Bilateral hypopyon corneal ulcers in pancreatic carcinoma

Suneel Sangaraju; Lokesh Koumar Sivanandam; Geeta Behera; Divyabala Thumaty; Krishna Ramesh Babu

doi:10.4103/ijo.IJO_1720_21

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CASE REPORT

Year : 2022 | Volume : 2 | Issue : 3 | Page : 647-648

Bilateral hypopyon corneal ulcers in pancreatic carcinoma

Suneel Sangaraju¹, Lokesh Koumar Sivanandam², Geeta Behera¹, Divyabala Thumaty³, Krishna Ramesh Babu¹
¹ Department of Ophthalmology, Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India
² Department of Internal Medicine, Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India
³ Department of Medical Oncology, Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry, India

Date of Submission	25-Jun-2021
Date of Acceptance	22-Feb-2022
Date of Web Publication	16-Jul-2022

Correspondence Address:
Dr. Geeta Behera
Department of Ophthalmology, Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry - 605006
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1720_21

Abstract

A 39-year-old woman on palliative chemotherapy for pancreatic carcinoma presented with painful bilateral vision loss. On examination, she had large bilateral corneal ulcers with hypopyon, with corneal and conjunctival xerosis. She was extremely malnourished. Investigations revealed macrocytic anemia with pancytopenia and hypoproteinemia suggestive of pancreatic enzyme insufficiency (PEI). Microbiology reported Pseudomonas aeruginosa infection that was sensitive to ceftazidime. Treatment with topical ceftazidime and oral vitamin A and B12 supplementation (therapeutic doses) led to rapid resolution of the ulcers in 4 weeks. Xerophthalmia with secondary keratitis due to malnutrition from pancreatic carcinoma is hitherto unreported but can be treated successfully with timely identification.

Keywords: Bilateral Keratitis, pancreatic carcinoma, vitamin A deficiency, vitamin B12 deficiency, xerophthalmia

How to cite this article:
Sangaraju S, Sivanandam LK, Behera G, Thumaty D, Babu KR. Bilateral hypopyon corneal ulcers in pancreatic carcinoma. Indian J Ophthalmol Case Rep 2022;2:647-8

How to cite this URL:
Sangaraju S, Sivanandam LK, Behera G, Thumaty D, Babu KR. Bilateral hypopyon corneal ulcers in pancreatic carcinoma. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 13];2:647-8. Available from: https://www.ijoreports.in/text.asp?2022/2/3/647/351126

Severe vitamin A deficiency in adults is reported with malnutrition and malabsorption syndromes in alcoholism, pancreatitis, and eating disorders.^[1],[2] We present a case of bilateral large hypopyon corneal ulcers in pancreatic carcinoma.

Case Report

A 39-year-old woman on palliative chemotherapy for periampullary pancreatic carcinoma [Figure 1] presented with painful bilateral diminution of vision for 4 days. She was moderately built and extremely malnourished (39 kg). Her best-corrected visual acuity (BCVA) was light perception (PL) in both eyes. She had marked conjunctival xerosis (thickened and wrinkled bulbar conjunctiva) with hyperemia, large corneal ulcers (7.5 mm × 7.5 mm) with surrounding infiltrates, and hypopyon (4.4 mm) in both eyes [Figure 2]a and [Figure 2]b. Ultrasonography (B-scan) revealed a normal posterior segment and orbit. Corneal scrapings were sent for microbiological evaluation, and she was started on 0.5% gatifloxacin eye drops hourly. Investigations revealed macrocytic anemia with pancytopenia (hemoglobin [Hb]: 5.7 g%, mean corpuscular volume (MCV): 108.9 fL, mean corpuscular hemoglobin (MCH): 33.9 pg, mean cell hemoglobin concentration (MCHC): 31.1 g%, total leukocyte count (TLC): 2640 cells/μL), serum total protein 5.7 g/dL (reference range: 6.6–8.3 g/dL), and serum albumin 3 g/dL (reference range: 3.5–5.2 g/dL), indicating moderate hypoproteinemia and malnutrition. Based on peripheral smear morphology (macrocytic anemia, leukopenia, and thrombocytopenia) and red blood cell (RBC) indices, vitamin B12 deficiency was diagnosed. Microbiology reported Pseudomonas aeruginosa that was sensitive to ceftazidime, so topical antibiotic was changed to 5% ceftazidime eyedrops. Based on the clinical finding of xerophthalmia and peripheral smear morphology, oral vitamin A (2,00,000 IU on days 0, 1, and 14) and vitaminB12 (1000 μg for 14 days) were added. Conjunctival xerosis resolved, and corneal ulcers healed with scarring in 4 weeks (BCVA: hand movements) [Figure 2]c and [Figure 2]d. We diagnosed her with xerophthalmia and bilateral infectious keratitis due to pancreatic carcinoma-related malnutrition from PEI.

Figure 1: Post-contrast portal phase axial CT section at the level of the uncinate process showing a hypoenhancing soft tissue density lesion in uncinate process and head of the pancreas (arrow) with loss of fat planes with the second part of duodenum

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Figure 2: Slit-lamp photographs of (a) right eye and (b) left eye, at presentation, showing corneal ulcer of size 7.5 × 7.5 mm with surrounding infiltrates and large hypopyon in the anterior chamber and conjunctival xerosis (arrows), and (c) right eye and (d) left eye, 4 weeks after treatment, showing macular corneal haze involving the entire cornea and resolved conjunctival xerosis

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Discussion

Pancreatic tumors of the head and periampullary region cause malabsorption and nutritional deficiencies by replacing healthy pancreatic tissue and obstructive damage to the normally secreting exocrine ducts.^[3] In our case, malabsorption due to PEI was evident as macrocytic anemia with pancytopenia, suggesting vitamin B12 deficiency. Failure to degrade haptocorrin prevents binding of B12 to intrinsic factor (IF), causing B12 malabsorption. Also, pancreatic enzymes modify the IF structure, enabling vitaminB12–IF complex absorption in the distal ileum.^[4] Though the pathomechanism of malabsorption of other nutrients is unclear, fat-soluble vitamins' deficiencies (especially vitamins A and D) are seen.^[3] Vitamin A deficiency causes night blindness, conjunctival and corneal xerosis, corneal ulcerations, and keratomalacia. Corneal erosions in xerophthalmia are prone to infections.^[1],[2],[5] Particularly, P. aeruginosa keratitis in a xerophthalmic cornea greatly increases the risk of perforation and abysmal visual prognosis.^[5] Timely clinical detection of macrocytic anemia and xerophthalmia in a background of severe malnutrition in pancreatic carcinoma should aid in identifying PEI, which is underrecognized and underreported.^[3] Pancreatic enzyme replacement therapy (PERT) has an independent association with more prolonged survival and better quality of life.^[3]

Conclusion

Early institution of vitamin A supplementation based on clinical findings alongside antimicrobial therapy may be vital in quick healing and preventing disastrous outcomes in xerophthalmia complicated with secondary infection. Vitamin supplementation/PERT should be integrated into the management of pancreatic tumors and chronic pancreatitis to prevent and overcome PEI.

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

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