Hypopion

Specialty: Ophthalmology.

• pus in the anterior chamber
• intraocular whitish level
• purulent meniscus in the eye

Why it occurs

• Infectious bacterial or fungal endophthalmitis (secondary to recent intraocular cataract surgery, intravitreal injection, or penetrating ocular trauma)
• Severe bacterial or fungal corneal ulcer with intense inflammatory reaction in the anterior chamber (sterile or infectious hypopion due to transfer of toxins)
• Severe acute anterior uveitis (associated with positive HLA-B27 antigen, ankylosing spondylitis, Behçet Syndrome or Sarcoidosis)
• Tumor masquerade syndrome (retinoblastoma or intraocular lymphoma that simulates inflammation)
• Drug toxicity or infectious keratopathy due to misuse of contact lenses

Initial workup

Slit lamp examination measuring the exact height in millimeters of the hypopyon meniscus in the lower vertical axis; Urgent sample collection of aqueous humor (anterior chamber paracentesis) and vitreous humor (vitreous puncture) in the operating room or procedure room for smears with Gram stain, Giemsa stain, cultures in aerobic/anaerobic/fungal media and polymerase chain reaction (PCR); B-mode ocular ultrasound to rule out diffuse vitreous infiltration or secondary retinal detachment.

Standard management

• Vancomycin — 1 mg/0.1 ml intravitreal injection) combined with Ceftacidime (2.25 mg/0.1 ml intravitreal injection; first-line broad-spectrum intravitreal empiric antibiotic treatment for bacterial endophthalmitis
• Reinforced vancomycin — 5% ophthalmic eye drops, 1 drop every hour) alternating with reinforced Ceftacidime (5% ophthalmic eye drops, 1 drop every hour)
• Ciclopentolate (1% eye drops, 1 drop every 8 hours to induce sustained mydriasis, mitigate the pain of ciliary spasm and prevent the formation of iridocrystalline adhesions or posterior synechiae).