Chlorambucil therapy in sympathetic ophthalmia

We used chlorambucil therapy in a 28-year-old man with sympathetic ophthalmia, which was incompletely controlled with systemic corticosteroids, and the patient developed serious side effects.

The patient sustained a penetrating injury with an intraocular metal foreign body. Attempts to remove it with a magnet failed. Vitrectomy with lensectomy successfully removed the intraocular foreign body. Five weeks after the injury and one week after the vitrectomy, sympathetic ophthalmia developed, with severe visual impairment and inflammation and serous retinal detachment in the fellow eye. Sympathetic ophthalmia was poorly responsive to topical cycloplegics, topical corticosteroids, and systemic corticosteroid therapy. The patient developed side effects to the corticosteroids, which were reduced to prednisolone 60 mg daily. Chlorambucil therapy was begun at 2 mg daily, increased by 2 mg per day each week to the maximum of 8 to 12 mg per day. The total dose of chlorambucil was 793 mg; the duration of therapy was 23 weeks.

Successful treatment was achieved with chlorambucil therapy. There was clinical remission of inflammation and absorption of exudative retinal detachment. The neurosensory retina sealed down; the retinal pigment epithelium demonstrated severe destruction, with the characteristic sunset-glow and moth-eaten appearance. No malignancy and no serious side effect developed during one year of follow-up. After termination of therapy, the patient had sustained remission of ocular disease.

Chlorambucil immunosuppressive therapy is an alternative to corticosteroids for the treatment of corticosteroid-resistant sympathetic ophthalmia; however, because chlorambucil has potentially serious late side effects, prolonged follow-up is necessary.