Segmental retinal arteritis in a case of presumed bilateral rifabutin-associated hypopyon uveitis.

Purpose: To describe the presentation and clinical course of bilateral hypopyon uveitis and subsequently diagnosed segmental retinal arteritis in an immunocompromised patient treated with intravitreal and systemic antibiotics while on rifabutin therapy for pulmonary tuberculosis (TB). Observations: A 63-year-old female from West Africa with a past medical history of HIV/AIDS, hepatitis B, and pulmonary TB presented with pain and acute vision loss in the left eye for two days. She was compliant with her treatment regimen for HIV and maintenance therapy for TB including rifabutin. Ocular examination revealed hypopyon uveitis in the left eye (OS). She was treated with broad spectrum systemic antimicrobials, topical prednisolone acetate, and intravitreal injections of vancomycin, ceftazidime, voriconazole, and ganciclovir, with resolution of hypopyon OS in 3 days. Aqueous sampling and systemic workup were unrevealing for causative infection. Two weeks later, she returned with a nearly identical presentation in the right eye (OD) with hypopyon uveitis and was again treated with intravitreal antibiotics. Anterior segment inflammation OD quickly improved after initiation of topical prednisolone acetate 1 % to reveal segmental retinal arteritis on fundus examination. As aqueous sampling was negative for infectious causes, she was diagnosed with presumed rifabutin associated-hypopyon uveitis in both eyes (OU) and segmental retinal arteritis OD, which has not been described previously with rifabutin use. Rifabutin was discontinued and there were no recurrences of uveitis over nine months of follow-up. Conclusions and importance/implications: Uveitis is an uncommon dose-related toxicity of rifabutin therapy. Segmental retinal arteritis (SRA) may be a rare finding when there is posterior segment involvement, especially in patients with concurrent TB infection. This report highlights a case of delayed bilateral hypopyon-uveitis and expands the presentation to include SRA. Patients treated with rifabutin should be counseled on signs and symptoms of uveitis. Development of rifabutin-associated uveitis may require medication discontinuation.

The Dilemma of Balancing Anti-Tumor Necrosis Factor-Alpha (Anti-TNF-α) Biologics for Psoriatic Arthritis Control With the Risk of Severe Systemic Infection.

The treatment landscape for psoriatic arthritis (PsA) has evolved significantly with the introduction of biologic therapies, such as adalimumab, which effectively inhibits tumor necrosis factor-alpha (TNF-α) activity. However, despite their efficacy in controlling inflammation, biologic therapies are associated with heightened risks of infectious complications and malignancies. We present a case of a 66-year-old female with PsA treated with adalimumab who presented with recurrent systemic bacterial infections. Despite attempts to adjust dosing intervals to minimize infection risks, the patient experienced severe complications, including urosepsis, endocarditis, and liver abscesses. The dilemma arises in balancing PsA control with anti-TNFα therapy while minimizing infection risks. Current evidence supporting prophylactic antibiotics in such cases is limited, and determining the next steps for treatment involves challenging decisions such as withholding TNF inhibitors or switching to alternative immunomodulators. This case underscores the need for further research into prophylactic treatment and monitoring protocols to manage recurrent infections during anti-TNF-α therapy effectively.

A Case Report of Fedratinib-Associated Uveitis.

Drug-induced uveitis is a rare but important subgroup of uveitis particularly among newer drugs in the market. Establishing a diagnosis can be challenging and requires the physician to have a high index of suspicion and a holistic approach with consideration being afforded to history, clinical examination, and investigations. In this case report, we describe a case of hypopyon uveitis in a 64-year-old male with a background of myelofibrosis for which he was started on fedratinib. A thorough history, negative investigation panel, and temporal association between the start of the drug and uveitis helped establish the diagnosis. A literature review showed no other published cases of uveitis secondary to fedratinib. While he could not be withdrawn from the drug, collaboration with the medical team enabled close monitoring and follow-up. He recovered following a course of steroids and remains under observation.

The Presence of Pigmentation on Central Anterior Lens Capsule in the Human Leukocyte Antigen B27-Associated Anterior Uveitis and Its Value in Clinical Diagnosis.

