The risk of sympathetic ophthalmia associated with open globe injury management strategies: a meta-analysis.

Topic Sympathetic ophthalmia (SO) is a sight threatening granulomatous panuveitis caused by a sensitizing event. The use of primary enucleation or primary evisceration, versus primary repair, as a risk management strategy following OGI remains controversial. Clinical relevance This systematic review was conducted to report the incidence of SO after primary repair compared to after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat (NNT). Methods Five journal databases were searched. This review was registered with PROSPERO: CRD42021262616. Searches were carried out on 29th June 2021 and updated 10th Dec 2022. Prospective or retrospective studies which reported outcomes (including sympathetic ophthalmia or lack of sympathetic ophthalmia) in a patient population who underwent either primary repair and primary enucleation, or primary evisceration, were included. A systematic review and meta-analysis were carried out in accordance with PRISMA guidelines. PROSPERO registration number CRD42021262616. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). Results Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total 7620 OGIs met the criteria for inclusion in this analysis; 21 developed SO. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval (CI) 0.00% to 0.25%) after OGI. Out of 779 patients who underwent primary enucleation or primary evisceration no SO cases were reported, resulting in pooled SO estimate of 0.05% (95% CI 0.00% – 0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI 0.00% to 0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal) (95% CI -0.0031 (in favour of eye removal) to 0.0011 (in favour of primary repair)). GRADE analysis highlighted a low certainty of evidence, as the included studies were observational and there was a risk of bias from missing data. Conclusion Based on the available data, there is no evidence that primary enucleation or primary evisceration reduce the risk of secondary SO.