Fellow eye’s revenge: Navigating sympathetic ophthalmia following penetrating keratoplasty

Sympathetic ophthalmia (SO) is a rare bilateral granulomatous uveitis that may occur following penetrating ocular injury or surgery. We report a 48-year-old man who developed SO in the left eye 3 weeks after therapeutic penetrating keratoplasty with cataract extraction for fungal keratitis in the right eye. He presented with decreased vision and floaters, and multimodal imaging, including optical coherence tomography, fundus fluorescein angiography, and fundus autofluorescence, demonstrated exudative retinal detachment with characteristic posterior segment findings. Prompt treatment with intravenous methylprednisolone followed by tapering oral corticosteroids and mycophenolate mofetil resulted in complete resolution of inflammation and subretinal fluid, with improvement of best-corrected visual acuity to 0.2 logMAR in both eyes at 6 months and no recurrence. This case highlights the importance of maintaining a high index of suspicion for SO after therapeutic penetrating keratoplasty and emphasizes that early diagnosis and aggressive immunosuppressive therapy can preserve vision.