Definition

Hypopyon is an accumulation of white blood cells in the anterior chamber of the eye (ANC), indicating severe inflammation of other eye structures. It is not a diagnosis but a symptom. If you have hypopyon, you may see white fluid in the black part of your eye when looking in the mirror.

Causes

Hypopyon can result from both infectious and non-infectious conditions.

• Endophthalmitis, or inflammation of the entire eye layer.
• Keratitis, or inflammation of the cornea.
• Toxoplasma infection
• Syphilis infection
• HSV infection

Non-infectious conditions that can cause hypopyon:

• HLA-B27 associated diseases
• Behçet's disease
• Spondyloarthropathy
• Malignancy/trauma/medical procedures

In non-infectious cases, hypopyon typically stems from inflammation of the uvea layer, termed anterior uveitis. Here are conditions often leading to hypopyon.

Keratitis

Keratitis, or corneal inflammation, can be bacterial (e.g., P. aeruginosa, S. aureus, S. pneumoniae, Enterobacteriaceae), viral (e.g., Herpes simplex virus, varicella-zoster virus), or fungal. Bacterial and fungal keratitis can significantly damage the cornea and create cavities in the corneal layer, causing vision impairment and hypopyon. Severe inflammation can cause white blood cells that aim to deal with the inflammation to leave the blood vessels and settle in the AMC. 

Endophthalmitis

Endophthalmitis is inflammation within the eyeball, including the vitreous humor, the fluid behind the iris. Typically infectious, it can also be non-infectious (endogenous endophthalmitis). The blood-eye barrier usually protects the eye from pathogens, but damage from surgery, trauma, or malignancy can cause the infection to spread, causing potential permanent blindness.

Anterior Uveitis

Anterior uveitis is an inflammation that affects the uvea layer at the front of the eyeball, including the iris and ciliary body. The iris is one of the layers of the uvea located on the front (anterior) side. Causes include autoimmune conditions (e.g., SLE, juvenile rheumatoid arthritis, sarcoidosis), genetics, trauma, and infections, though many cases are idiopathic. Autoimmune conditions associated with anterior uveitis are SLE (4.8%), juvenile rheumatoid arthritis (5.6%), and sarcoidosis (9.6%).

Risk Factor

The risk factors for hypopyon depend on the underlying condition:

Keratitis

• Use of contact lenses
• Eyeball trauma
• Previous eye surgery
• Exposure to organic materials (plants, rice, weeds)
• Decreased immunity
• Use of corticosteroids

Endophthalmitis

• Eyeball trauma
• Non-sterile trauma treatment
• Lens rupture
• Age >50 years
• Delayed medical attention after trauma
• Post-cataract surgery

Anterior Uveitis

• Autoimmune disease
• Family history of anterior uveitis or other autoimmune diseases

Symptoms

Hypopyon manifests as a visible white fluid in the black part of the eye. Symptoms vary with the underlying condition.

Keratitis

Apart from hypopyon, you can experience:

• Eye redness
• Eye pain
• Persistent watery eyes
• Thick discharge (white, yellow, or green)
• Blurred vision
• Photophobia
• Foreign body sensation in the eye

Endophthalmitis

Apart from hypopyon, you can experience:

• Sudden severe vision loss
• Eye redness
• Intense eye pain
• Swollen eyelids
• Persistent watery eyes
• Inability to perceive light

Anterior Uveitis

Apart from hypopyon, you can experience:

• Eye redness
• Blurred vision
• Floaters
• Photophobia

Diagnosis

To diagnose hypopyon, the doctor will start by taking a comprehensive medical history, focusing on when the hypopyon appeared, any events that might have triggered it, and the associated risk factors. The doctor will inquire about the presence of decreased visual acuity and possible infectious or non-infectious causes. The doctor will also ask about personal or family history of autoimmune diseases, history of prior eye surgery, medications currently being taken, and any history of eye trauma.

During the physical examination, the doctor will assess visual acuity and examine the eyeballs using a slit lamp or funduscopy. A fluorescein examination might be conducted to check for corneal damage. If a systemic disease is suspected, additional tests such as a complete blood count, urine test, chest radiology, and tests for other infections might be ordered.

Management

Treatment for hypopyon depends on the underlying condition:

Keratitis

• For non-infectious keratitis (e.g., caused by corneal scratches), observe for a few days and you can use artificial tears in the meantime. However, if pain and watering occur, close the eyes by wearing eye patches for 24 hours.
• In infection keratitis, the treatment relies on the causes:
• Bacterial keratitis: Antibiotic eye drops or oral antibiotics for severe cases.
• Fungal keratitis: Antifungal medications.
• Viral keratitis: Antiviral eye drops and oral antiviral drugs.
• If keratitis does not improve with treatment and vision is severely impaired, a corneal transplant may be necessary.

Endophthalmitis

Treatment depends on the infected area. Antibiotics may be administered via injection directly into the eyeball. Corticosteroids can be added to reduce swelling. Any foreign object in the eye will be removed by the doctor; self-removal should be avoided. Generally, treatment is operative and performed by an eye specialist.

Anterior Uveitis

The treatments to be given include:

• Medications to reduce inflammation, such as corticosteroids
• Medications to control spasms by dilating the pupil to reduce pain.
• Antibiotics if the condition is caused by bacterial infections.

Potential side effects of treatment include glaucoma. In addition, surgical treatments such as vitrectomy, may be considered.

Complications

Complications of hypopyon depend on the underlying disease:

• Keratitis can lead to corneal ulceration and permanent vision loss. Other potential complications include glaucoma, synechiae (iris adhesion to the lens or cornea), endophthalmitis, and cataracts.
• Endophthalmitis can result in permanent vision loss, and in severe cases, enucleation (removal of the eyeball) may be necessary to prevent ongoing infection.
• Anterior uveitis, if left untreated, can cause retinal swelling, glaucoma, cataracts, optic nerve damage, retinal detachment, and permanent vision loss.

Prevention

• Regularly clean contact lenses, avoid sleeping in them, and ensure hands are clean before handling.
• Replace contact lenses every 3-6 months.
• Avoid wearing contact lenses while swimming.
• Use medications only as prescribed.
• Wash hands thoroughly (WHO 5 steps) before touching the eyes.
• Wear protective eyewear during activities that pose a risk to the eyes, such as woodworking, welding, or sports. Suitable eye protection includes goggles, eye shields, and helmets.
• Follow postoperative instructions meticulously after eye surgery.

When to See a Doctor?

Seek immediate medical attention if you experience:

• Hypopyon.
• Signs of keratitis, endophthalmitis, or uveitis.
• Sudden decreased vision.
• Red eyes, pain, and sudden decreased vision after cataract surgery or eye trauma.
• Decreased vision with a known autoimmune disease.

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