Sympathetic Ophthalmia (SO)

What is Sympathetic Ophthalmia?

Sympathetic ophthalmia is a rare, serious inflammation of the middle layer of both eyes (granulomatous panuveitis) that follows a penetrating injury or surgery to one eye.^{[1, 2]} The injured eye is called the inciting eye and the other the sympathizing eye, and both can lose vision.^[1] It is an emergency condition for an ophthalmologist, and complementary care has no role in treating the inflammation itself.

Common symptoms

The most common symptoms are decreased vision, eye redness, eye pain and sensitivity to light.^[1] Some people also notice floaters. Symptoms usually appear weeks to months after the original injury or surgery, most often within the first year, although a delay of many years is possible.^{[1, 2]}

Causes and risk factors

The cause is thought to be an immune reaction. After a penetrating injury or surgery, eye proteins that are normally hidden from the immune system are exposed, and the immune system then attacks both eyes.^[1] Sympathetic ophthalmia is rare after eye surgery. A meta-analysis of 19 studies estimated about 0.06 percent of operations were followed by it, with low-certainty evidence.^[3] Risk depends on the type of trauma and how much of the eye's inner tissue was exposed.^[1]

How it is diagnosed and treated conventionally

An ophthalmologist diagnoses it mainly from the eye examination and the history of earlier trauma or surgery. Imaging such as optical coherence tomography and fluorescein angiography can support the diagnosis.^{[1, 4]}

Treatment starts with high-dose corticosteroids, and many patients then need long-term immune-suppressing medicines such as methotrexate, azathioprine or biologic drugs to prevent relapses.^{[1, 2]} Early diagnosis and prompt treatment have improved visual outcomes.^{[4, 5]}

Why Sympathetic Ophthalmia calls for a whole-person approach

The disease itself is an immune attack on the eye, treated by eye specialists. Living with it can also mean years of strong medicines, worry about vision and disrupted sleep.

Supportive care is aimed at those parts of life, not at the eye inflammation. The evidence cited below comes from other groups of people and is not specific to this disease.

Immune activity in the eye

Researchers think the condition arises when previously hidden eye tissue is exposed to the immune system, and treatment is aimed at calming that response.^[1] No research shows that acupuncture, Ayurveda or herbs control this response in sympathetic ophthalmia.

Long-term medicine effects

Because many patients need long-term corticosteroids, bone health is a concern. The American College of Rheumatology publishes guidance on assessing and treating glucocorticoid-induced osteoporosis, and that care belongs with your physician.^[6]

Stress and sleep

Sudden eye injury, the risk of vision loss and years of treatment can be stressful, and stress and poor sleep are the symptoms where supportive therapies have been studied most, although not in this condition.

Acupuncture as supportive care in Sympathetic Ophthalmia

What the research shows

No clinical trials of acupuncture for sympathetic ophthalmia were found in PubMed, and no studies of acupuncture for other forms of uveitis turned up either. Acupuncture has not been shown to affect the eye inflammation or protect vision in this disease.

For symptoms that people with the disease may share, evidence comes from other patient groups. A meta-analysis of 24 trials in insomnia found that acupuncture improved sleep scores compared with drug treatment after about three weeks, although results varied widely between trials.^[7] A meta-analysis of 16 trials in chronic fatigue syndrome found acupuncture more effective than sham acupuncture and other treatments, but most studies were of low quality and the authors reached no firm conclusion.^[8]

How acupuncture may work

A review of laboratory and clinical literature proposes that acupuncture may release nerve signaling molecules that affect blood vessels and inflammatory messengers. It also notes that large randomized trials showing a lasting effect were missing.^[9] This is a proposed mechanism, not a demonstrated effect on uveitis.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes, over a course of several visits with reassessment. Treatment around the eyes should not be considered without your ophthalmologist's agreement.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, pain or a mark at the needle site, and serious events occurred in about 1 in 10,000 patients.^[10] Tell your practitioner first if you take blood thinners, have a bleeding disorder, are pregnant, or have a pacemaker. Also say that you take immune-suppressing medicines, since this can affect how infections are handled.

Ayurvedic medicine as supportive care in Sympathetic Ophthalmia

The Ayurvedic view

Ayurveda has no classical name for sympathetic ophthalmia, so any traditional description of it is an interpretation. Eye inflammation is generally discussed in Ayurveda in terms of imbalance of the doshas, especially Pitta, the principle linked to heat and inflammation. This is a traditional framework and not a medical diagnosis.