PURPOSE: To report on the value of presence of pigmentation on central anterior lens capsule (PioLe) in HLA B27- associated anterior uveitis (HLA B27-AU). METHODS: 268 patients (320 eyes) with AU were reviewed. Two diagnostic models to predict probability of HLA-B27-AU were developed. The first model included 6 variables (age, gender, unilaterality, presence of non-granulomatous keratic precipitates, hypopyon, and intraocular pressure (IOP). The second model was developed to investigate the added value of PioLe into the first model. RESULTS:      Unilaterality, presence of hypopyon, IOP <21 mmHg and PioLe were characteristic for HLA-B27 positive patients (P≤0.003 for all). All of 6 variables had area under receiver operating characteristic curves (AuROC) ≤ 60, but PioLe reached even higher value (65.5). Diagnostic model I and II had AuROC 76.3% (95%CI, 68.4%-84.2%) and 80.0% (95%CI, 72.6%-87.5%), respectively. CONCLUSIONS: Unilaterality, hypopyon, IOP <21 mmHg and presence of PioLe are clinical signs suggesting HLA B27- AU.

Stenotrophomonas maltophilia endophthalmitis following keratoplasty.

Endophthalmitis is among the most sight-threatening infections in ophthalmology practice. Many microorganisms causing endophthalmitis have been reported. Stenotrophomonas maltophilia is among the rare causes of endophthalmitis and has been reported after cataract surgery, intravitreal injections and ocular trauma. We report a case of S. maltophilia endophthalmitis after keratoplasty, which is a rare entity, in a 63-year-old female patient.

The Epidemiological Profile and Predisposing Factors of Microbial Keratitis Over a 10-Year Period at a Tertiary Hospital in Central Saudi Arabia.

PURPOSE: To evaluate the demographic and predisposing factors and clinical presentation of microbial keratitis (MK) patients over 10 years at a tertiary hospital in central Saudi Arabia. METHOD: In 2020, a retrospective review of data from clinical and pathology departments from 2010 to 2019 was conducted. Demography includes age, gender, residence, and the risk factor of microbial keratitis, clinical features, and organism profile as number and percentage. RESULT: We reviewed 181 eyes of 179 patients with microbial keratitis. The mean age was 40.1 years. Contact lens usage (55; 30%), ocular trauma (30; 16.5%), and ocular surface diseases (42; 23.2%) were the main predisposing factors. Hypopyon was noted in 60 (33%) eyes, impaired vision at presentation was observed in 78 (43%) eyes, and endophthalmitis with microbial keratitis was noted in eight (4.4%) eyes at presentation. Ninety-eight (54,1%) cases were culture positive, while gram-positive organisms were seen in 50 (27.6%) eyes, gram-negative organisms in 35 (19.3%) patients, and fungi in 13 (7.2%) patients. Microbial keratitis was central in 67 (37%), paracentral in 94 (52%), and peripheral in 20 (11.3%) patients. All instances of fungal keratitis occurred in the eyes of men who work in the agriculture field. CONCLUSION: Standard operating procedures to manage microbial keratitis at primary and secondary eye care levels are recommended. Health promotion to prevent trauma, appropriate use of contact lens, and early treatment could prevent the incidence of microbial keratitis.

A novel terminologic "naming-meshing" system using anterior chamber sedimentation for early diagnosis and prompt treatment of ocular or systemic diseases: is it hypopyon or pseudohypopyon?

A novel, algorithmic "naming-meshing" system was introduced for the distinction of hypopyon from pseudohypopyon to make an early diagnosis and prompt treatment of anterior chamber collection standardized to encompass all sediment characteristics. For this reason, a literature review of "hypopyon" and "pseudohypopyon" was conducted in MEDLINE/PubMed, Scopus, and Web of Science from 1966 to May 15, 2023. Two issues were clarified: 1) which strategies should the ophthalmologist follow when asked to evaluate an eye with anterior chamber sedimentation to distinguish hypopyon from pseudohypopyon, and 2) in which systemic disorders should a non-ophthalmologist order a prompt ophthalmic consultation to distinguish pseudohypopyon from hypopyon. Pathognomonic characteristics of the sediment were examined; scleral show (warm/cold), location (corneal/anterior chamber/capsular/posterior), visibility (macro/micro/occult-angle), orientation (horizontal/vertical/oblique), number (single/double), shape (convex/triangular/pyramidal/ring/lumpy/inverse), and color (white/yellow/pink/brown/black). Associated findings were then assessed; acute/chronic, spontaneous/provoked, unilateral/bilateral, inflammatory/non-inflammatory, suppurative (non-sterile)/non-suppurative (sterile), granulomatous/non-granulomatous, recurrent/non-recurrent, shifting/non-shifting, and transient/persistent. The type of precipitation was named (naming) and matched (meshing) to a potential list of etiologies (inflammatory, infective, therapeutic, masquerades). Given that (pseudo)hypopyon predominantly afflicts younger patients in their most productive years, clinicians supervising such patients should be aware of all sediment characteristics. The ophthalmologist should never ask non-ophthalmologists to run the full battery of tests in a patient with (pseudo)hypopyon, and rather indicate which type of collection is present, what its pathognomonic feature is, and what the most likely diagnoses to be excluded are.

