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| CASE REPORT |
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| Year : 2022 | Volume
: 2
| Issue : 2 | Page : 404-406 |
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Pigmented hypopyon – An approach to management
Kushal Umeshbhai Agrawal1, Kashmira Limaye Joshi2
1 Department of Ophthalmology, Jupiter Netralay, Jupiter Hospital, Thane, Maharashtra, India
2 Department of Microbiology, Jupiter Netralay, Jupiter Hospital, Thane, Maharashtra, India
| Date of Submission | 27-May-2021 |
| Date of Acceptance | 22-Sep-2021 |
| Date of Web Publication | 13-Apr-2022 |
Correspondence Address:
Kushal Umeshbhai Agrawal
Department of Ophthalmology, Jupiter Netralay, Jupiter Hospital, Thane - 400 601, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_1353_21
A 60-year-old Indian male presented with diminution of vision in the right eye for 3 months duration. Subsequent evaluation showed signs of granulomatous anterior uveitis, scleral thinning and brown colored pigmented hypopyon in the right eye. Patient was thoroughly evaluated for all possible associations of pigmented hypopyon. He was found to have positive mantoux test, QTB Gold test, positive culture for Mycobacterium tuberculosis on Middlebrook 7H9 medium and positive MPT64 antigen test confirming the diagnosis of intraocular tuberculosis. He was treated with anti-tubercular treatment and oral steroids and subsequently with dexamethasone intravitreal implant. He had complete resolution of pigmented hypopyon with improvement in visual acuity. This case highlights an approach to management in cases of pigmented hypopyon and also highlights that an aggressive management in such cases is pertinent to saving the eye and vision.
Keywords: Intraocular tuberculosis, Middlebrook 7H9 medium, Mycobacterium tuberculosis, pigmented hypopyon, scleral thinning
How to cite this article:
Agrawal KU, Joshi KL. Pigmented hypopyon – An approach to management. Indian J Ophthalmol Case Rep 2022;2:404-6 |
Pigmented hypopyon is a rare entity, and it is associated with a variety of ocular and systemic diseases. A multimodal diagnostic approach is needed to make a definitive diagnosis. Here, we describe the mechanism of formation of pigmented hypopyon and an approach of management to these types of cases. We have also discussed two previously reported cases of pigmented hypopyon due to Mycobacterium tuberculosis (Mtb).
| Case Report | |  |
A 60-year-old Indian male presented with a 3 months history of diminution of vision, pain, and redness in the right eye (OD). He was diagnosed with anterior uveitis by the local ophthalmologist and was treated with topical steroids and cycloplegics with minimal improvements. He was a known case of cirrhosis of the liver and was advised to have liver transplantation, suggestive of immunodeficient status. The patient denies a history of tuberculosis close-contact, ocular trauma, recent surgery, joint pains, oral or genital ulcers, skin disorders, or any high-risk sexual behavior.
On examination, the best-corrected visual acuity in OD was counting finger at 1 foot and 20/20 in the left eye (OS). Goldmann applanation tonometry showed intraocular pressure of 38 mmHg OD and 14 mmHg OS.
Slit-lamp examination of OD showed two pockets of the scleral thinning in the superior part with dilated scleral vessels [Figure 1]b, diffuse circumcilliary congestion, corneal epithelial edema, diffuse mutton fat keratic precipitates at inferior corneal endothelium, muddy iris without nodules, almost half anterior chamber full brown-colored pigmented hypopyon [Figure 1]a, and immature senile cataract (IMSC) with some pockets of posterior synechiae. Fundus examination of OD appeared normal, but the view was hazy due to corneal edema and hypopyon. Ultrasonography of OD did not reveal any vitreous opacity and showed an attached retina and healthy optic nerve. Examination of OS was unremarkable except for IMSC. | Figure 1: (a) Brown pigmented hypopyon with corneal epithelial edema. (b) Two pockets of scleral thinning in superior sclera near limbus
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We proceeded with the provisional diagnosis of granulomatous chronic anterior uveitis with scleritis OD and the patient was first started with antiglaucoma medication, prednisolone acetate (1%) every 1 hourly and atropine (1%) three times a day. Anterior chamber tap was taken and sent for Gram-KOH (Gram–potassium hydroxide) and Ziehl–Neelsen (ZN) staining, culture for bacteria, fungus, and tuberculosis bacilli and for cytological analysis. The following systemic investigations were performed: Complete blood counts with peripheral smear, erythrocyte sedimentation rate, Mantoux test, QuantiFERON TB (QTB) Gold test, serum angiotensin-converting enzyme, venereal disease research laboratory test, human immunodeficiency virus, hepatitis B surface antigen, blood culture, and chest X-ray.