Therapies that may be used

Ayurvedic care is chosen for the individual. In a supportive role it may include:

• Diet and daily routine advice aimed at regular meals, steady sleep and stress reduction
• Relaxation practices and gentle body massage
• Individually prescribed herbs, such as ashwagandha, traditionally used for stress and low energy

Panchakarma and any treatment applied to or around the eyes are not appropriate for this condition, as eye procedures belong with your ophthalmologist. Panchakarma is also not suitable during pregnancy, acute illness or frailty, or while the disease is active or immune-suppressing treatment is being adjusted. A herbal preparation applied to the skin (transdermal medication therapy) is a supportive option only, and we make no claim of benefit for it in this disease.

What the research shows

No studies of Ayurvedic medicine for sympathetic ophthalmia were found. For related symptoms, two meta-analyses of randomized trials found that ashwagandha extract reduced stress and anxiety scores compared with placebo. One reviewed 12 trials and rated the certainty of the evidence as low.^{[11, 12]} Another meta-analysis of five trials found a small improvement in sleep and noted limited long-term safety data.^[13] These trials enrolled adults with stress, anxiety or insomnia and not people with eye disease or on immunosuppressants.

Herbal medicine as supportive care in Sympathetic Ophthalmia

Herbs and formulas that have been studied

No herbal medicine has been tested in people with sympathetic ophthalmia. Research on uveitis in general has looked at curcumin, the main compound in turmeric, and at Tripterygium wilfordii, a Chinese herb.^{[14, 15]}

What the research shows

There is no evidence for herbal medicine in this disease, and for other forms of uveitis it is very limited. A placebo-controlled trial in HLA-B27-related acute anterior uveitis tested a specially formulated curcumin product for 12 months. The proportion of responders was higher with curcumin, while the severity of attacks was similar, and the authors described the benefit only as suggested.^[14] A small Chinese trial of Tripterygium polyglycoside in acute anterior uveitis reported lower blood levels of two inflammatory markers, but it compared two treated groups and did not show a clinical benefit for vision.^[15]

A review of curcumin in retinal diseases describes it as anti-inflammatory and antioxidant, but notes poor absorption and the need for large human studies.^[16] None of this shows that herbs help sympathetic ophthalmia, and no herb should be used in place of corticosteroids or other immune-suppressing treatment.

Safety and herb-drug interactions

This matters more here than in many conditions, because people with sympathetic ophthalmia often take long-term immune-suppressing medicines. A review of herb-drug interactions describes St. John's wort lowering levels of cyclosporine and tacrolimus, and reports of bleeding when danshen, garlic or ginkgo were combined with warfarin or aspirin.^[17] A review of warfarin cases also lists dang gui, ginger and Boswellia.^[18]

Herbal and dietary supplements account for a notable share of drug-induced liver injury in the United States.^[19] About one fifth of Ayurvedic medicines bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually after review of your full medicine list. Tell us if you are pregnant or breastfeeding or have liver or kidney disease.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine describes eye disease in terms of liver heat or fire and disturbed flow of qi and blood, and Ayurveda in terms of excess Pitta. Researchers study ideas that loosely parallel these pictures, such as inflammatory signaling, immune regulation and the nervous system's stress response.^[9]

No study has shown that a traditional pattern corresponds to the autoimmune process in sympathetic ophthalmia. The traditional language is used to guide supportive care for the person, not to explain the disease.

How this care fits with your medical care

Supportive care here is complementary. For a condition like this, we ask that you are under a physician's care for it and that your treating team knows you are receiving complementary care. Keep your ophthalmologist, and any other physician who prescribes your medicines, and do not stop or change corticosteroids or other prescribed treatment without your prescriber.

We do not diagnose or monitor the eye disease, judge whether it is active or adjust medication. Please bring your diagnosis, recent eye examination notes, your full list of medicines and supplements, and the name of your eye specialist.

When to seek urgent medical care

Any new eye symptom after an eye injury or eye surgery needs an eye specialist promptly, because early treatment is important to protect vision.^{[1, 4]}

• New blurred vision or loss of vision in either eye
• New eye redness or eye pain
• New sensitivity to light or new floaters
• Any eye injury, especially a penetrating injury or an eye that may have been punctured
• Vision changes, redness or pain while tapering or after stopping prescribed eye treatment
• Fever or a new infection while taking immune-suppressing medicine

If any of these occur, call your ophthalmologist right away. For sudden vision loss or a serious eye injury, call 911 or go to the nearest emergency department.