Endogenous listeria monocytogenes endophthalmitis in a cirrhotic patient.

Endogenous endophthalmitis caused by listeria monocytogenes is rare and serious, which is easily misdiagnosed initially. We present one case of endogenous endophthalmitis due to listeria monocytogenes in a cirrhotic patient, whose diagnosis was delayed 17 days after admission.

Intraocular foreign body presenting as recalcitrant hypopyon anterior uveitis.

A 38-year-old male with a history of trauma presented to us with pain and decreased vision in the left eye (LE). Previously, the patient had been diagnosed with hypopyon uveitis and was prescribed topical steroids. We performed slit-lamp examination of the LE and found exudates in the anterior chamber (AC) extending from 6 to 9 o'clock, along with circumciliary congestion and pigmented keratic precipitates. We made a diagnosis of infectious anterior hypopyon uveitis; however, all of its causes were ruled out upon the necessary investigations, which returned normal results. The patient was started on topical and oral antibiotics, and subsequently, there was complete hypopyon resolution. Five months later, he presented with similar complaints. An examination revealed a black elevated lesion in the AC at 8 o'clock suspicious of an intraocular foreign body (IOFB), along with 1 mm hypopyon. An X-ray orbit examination confirmed the IOFB presence, and the IOFB was surgically removed from the AC. Three weeks after this surgery, the patient presented with a recurrence of similar symptoms. The nasal pterygium adjacent to the location of the previously removed IOFB was inflamed with an underlying black elevated limbal nodule, which was determined to likely be a remnant of the IOFB in the subconjunctival space. Here, we report a case of penetrating IOFB that was initially detected in the AC. Its remnant extraocular component persisted in the subconjunctival space, and its incomplete removal led to recurrent inflammation.

Intraocular Spread of Ocular Surface Squamous Neoplasia Presenting as a Postoperative Anterior Chamber Opacity after Excisional Biopsy.

We describe a rare case of ocular surface squamous neoplasia (OSSN) with intraocular spread after excisional biopsy which presented as a postoperative anterior chamber (A/C) opacity, initially thought to be a hypopyon. A 60-year-old female with history of a right (OD) conjunctival mass involving the cornea, surgically excised and diagnosed as OSSN, presented 2 months postoperatively with an A/C opacity concerning for infection. The patient was prescribed prednisolone acetate and ofloxacin drops postoperatively; topical chemotherapy was not given. When the opacity did not respond to 3 weeks of topical treatment, they were referred to an ocular oncologist for management. Intraoperative records from biopsy were unavailable; use of cryotherapy is unknown. On presentation, the patient had reduced vision OD. On slit-lamp exam, a white plaque in the A/C was seen, obscuring the iris. Given concern for postoperative intraocular cancer spread and extent of disease, enucleation with extended conjunctival excision was done. Gross pathology revealed an A/C mass with a diffuse hazy membrane. Histopathology diagnosed moderately differentiated OSSN with extensive intraocular invasion; a full-thickness limbal defect was visualized. Disease was confined to the globe, without residual conjunctival malignancy. This case emphasizes the importance of taking surgical precaution when excising conjunctival lesions, especially large lesions which obscure ocular anatomy, to maintain scleral integrity and Bowman's layer with limbal lesions. Intraoperative cryotherapy and postoperative chemotherapy should also be employed. If a patient with history of ocular surface malignancy displays symptoms concerning postoperative infection, this case highlights the importance of considering invasive disease.

Intensive care unit presentation of central corneal descemetocele secondary to Methicillin-Resistant staphylococcal infection superimposed by a hypopyon: a case report.

A descemetocele is a rare type of keratopathy that occurs when an intact descemet's membrane of the eye undergoes a herniation through an overlying stroma. Previous literature has documented corneal damage via bacterial enzymes, especially, Pseudomonas and Neisseria species. Most recent prospective interventional studies showed treatment of these infections. Case presentation: This report presents the first instance of a methicillin-resistant Staphylococcus aureus descemetocele presentation in a 51-year-old African American male, with co-presenting hypopyon sequelae successfully managed conservatively in an intensive care unit setting. Clinical discussion: An instance of a methicillin-resistant Staphylococcus aureus has not yet been documented in the literature. Likewise, a co-presentation with a hypopyon, which is known as a formation of inflammatory debris rich in white blood cells has not been studied. Conclusion: The presence of a hypopyon in the instances of bacterial descemetocele herniation should be further evaluated to see if there are associations with conservative, nonsurgical intervention outcomes.