Gram stain showed plenty of uveal pigments and few pus cells, but no bacteria were seen. KOH and ZN staining were negative. The Mantoux test was positive with 12 mm induration after 48 hours; the QTB Gold test was also positive and the erythrocyte sedimentation rate was 38 mm/hour. Cytopathology showed numerous neutrophils, necrotic cells, and uveal pigments but did not reveal any malignant cells, and the blood culture did not reveal the growth of any organism. The rest of the blood reports were unremarkable. Chest X-ray did not reveal any lung involvement, and there was no clinical evidence of extraocular tuberculosis. With the above findings and investigations, the diagnosis of possible intraocular tuberculosis was made,[1] and the patient was started on antitubercular treatment (ATT), oral prednisolone 1 m/kg body weight, antacids, and calcium supplements. The hepatologist's opinion was taken in view of liver cirrhosis, and the ATT was modified as per the advice.
Three weeks after starting the treatment, we noted fine granular colonies of Mtb on Middlebrook 7H9 medium [Figure 2]. The identification was confirmed by an acid-fast bacillus smear and MPT64 antigen test, an immunochromatographic test [Figure 3]. Line probe assay test from the isolate showed sensitivity to Isoniazid and rifampicin. Our final etiological diagnosis was confirmed as intraocular tuberculosis of the right eye. | Figure 2: Granular colonies of Mycobacterium tuberculosis on Middlebrook 7H9 medium
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After 3 weeks of starting treatment, vision improved to 20/120 right eye. Complete resolution of hypopyon was noted [Figure 4], with improvement in the circumcilliary congestion and scleral thinning [Figure 5]. Unfortunately, the patient developed ascites as an adverse effect of oral steroids, and we had to taper and stop it rapidly. However, because of persistent significant scleral thinning, intravitreal dexamethasone implant OD was placed,[2] and topical therapy was continued. After 1 month postintravitreal implant, the patient's vision improved to 20/60 OD, and there was complete resolution of circumcilliary congestion and scleral thinning. However, there was visually significant IMSC OD. Fundus examination of OD was normal at that time also. ATT was continued for 9 months; prednisolone acetate eye drop was tapered every week, and the other medications were stopped. | Figure 5: Resolving scleral thinning after starting antitubercular therapy and oral steroids
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| Discussion | | |
Pigmented hypopyon is quite a rare finding. It can be seen in various infections and systemic and intraocular malignancies.[3] Differential diagnosis of pigmented hypopyon includes intraocular tuberculosis, leukemia, intraocular melanoma, fungus (dematiaceous), Listeria monocytogenes  nes or serratia marcescens related endogenous endophthalmitis.[4]
Pigmentation in hypopyon can be associated with the dispersion of melanin from a necrotic iris.[3] Isolation of tubercular bacilli on culture also indicates multibacillary disease. Intravitreal dexamethasone implant was given because of persistent scleral inflammation at 3 weeks of treatment and the necessity to stop oral steroids due to ascites. Along with ATT, dexamethasone implant can help in reducing inflammation in tubercular uveitis.[2]
As per PubMed search with the words “pigmented hypopyon” and “tuberculosis,” there are only two reported cases of pigmented hypopyon related to Mtb, which are described in [Table 1]. In both cases, the patients were immunosuppressed; our patient also had liver cirrhosis and diabetes, suggestive of an immunodeficient state. In all three patients, immunodeficiency could be a reason for uveal necrosis and pigment dispersion leading to a pigmented hypopyon. A case reported by Dr. Rathinam showed that multiple scleral abscesses were formed due to the aggressive nature of Mtb, and the eye had to be enucleated. This suggests that aggressive management in such cases is pertinent to save the eye and the vision. | Table 1: Mtb-related pigmented hypopyon cases, their characteristics, and management
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| Conclusion | | |
Pigmented hypopyon is a rare association of intraocular tuberculosis and can be seen in immunocompromised patients. Cases of pigmented hypopyon need to be evaluated on the basis of etiology, and aggressive management in such cases may be helpful to save the eye and the vision.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Gupta A, Sharma A, Bansal R, Sharma K. Classification of intraocular tuberculosis. Ocular Immunol Inflamm 2015;23:7-13.  |
| 2. | Agarwal A, Handa S, Aggarwal K, Sharma M, Singh R, Sharma A, et al. The role of dexamethasone implant in the management of tubercular uveitis. Ocular Immunol Inflamm 2018;26:884-92. |
| 3. | Rathinam SR, Rao NA. Tuberculous intraocular infection presenting with pigmented hypopyon: A clinicopathological case report. Br J Ophthalmol 2004;88:721-2. |
| 4. | Shetty SB, Devulapally SH, Murali S, Walinjkar JA, Biswas J. Tuberculous uveitis presenting as pigmented hypopyon- A case report. AM J Ophthalmol Case Rep 2017;7:1-3. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1]
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