Sir,

We read with interest N Ahmad and J Wests' survey with regard to treatment of asymptomatic retinal detachments.1 We would like to offer a cautious warning illustrated with sobering case report.

Case report

A 27-year-old woman with a refractive error of −7.00DS bilaterally presented to the eye casualty with a subconjunctival haemorrhage. She had no previous ocular or medical history; in particular no ocular trauma. Her visual acuity was 6/6 bilaterally. Dilated fundal examination revealed no posterior vitreous detachment and an incidental retinal detachment associated with two round holes inferotemporally on the right eye. A small retinal detachment with no posterior vitreous detachment associated with a round hole was also noted on the temporal retina of the left eye. Faint demarcation lines were noted. Argon laser demarcation was carried out bilaterally. Subsequently, cryotherapy with buckle attachment to the right eye was undertaken. She returned 2 months later with blurring of the vision bilaterally. Her visual acuities were 6/6 and 6/36 on the right and left eye. Examination showed bilateral granulomatous pan uveitis, Dallen Fuchs deposits (Figure 1) with choroidal thickening, confirmed by ultrasonography (Figure 2). Investigations excluding other causes, fundus fluorescein angiography (Figure 3), and indocyanine green angiography suggested the diagnosis of sympathetic ophthalmia. She was started on oral and topical steroids. She developed ocular hypertension, which was managed topically. She improved, and at her last check, 3 months since the onset of the uveitis, her visual acuities were 6/6 bilaterally.

Figure 1
figure 1

Left fundus showing Dallen Fuchs deposits.

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Figure 2
figure 2

B-scan ultrasound of left eye showing thickened choroid.

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Figure 3
figure 3

Left eye fundus fluorescein angiogram at 30 s.

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Comment

Although the association between cryotherapy and the development of sympathetic ophthalmia has been reported in the past,2, 3, 4, 5 all these cases were after cyclodestructive procedures. This is the first such case associated with cryotherapy for retinal holes in the management of retinal detachment. This patient's retinal detachment most closely related to scenario 4 in Ahmad's paper.1 From the survey, 51–78% of respondents elected for surgical intervention, depending on the presence of a demarcation line. The management of these conditions is clearly controversial. The complication encountered here, although rare, is a cautionary tale and reminds us of the old adage primum non nocere.