Bilateral Endogenous Endophthalmitis Secondary to Streptococcus pneumoniae: An Uncommon but Devastating Complication.

Endophthalmitis is an infection of the vitreous and/or aqueous humours, caused by bacteria or fungi, and can be either exogenous (resulting from trauma or intraocular procedures) or endogenous (hematogenous in origin). Although less common than exogenous endophthalmitis, endogenous endophthalmitis can have serious, vision-threatening consequences. Streptococcus pneumoniae is a rare cause of endogenous endophthalmitis and is associated with a poor prognosis. In this report, we present a rare case of pneumococcal endogenous endophthalmitis that led to a devastating outcome despite both medical and surgical interventions. Early systemic treatment and prompt identification of the primary source are crucial and potentially life-saving.

Diagnostic and therapeutic challenges in non-specific orbital inflammation - a case report.

Objective: The aim of this report is to present the diagnostic and therapeutic approach in a case of non-specific orbital inflammation complicated with sight-threatening exposure keratopathy. Case presentation: An 81-year-old female patient presented to our Ophthalmology Department for left, painful, unilateral exophthalmia and decreased vision in the same eye. The clinical examination revealed left proptosis, inferior dystopia, upper lid edema, erythema and moderate retraction, ocular motility restriction, chemosis and corneal epithelial defect. The keratopathy complicated in evolution with hypopyon. The patient received treatment for the exposure keratopathy and, after every specific cause of unilateral exophthalmia was ruled out using imagistic and laboratory examinations, systemic corticosteroid treatment was initiated. Although the response to treatment was prompt, it was incomplete because of the long-standing evolution. Discussions: In this case, the diagnosis was difficult because a malignant breast tumor was encountered and an orbital biopsy was impossible to be performed. The presence of exposure keratopathy complicated with hypopyon imposed the exclusion of an infectious process and delayed the initiation of the corticosteroid therapy. Conclusions: The diagnosis and treatment of this disease represent a challenge given the need to rule out all the local and systemic conditions that may present with exophthalmia.

[Clinical features and treatment of endophthalmitis after cataract surgery]. / Klinicheskie osobennosti i lechenie endoftal'mita posle khirurgii katarakty.

PURPOSE: The study analyzes the frequency of acute endophthalmitis occurrence after cataract surgery, the risk factors, characteristic symptoms, and the effectiveness of peri-operative prevention measures. MATERIAL AND METHODS: The study retrospectively analyzed 59 670 cases of patients operated for cataract in 2017-2021. To prevent infections, patients received four instillations of third generation fluoroquinolone (quinolone antibiotic) in the course of two days prior to cataract phacoemulsification (PE), and two instillations immediately (1 hour and 30 minutes) before the surgery; three-minutes treatment of the cornea, conjunctival sac and periocular skin with 5% povidone iodine before the surgery; and as the last step of surgery, patients received subconjunctival injection of 0.05 g cefazolin with 2 mg dexamethasone. Follow-up after surgery included four injections of 0.5% levofloxacin in the course of 7-10 days, and 0.1% dexamethasone for two weeks, or fixed combination of tobramycin and dexamethasone four times per day for two weeks. The criteria for acute endophthalmitis are: loss of spatial vision, absence of red reflex, pronounced thickening of the choroid, suspended particulates in the retrovitreal space and the vitreous observed with ultrasonography in the early postoperative period (day 4-7 after surgery). RESULTS AND DISCUSSION: There were 32 patients (0.054%) diagnosed with acute endophthalmitis. Posterior capsule rupture was the main complicative risk factor of endophthalmitis development (OR=11.75, p=0.026). Main diagnostic criteria of acute endophthalmitis were hypopyon (OR=22.5, p=0.001) and absence of red reflex (OR=19.59, p<0.001). The use of the fixed combination of tobramycin and dexamethasone was associated with 5.8-times higher risk of acute endophthalmitis than separate application of levofloxacin and dexamethasone (p=0.042). CONCLUSIONS: Povidone iodine and third generation fluoroquinolone as a method of acute endophthalmitis prevention after cataract surgery demonstrate comparable efficacy to intracameral antibiotic injections.

Infectious Endophthalmitis vs Noninfectious "Pseudohypopyon" After Intravitreal Triamcinolone Acetonide.

