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Unilateral Hypopyon in an Elderly Man With Dementia

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 78-year-old man presented with decreased visual acuity and hypopyon in his right eye. He had a history of Philadelphia chromosome–positive acute lymphocytic leukemia (ALL), Stevens-Johnson syndrome (attributable to treatment with the tyrosine-kinase inhibitor [TKI] imatinib), and diabetes. He had senile dementia but did not complain of constitutional symptoms. His visual acuity was 20/80 OD and 20/32 OS, and his intraocular pressures were 31 mm Hg OD and 16 mm Hg OS. A slitlamp examination of the right eye showed redness, with small, white, nongranulomatous keratic precipitate as well as a cataract. His iris was diffusely thickened and the anterior chamber was slightly shallow, with 4+ cells and white hypopyon, which did not change position with head movements (Figure 1). There was also an extensive rubeosis iridis (Figure 1) with posterior synechiae in the right eye. The left anterior chamber was normal. A fundus examination had unremarkable results in both eyes. A complete blood cell count had normal results, and his hemoglobin A1c level was 16.5%. A syphilis test result was negative.

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Intraocular relapse of ALL

B. Anterior chamber tap for hypopyon cytology tests

Hypopyon cytology testing revealed numerous small, atypical lymphocytes (Figure 2). The patient was later diagnosed with Alzheimer disease. It was discovered that the patient had self-discontinued all the medications that he should have been taking (including TKI and antidiabetic drugs) 8 months prior, owing to decreased cognitive function. Magnetic resonance imaging of the brain and a lumbar puncture revealed no further central nervous system involvement. Messenger RNA from the breakpoint cluster region–tyrosine-protein kinase ABL1 (BCR-ABL) gene was not detected in the peripheral blood. The patient was diagnosed with an intraocular relapse of Philadelphia chromosome–positive ALL.

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Article Information

Corresponding Author: Yosuke Harada, MD, PhD, Department of Ophthalmology and Visual Science, Hiroshima University Graduate School of Biomedical Sciences, Kasumi 1-2-3 Minami-ku, Hiroshima 734-8551, Japan (yharada@hiroshima-u.ac.jp).

Published Online: February 25, 2021. doi:10.1001/jamaophthalmol.2020.4633

Conflict of Interest Disclosures: Dr Kiuchi reported grants and personal fees from Santen Pharma, Senju Pharma, and Kowa and grants from Alcon Japan and Pfizer outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank Claire Barnes, PhD, Edanz Group (https://en-author-services.edanzgroup.com/), for editing a draft of the manuscript. She was compensated for her input. We thank the patient for granting permission to publish this information.

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