steroid-sparing immunosuppressant (ciclosporin, mycophenolate, azathioprine, or biologics such as adalimumab).
• Starting treatment within about 2 weeks of symptoms is associated with better vision.

The enucleation question

• Enucleation of a blind, severely injured eye within 2 weeks of injury was historically thought to prevent sympathetic ophthalmia; the evidence is weak, and primary repair with an attempt to save the eye is now standard.
• Once sympathetic ophthalmia has started, removing the exciting eye does not help the sympathising eye, and the exciting eye may end up the better one.

Test yourself: flip cards

Related: Vogt-Koyanagi-Harada Disease, Open Globe Injury: The BETT Classification, Uveitis Made Easy: SUN Terms, Patterns and Work-up.

Key sources

• StatPearls: Sympathetic Ophthalmia (current version)
• Chu XK, Chan CC. Sympathetic ophthalmia: to the twenty-first century and beyond. J Ophthalmic Inflamm Infect. 2013;3:49
• Kilmartin DJ, et al. Prospective surveillance of sympathetic ophthalmia in the UK and Republic of Ireland. Br J Ophthalmol. 2000;84:259-263