Introduction: To describe a patient who presented with visual loss and an apparent hypopyon but none of the other symptoms or signs most common with infectious endophthalmitis. Methods: A case and its findings were analyzed. Results: A 73-year-old woman was treated with intravitreal triamcinolone acetonide (IVTA) for cystoid macular edema. The eye had 12 previous injections without complication. After the 13th injection, the patient noted painless visual loss. An examination showed a visual acuity (VA) of finger counting and an apparent hypopyon, which shifted after a head-tilt test, suggesting a noninfectious "pseudohypopyon." Two days later, the VA worsened to hand motions and the hypopyon had increased in size. The eye was treated with a vitreous tap and injection with vancomycin and ceftazidime. The inflammation resolved, VA improved to 20/40, and cultures showed no growth. Conclusions: Distinguishing infectious endophthalmitis from noninfectious inflammation remains challenging. There is no definitive technique by which to distinguish between the 2 conditions; thus, clinicians must use their best judgment and follow the patient closely.

Twenty Years of Quiescence after Nonstop Remicade® (Infliximab) Infusions in a Child with Ocular Behçet Disease Presenting as Hypopyon-Anterior Uveitis Refractory to Immunosuppressants.

I report a case with ocular Behçet disease presenting as hypopyon-anterior uveitis refractory to conventional immunosuppressive drugs who was safely and effectively managed for 20 years by nonstop infusions of a modern anti-TNF agent, infliximab. A 14-year-old girl who had a history of recurrent oro-genital ulcers, arthralgia, and pathergy test positivity presented with the symptoms of bilateral blurred vision, ocular pain, photophobia, and lacrimation. Initial visual acuities were 20/25 bilaterally, and biomicroscopy revealed bilateral iridocyclitis with left shifting cold hypopyon formation in the anterior chamber of the eye. The diagnosis of ocular Behçet disease was made, and topical anti-inflammatory drops were initiated with a cycloplegic agent. In due course, the child complained of chronic floaters and decreased vision from 20/25 to 20/200 bilaterally. Vitreitis, retinitis, perivasculitis, and cystoid macular edema (CME) were encountered, and the combination of corticosteroid, azathioprine, and cyclosporine-A was immediately started. However, the child did not respond to this conventional management for 3 months. A prompt and dramatic response was obtained with repeated Remicade® (infliximab) infusions (weeks 0, 2, 6, and 10), which led to fast improvement in her systemic and ocular symptoms. Long-term remission of 20 years was obtained by regular infliximab infusions at each 6- to 9-week interval with stabilized vision (20/20) and resolution of CME. The present case shows the significant role of biologicals in pediatric severe panuveitis and that nonstop infliximab infusions initiated early led to rapid and long-term control of intraocular inflammation and recurrent sight-threatening uveitis attacks for protecting the vision in children with severe OBD.

A Case of Syphilis with a Rare Finding: Subretinal Hypopyon.

PURPOSE: To report clinical features and follow-up of a case with subretinal hypopyon due to syphilis infection. CASE PRESENTATION: We present a case of syphilis admitted with optic neuritis and treated with intravenous pulse steroids without antibiotics. The patient was referred to the uvea clinic in the follow-up because of decreased vision and the onset of multiple retinitis foci. We determined subretinal hypopyon in the left eye and a positive TPHA test. A significant regression was observed in retinitis and hypopyon with antibiotic therapy. CONCLUSION: Before starting a steroid treatment, infective etiologies should be considered in patients with optic neuritis. Treating with a high dosage of steroids without antibiotics in syphilis would worsen the clinical features and prognosis.

Oral Lymphangiomas: A Rare Presentation of Two Cases with Dermoscopic Findings.

Lymphangiomas are benign hamartomatous malformations, infrequently seen in the oral cavity. They can cause aesthetic issues and functional impairments if not treated in the initial stages, thus necessitating the need to diagnose early. Two presentations were observed: a 35-year-old male with classical frog-egg appearance involving lower buccal mucosa with macrocheilia for two years, which was diagnostic on mucoscopy and histopathology, confirming acquired capillary lymphatic malformation. The second case was of a 12-year-old girl with a gradual appearance of reddish lesions over the tongue and episodic history of bleeding, which was confirmed on mucoscopy, and histopathology is highlighted. Mucoscopy of both the cases showed yellowish-pink lacunae with a hypopyon-like feature and surrounding pale septa. We present two cases of oral lymphangiomas with different presentations and highlight the importance of dermoscopy of oral lesions to bypass invasive techniques such as biopsy.