Photo Quiz

February 2022

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Volume 105, Number 2 www.aafp.org/afp American Family Physician 191

A 65-year-old man presented with three days of

pain and pressure in his right eye, accompanied

by blurred vision and photosensitivity. He did

not have pain with eye movement. He had a fever

and chills. He had a history of poorly controlled

diabetes mellitus and a urinary tract infection a

week earlier that was treated with ciprooxacin.

Physical examination revealed a mildly dilated

right pupil, with incomplete constriction to light,

compared with the le pupil. A small collection

of white uid was observed in the anterior cham-

ber of the right eye (Figure 1).

Question

Based on the patient’s history and physical

examination ﬁndings, which one of the follow-

ing is the most likely diagnosis?

l A. Acute glaucoma.

l B. Behçet syndrome.

l C. Corneal ulcer.

l D. Endogenous bacterial endophthalmitis.

l E. Pseudohypopyon.

See the following page for discussion.

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Photo Quiz

Inﬂammation of the Eye

Richard M. Rubin, MD, and Ayodeji Alaketu, MD, Travis Air Force Base, California

FIGURE 1

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192 American Family Physician www.aafp.org/afp Volume 105, Number 2

◆

February 2022

PHOTO QUIZ

Discussion

e answer is D: endogenous bacterial endophthal-

mitis, an intraocular infection caused by hematog-

enous spread of organisms from an extraocular

location.

Findings include decreased vision, eyelid

edema, pupillary abnormalities, hypopyon, and

conjunctival injection. Diagnosis is based on phys-

ical examination and blood culture ndings. Intra-

ocular uid culture from the anterior chamber and

vitreous may be needed to conrm the diagnosis if

blood culture results are negative.

is patient was

found to have group B streptococcus bacteremia,

conrmed with vitreous culture.

Treatment of endogenous bacterial endoph-

thalmitis includes intravenous antibiotics to

manage the systemic infection. e ocular infec-

tion may be managed with pars plana vitrectomy,

intravitreal antibiotics, and steroids, and the intraocular

infection managed with topical steroids, antibiotics, and

cycloplegics.

e prognosis for visual improvement is poor

despite treatment. Patients with a history of alcoholism, car-

diovascular disease, and diabetes mellitus are at increased

risk of endogenous bacterial endophthalmitis.

Patients with

endogenous bacterial endophthalmitis should be evaluated

for endocarditis. e hypopyon in this patient indicates leu-

kocytes within the anterior chamber of the eye, which war-

rants emergent evaluation by an ophthalmologist.

Acute glaucoma is an ocular emergency. It presents with

a mid-dilated xed pupil with severe eye pain and a prom-

inent ciliary ush. Patients also report nausea, vomiting,

cloudy vision, seeing rings around lights, and headache.

Acute glaucoma is caused by anterior chamber angle clo-

sure in the aected eye, leading to an increased intraocular

pressure of more than 40 mm Hg. Hypopyon is not seen

in patients with glaucoma. Patients should be emergently

referred to an ophthalmologist. Patients should not receive

topical steroids or antibiotics because these treatments may

lead to infection or corneal ulceration.

Behçet syndrome is a multisystem inammatory disor-

der. e classic presentation is painful mucocutaneous sores

in the mouth, anterior uveitis, genital sores, and pathergy

(skin rashes resistant to healing). e cause is unknown but

may be genetic. Diagnosis is based on the presence of recur-

rent oral ulcers and at least two of the other classic ndings.

Hypopyon may occur in 10% to 30% of patients who have

Behçet syndrome with anterior uveitis. Behçet syndrome is

treated with immunomodulatory therapy and systemic cor-

ticosteroids if the patient reports vision changes.

Most corneal ulcers are caused by direct minor trauma to

the eye, such as from contact lenses. e area may become

infected with bacteria, viruses, or fungi, usually secondary to

the breakdown of the protective epithelial barrier of the eye.

Patients with corneal ulcers present with decreased

visual

acuity, photophobia, and conjunctival injection. Patients

should be referred to an ophthalmologist. If consultation or

referral is not available within hours, it is reasonable to obtain

cultures and start ophthalmic antibiotics immediately.

Pseudohypopyon is the accumulation of neoplastic cells

in the anterior chamber of the eye that usually occurs in

patients with lymphoma, leukemia, or retinoblastoma. It

may be the only presenting feature of recurrent lymphoma,

even in the setting of negative imaging and cerebrospinal

uid ndings. Diagnosis can be conrmed with ow cytom-

etry of an anterior chamber aspirate. Patients with bilateral

pseudohypopyon have a poor prognosis.

The opinions and assertions contained herein are the private

views of the authors and are not to be construed as ocial or as

reﬂecting the views of the U.S. Air Force Medical Department or

the U.S. Air Force at large.

Address correspondence to Ayodeji Alaketu, MD, at ayodeji.f.

alaketu.mil@ mail.mil. Reprints are not available from the authors.

References

1. Jackson TL, Paraskevopoulos T, Georgalas I. Systematic review of 342

cases of endogenous bacterial endophthalmitis. Surv Ophthalmol.

2014; 59(6): 627-635.

2. Jenkins TL, Talcott KE, Matsunaga DR, et al. Endogenous bacterial

endophthalmitis. Ocul Immunol Inﬂamm. 2020; 28(6): 975-983.

3. Nishida T, Ishida K, Niwa Y, et al. An eleven-year retrospective study of

endogenous bacterial endophthalmitis [published online January 31,

2015]. J Ophthalmol. Accessed August 4, 2020. https:// www.hindawi.

com/journals/joph/2015/261310/

4. Huang JJ, Gaudio PA, eds. Ocular Inﬂammatory Disease and Uveitis:

Diagnosis and Treatment. Lippincott Williams & Wilkins; 2010.

5. Goroll AH, Mulley AG, eds. Primary Care Medicine: Oce Evaluation and

Management of the Adult Patient. 7th ed. Wolters Kluwer Health; 2014.

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2014; 90(10): 711-716. Accessed January 6, 2022. https:// www.aafp.org/

afp/2014/1115/p711.html

7. Domino FJ, ed. 5-Minute Clinical Consult. 21st ed. Lippincott Williams

& Wilkins; 2013.

8. Dorrepaal SJ, Margolin EA, Wang C. Bilateral pseudohypopyon as

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roophthalmol. 2010; 30(1): 67-69. ■

SUMMARY TABLE

Condition Characteristics

Acute glaucoma Severe eye pain and prominent ciliary ﬂush; nausea,

vomiting, cloudy vision, rings around lights, headache

Behçet

syndrome

Classically presents with recurrent painful mucocu-

taneous sores in the mouth, anterior uveitis, genital

sores, and pathergy

Corneal ulcer Infection of cornea usually secondary to minor

trauma such as from contact lenses; decreased visual

acuity, photophobia, conjunctival injection

Endogenous

bacterial

endophthalmitis

History of recent bacteremia; decreased vision,

eyelid edema, pupillary abnormalities, hypopyon,

conjunctival injection

Pseudohypopyon Accumulation of neoplastic cells in the anterior

chamber of the eye; usually occurs in patients with

lymphoma, leukemia, or retinoblastoma