Atypical Posterior Sympathetic Ophthalmia Shortly After PRESERFLO™ MicroShunt Implantation Masquerading as Hypotony Maculopathy: A Case Report

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We report a rare case of presumed posterior sympathetic ophthalmia (SO) occurring shortly after PRESERFLO™ MicroShunt (PMS) (Santen Pharmaceutical Co., Ltd., Osaka, Japan) implantation that initially mimicked hypotony maculopathy. A 42-year-old woman with a history of multiple prior intraocular surgeries underwent PMS implantation in her left eye for glaucoma with uncontrolled intraocular pressure (IOP). At three days post-surgery, visual acuity (VA) decreased to hand motion, and IOP dropped to 6 mmHg. Slit-lamp examination showed no keratic precipitates or anterior chamber inflammation, while fundoscopy imaging revealed choroidal folds and serous retinal detachment. Given a provisional diagnosis of hypotony maculopathy, an anterior chamber air injection was performed at six days post-surgery. Despite a resultant rise in IOP, the posterior findings did not improve. Thus, a diagnosis of SO was made, and high-dose intravenous corticosteroid pulse therapy followed by oral corticosteroids was initiated at 10 days post-surgery, which led to anatomic improvement. Human leukocyte antigen (HLA) typing was positive for HLA-DR4. At two years post-surgery, her left eye had a decimal VA of 0.2 and a stable IOP of 10 mmHg. Oral prednisolone was tapered to 5 mg/day without recurrence. Fundoscopy examination of her right eye was difficult due to long-standing total retinal detachment. This case underscores several atypical features of posterior SO, including very early-onset, posterior-predominant disease without anterior inflammation, and diagnostic challenges in the fellow eye, and highlights the importance of considering SO in atypical postoperative presentations, even after less invasive glaucoma surgery, and the need for early recognition with timely corticosteroid therapy to preserve vision.

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