Sympathetic ophthalmia complicating proliferative diabetic retinopathy: diagnostic and therapeutic challenges during pregnancy

Sympathetic ophthalmia is a rare, bilateral granulomatous uveitis that typically follows penetrating ocular trauma or intraocular surgery. Its coexistence with proliferative diabetic retinopathy is uncommon and complicates diagnosis and treatment. A 27-year-old woman with poorly controlled type 1 diabetes developed sympathetic ophthalmia in the fellow eye ten weeks after repair of a penetrating ocular injury. The sympathizing eye showed keratic precipitates, vitritis, papillitis, and exudative retinal detachment superimposed on proliferative diabetic retinopathy. High-dose intravenous methylprednisolone was initiated, followed by an oral taper and early introduction of adalimumab to reduce the risk of corticosteroid-induced hyperglycemia. After inflammatory control, panretinal photocoagulation was augmented. Visual acuity improved from 20/100 to 20/25 with marked resolution of subretinal fluid and partial regression of neovascularization. The clinical course was further complicated by a second pregnancy. The patient developed recurrent vitreous hemorrhage and progressive tractional changes that required postpartum pars plana vitrectomy; the eye remained quiet with a flat retina and visual acuity of 20/40 at last follow-up. This case underscores the importance of recognizing sympathetic ophthalmia as a potential inflammatory trigger for worsening diabetic retinopathy. Severe intraocular inflammation may exacerbate retinal ischemia and neovascular activity, whereas controlling sympathetic ophthalmia systemically can facilitate regression of diabetic changes. Early recognition and prompt, pregnancy-appropriate immunomodulatory therapy are critical to preserve vision and stabilize both inflammatory and microvascular disease components.