OSLI Retina

May/June 2013

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■ C A S E Hypopyon and Pseudoendophthalmitis 1 Month After Vitrectomy for Retinal Detachment With Subretinal Hemorrhage Zayna Nahas, MD; Gary Shienbaum, MD; William E. Smiddy, MD; Harry W. Flynn Jr., MD ABSTRACT: The presence of postoperative hypopyon warrants consideration of the diagnosis of infectious endophthalmitis, but other etiologies may mimic a hypopyon. The differential diagnosis of a postoperative hypopyon must include causes of pseudoendophthalmitis to avoid unnecessary and invasive interventions. The context and clinical presentation are the most important factors allowing such a distinction. A patient with a hypopyon and elevated intraocular pressure presented 1 month after pars plana vitrectomy for a hemorrhagic retinal detachment. Slit lamp examination disclosed khaki-colored cells layered in the anterior chamber, and a diagnosis of pseudoendophthalmitis was made. The hypopyon resolved without intervention. [Ophthalmic Surg Lasers Imaging Retina. 2013;44:281-283.] From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida. Originally submitted February 8, 2013. Accepted for publication March 5, 2013. The authors have no financial or proprietary interest in the material presented herein. Address correspondence to Harry W. Flynn Jr., MD, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136; 305-326-6118; Fax: 305-326-6417; Email: hflynn@ med.miami.edu. doi: 10.3928/23258160-20130503-13 May/June 2013 · Vol. 44, No. 3 R E P O R T ■ INTRODUCTION The incidence of endophthalmitis after pars plana vitrectomy is about 0.02%.1 Early recognition and intervention are necessary to optimize visual outcomes. A hypopyon is one of the hallmark clinical features of endophthalmitis. Its presence should alert the physician to the possibility of endophthalmitis.2 However, some conditions may mimic a hypopyon, and there are noninfectious causes of hypopyon such as accumulation of triamcinolone crystals, malignancy, and dehemoglobinized blood from previous vitreous hemorrhage.3-15 Distinguishing true infectious endophthalmitis from pseudoendophthalmitis requires a focused history, careful clinical examination, and awareness of the clinical setting. Patients with endophthalmitis typically present with pain, redness, and marked loss of vision in close proximity to a surgical intervention. Commonly associated clinical findings include conjunctival injection, fibrinous anterior chamber reaction, hypopyon or pseudohypopyon, and vitritis.2,16 We recently encountered a patient with pseudoendophthalmitis due to dehemoglobinized blood in the anterior chamber that appeared 1 month after vitrectomy for hemorrhagic retinal detachment and vitreous hemorrhage. CASE REPORT A 42-year-old man presented to the emergency department after his wife noticed a "white line" in his right eye. One month previously he had undergone pars plana vitrectomy for hemorrhagic retinal detachment and severe vitreous hemorrhage. Silicone oil tamponade had been utilized in this phakic eye. The patient denied a recent change in vision, pain, or discharge. Visual acuity was hand motion, intraocular pressure was 31 mm Hg, and slit lamp examination revealed minimal conjunctival injection, a clear cornea, a 2-mm khaki-colored "hypopyon" with 4+ khaki circulating cells without fibrin, and 2+ nuclear sclerosis (Figure). The view to the posterior pole was hazy, and silicone oil precluded echography. He had been examined within the previous week with a similarly limited view and poor visual acuity but no layering of anterior chamber cells. The insignificant conjunctival injection, the lack of corneal edema, and the absence of pain in conjunction with the atypical time course and appearance of the apparent hypopyon suggested a noninfectious etiology. 281

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