Man presents with blurry vision, discomfort after contact lens use
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A 70-year-old man presented to the New England Eye Center with 1 day of blurry vision in the right eye, as well as a feeling of dryness and slight discomfort. He reported a history of contact lens use only in the right eye.
One week before presentation, the patient had inserted a contact lens in his right eye before playing tennis and subsequently forgot to remove it and slept with it in place. His medical history was remarkable for hypertension and cutaneous T-cell lymphoma. His ocular history included ciliary body melanoma treated with a radiation plaque in his right eye. His ocular surgical history included cataract extraction in both eyes. His medications included lisinopril, finasteride and tamsulosin. He did not have any medication allergies. His family history was noncontributory.
Examination
At the initial examination, the patient’s vision was 20/400 in the right eye, decreased from a baseline of 20/50. His pupils were equal in size, round and reactive to light, without an afferent pupillary defect. Extraocular movements were full. IOP was 14 mm Hg in the right eye.
The initial slit lamp exam of the right eye was significant for 4+ conjunctival injection and a contact lens still in place. Once the contact lens was removed, an epithelial defect measuring 7.5 mm vertically by 5 mm horizontally with a small infiltrate superiorly and two infiltrates in the inferior cornea were noted (Figure 1). The infiltrate in the inferior periphery measured around 1 mm, and another was located slightly more superiorly, paracentrally measuring around 0.5 mm. There was a question of a focal hyphema associated with both inferior infiltrates due to an area that had a pinkish appearance. There was also a hypopyon and diffuse fibrin throughout the anterior chamber. The view to the posterior pole was difficult, thus a B-scan ultrasound was obtained, with findings reassuring against vitritis (Figure 2).
Source: Eleni K. Konstantinou, MD, and Lisa V. Sitterson, MD
Examination of the left eye was unremarkable.
What is your diagnosis?
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Pink hypopyon
After removal of the contact lens, our patient was found to have a large epithelial defect with small corneal infiltrates. The associated hypopyon had an interesting appearance with focal pinkish discoloration.
Our differential diagnosis included infectious keratitis with a pink hypopyon vs. infectious keratitis with an associated hypopyon and hyphema. In the latter case, neovascularization of the iris could cause a reddish appearance of the hypopyon. However, no neovascularization of the iris was seen. A hemorrhagic response in uveitis, which can be seen with HLA-B27-associated anterior uveitis, can also lead to a pinkish appearance of a hypopyon. Or, an infectious process could have led to extensive necrosis and hemorrhage. A B-scan ultrasound did not demonstrate any vitritis, thus the extent of the process was most likely limited to the anterior segment. Due to the history of the forgotten contact lens, the presence of the epithelial defect over the stromal infiltrate and the associated hypopyon, the most likely diagnosis was corneal ulceration with anterior chamber involvement. The ulcerated area was swabbed and cultured, and the patient was advised to abstain from contact lens use. He was started on fortified vancomycin and tobramycin drops every hour around the clock. The culture returned positive for gram-negative rods, and the organism was found to be Serratia marcescens, which was susceptible to ceftazidime, ceftriaxone, cefepime, ertapenem, meropenem, amikacin, gentamicin, tobramycin and ciprofloxacin.
Discussion
Serratia marcescens was discovered in 1823 by Bizio. It was initially known as Bacterium prodigiosum, named after a substance called prodigiosin, the pink pigment the bacterium produces. The pigment has been found in the urine of patients with urinary tract infections secondary to Serratia marcescens. A pink hypopyon has been described as a sign of both Serratia marcescens endophthalmitis and corneal ulceration.
Other organisms that can produce a pink hypopyon are Klebsiella pneumoniae, Staphylococcus aureus and Rothia dentocariosa.
Clinical course and management
The patient was continued on hourly fortified tobramycin drops with improvement of the infiltrate and hypopyon, as well as an improvement of his vision to 20/200 from 20/400. As the organism was susceptible to tobramycin drops and based on his clinical improvement during the second week, he was then switched to non-fortified tobramycin every 2 hours during the day and every 4 hours at night. He continued to improve, and by week 3, his vision was 20/100 but stromal haze was observed. As the infection was well controlled by the third week, prednisolone acetate was added on four times a day. The tobramycin was then decreased to four times a day as well.
By the fourth week, his vision had improved to 20/60; his exam at that point demonstrated a crescent-shaped stromal opacity without an epithelial defect and no infiltrate, thus tobramycin was stopped and prednisolone was tapered. At his 1-month follow-up, the patient had tapered off prednisolone and his vision was 20/30. Two months after the initial presentation, he was instructed that he could return to contact lens use with extreme caution.
- References:
- al Hazzaa SA, et al. Br J Ophthalmol. 1992;doi:10.1136/bjo.76.12.764.
- Davis JT, et al. JAMA. 1970;doi:10.1001/jama.1970.03180120062015.
- Gammon JA, et al. Arch Ophthalmol. 1980;doi:10.1001/archopht.1980.01020040073007.
- Gaughran ER. Trans N Y Acad Sci. 1969;doi:10.1111/j.2164-0947.1969.tb02887.x.
- Greenwald MJ, et al. Surv Ophthalmol. 1986;doi:10.1016/0039-6257(86)90076-7.
- Kass EH, et al. N Engl J Med. 1957;doi:10.1056/NEJM195703212561206.
- Lazachek GW, et al. Arch Ophthalmol. 1971;doi:10.1001/archopht.1971.01000010601020.
- For more information:
- Eleni K. Konstantinou, MD, and Lisa V. Sitterson, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 800 Washington St., Box 450, Boston, MA 02111; website: www.neec.com.
- Edited by Christine Benador-Shen, MD, and Malgorzata Dymerska Peterson, MD. They can be reached at New England Eye Center, Tufts University School of Medicine, 800 Washington St., Box 450, Boston, MA 02111; website: www.neec.com.