A 71 y.o. male with Warkany syndrome and developmental delay comes to the ED from a nursing home because "his eye is turning white"
he has apparently had a “dense cataract” for many years; this change seems to be painless
What could be wrong?
Our patient had a hypopyon. This is a condition where the anterior chamber has white blood cells present. They often settle in the dependent portion of the eye due to gravity. A hypopyon can be sterile as in corneal ulcers, behcet’s,HLA-B27, and uveitis; or it can be part of a bacterial infection as in endophthalmitis.
A hypopyon should not be drained if is not infected because it offers protection against the invading pathogen due to the presence of white blood cells. Where there is bacterial infection antibiotics are injected into the anterior chamber.
CAUSES OF HYPOPYON
Infection- Acanthamoeba, toxicariasis and fungal infections in the immunosuppressed can result in endophthalmitis. Bacterial (staph predominating), fungal, and viral (EBV,HIV, CMV) infections can also canse endophthalmitis.
Post op- patients with recent eye surgery there is an acute sterile anterior chamber inflammatory reaction that develops 12-48 hours after surgery. It is responsive to topical steroids.
Cataracts- Rupture of a hypermature cataract can cause inflammation in the anterior chamber. This is refered to as phakolytic endopthalmitis.
Sytemic inflammatory disease- Uveitis is often associated with systemic inflammatory diseases. In large studies 37% of patients with uveitis are HLA-B27 positive, 20% had Behcet’s, . Other systemic inflammatory diseases include: lupus, JRA, inflammatory bowel disease and other spondyloarthropathies also cause uveitis.
Tumors- retinoblastomas and other tumors can cause clouding of the anterior chamber.
toxicara canis causing a hypopyon
retinoblastoma causing clouding of the anterior chamber
Complications can occur from a hypopion including synechiae, glaucoma and a descemetocele ( thinning of the cornea so only the decemet membrane remains) This complication predisposes to globe rupture. Our patient was felt to have a degenerating cataract and his family opted for observation since he was already blind in the eye and had severe intellectual disability.
complication of a hypopyon; a descemetocele, thinning of the cornea leaving only decemets membrane.
Huang J, Gaudio P , eds. 2010 Hypopyon Ocular Infammatory Disease and Uveitis: Diagnosis and Treatment. Lippincott Williams & Wilkins. 204.
Zaldi A, Gul-Shuang, Ying, Daniel E, et al. Hypopyon in patients with uveitis. Ophthalmology 2010 Feb 117(2):336.
AStbury N, Nyamai L Detecting and managing complications in cataract patients. Community Eye Health Joural 2016;29(94):27-29.
Martines-Pulgarin D, Munoz-Urbano M, et al. Ocular toxocariasis: new diagnostic and therapeutic perspectives. Recent Pat Antinfect Drug discov 2015;10(1):35-41.
Garg P, Fungal, Mycobacterial and nocardia infections and the eye : an update. 2012 Eye 26, 245-251.