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| COMMENTARY |
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| Year : 2022 | Volume
: 2
| Issue : 2 | Page : 407 |
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Commentary: Pigmented hypopyon - An approach to management
Atul Arora
Advanced Eye Centre, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| Date of Web Publication | 13-Apr-2022 |
Correspondence Address:
Atul Arora
Advanced Eye Centre, Department of Ophthalmology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh - 160 012
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_2597_21
How to cite this article:
Arora A. Commentary: Pigmented hypopyon - An approach to management. Indian J Ophthalmol Case Rep 2022;2:407 |
The authors have reported a unique case of pigmented hypopyon in a patient with intraocular tuberculosis.[1] Also, they have described the mechanism of formation of pigmented hypopyon and an approach of management to these types of cases. I credit the authors for good clinical workup and management of this case. Additionally, some important points are highlighted here.
Hypopyon results from the accumulation of white blood cells (WBCs) and fibrin in the anterior chamber (AC).[2],[3],[4] Intraocular inflammation, infection, and keratitis are the conditions commonly associated with hypopyon. Due to severe inflammation or infection, there occurs exudation of plasma proteins, fibrin, and WBCs, predominantly neutrophils which settle down in the dependent part of the AC. The breach of blood-ocular barrier in the anterior uveal tissue resulting from inflammatory mediators, cytokines, and bacterial toxins is the pathophysiology behind hypopyon formation.[2],[3],[4] Rarely, hypopyon may be seen in intraocular malignancy, masquerades, and metastasis. Hypopyon is, thus, an important clinical sign. In a large series by Zaidi et al.[4] to evaluate the risk factors for hypopyon among patients with uveitis, the incidence of hypopyon among uveitis patients was 8.3/1000. The eyes with hypopyon, however, did not show any increased risk of developing structural ocular complications or vision loss. This could be explained by the fact that Behçet's disease, Human Leukocyte Antigen (HLA)-B27 positivity, and spondyloarthropathy-associated acute anterior uveitis were the main etiological conditions in their series. As all these eyes responded to the treatment by topical and oral steroids, favorable long-term outcomes are expected. However, this is not the case with other pathological conditions presenting with hypopyon, and in certain cases, hypopyon may be an ominous sign indicating severe infection or malignancy.
It, therefore, becomes important to observe the character of hypopyon as this can provide important clue toward possible etiology. Mobile/shifting hypopyon is seen in Behçet's disease while convex hypopyon in a setting of keratitis indicates fungal etiology.
The presence of dark/pigmented hypopyon is rare but a remarkable finding. Pigmented hypopyon has been reported in the eyes with Listeria monocytogenes[5] and Serratia marcescens  infections.[6] Additionally, endogenous melanoma cells[7] and juvenile xanthogranuloma[8] may present with pigmented hypopyon. The dispersion of melanin pigment from necrotic iris tissue is responsible for the dark color of hypopyon in these cases. Pigmented hypopyon has also been reported in tubercular uveitis in a setting of compromised immune status.[9],[10] In both the reported cases and also in the one described by the authors, acid fast bacilli could be isolated from the intraocular fluid indicating a multibacillary pathology. In the setting of subdued immune system, tubercle bacilli may result in necrosis and damage to the pigmented uveal tissue resulting in the release of pigment. It is thus interesting that the presence of the pigment in hypopyon may point toward a multibacillary phenotype of tubercular uveitis. Such phenotypes of tubercular uveitis require aggressive treatment with ant-tubercular therapy in addition to the local and systemic steroids to control the inflammation. The outcome may be rewarding and a timely intervention can play a sight-saving role as the authors have shown in this case.
| References | |  |
| 1. | Agrawal KU, Joshi KL. Pigmented hypopyon – An approach to management. Indian J Ophthalmol Case Rep 2022;2:404-6.  [Full text] |
| 2. | Ramsay A, Lightman S. Hypopyon uveitis. Surv Ophthalmol 2001;46:1-18. |
| 3. | Zaidi AA, Ying G-S, Daniel E, Gangaputra S, Rosenbaum JT, Suhler EB, et al. Hypopyon in patients with uveitis. Ophthalmology 2010;117:366-72. |
| 4. | D'Alessandro LP, Forster DJ, Rao NA. Anterior uveitis and hypopyon. Am J Ophthalmol 1991;112:317-21. |
| 5. | Alkatan HM, Al-Dhibi HA, Edward DP, Al-Rajhi AA. Pigmented hypopyon in association with Listeria monocytogenes endopthalmitis: An interesting case report following refractive surgery procedure with literature review. Middle East Afr J Ophthalmol 2014;21:40-3. [ PUBMED] [Full text] |
| 6. | Al Hazzaa SA, Tabbara KF, Gammon JA. Pink hypopyon: A sign of Serratia marcescens endophthalmitis. Br J Ophthalmol 1992;76:764-5. |
| 7. | Abbott RL, Forster RK, Rebell G. Listeria monocytogenes endophthalmitis with a black hypopyon. Am J Ophthalmol 1978;86:715-9. |
| 8. | Fontanilla FA, Edward DP, Wong M, Tessler HH, Eagle RC, Goldstein DA. Juvenile Xanthogranuloma masquerading as melanoma. J AAPOS 2009;13:515-8. |
| 9. | Rathinam SR, Rao NA. Tuberculous intraocular infection presenting with pigmented hypopyon: A clinicopathological case report. Br J Ophthalmol 2004;88:721-2. |
| 10. | 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. |
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