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Bilateral Hypopyon in a Patient With Glaucoma

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

A 72-year-old woman presented with new-onset decreased vision in the right eye. Her ocular history included pseudoexfoliation syndrome and glaucomatous optic neuropathy in the right eye. Past ocular surgery included uncomplicated trabeculectomy in the right eye treated with mitomycin C (3 months prior) and no ocular surgery history in the left eye. Her medical history included pulmonary Mycobacterium avium infection secondary to hypogammaglobulinemia. Computed tomography scan 2 months prior exhibited reactivation and she started treatment with clarithromycin (1000 mg/d), ethambutol (15 mg/kg/d), and rifabutin (300 mg/d).

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A 72-year-old woman presented with new-onset decreased vision in the right eye. Her ocular history included pseudoexfoliation syndrome and glaucomatous optic neuropathy in the right eye. Past ocular surgery included uncomplicated trabeculectomy in the right eye treated with mitomycin C (3 months prior) and no ocular surgery history in the left eye. Her medical history included pulmonary Mycobacterium avium infection secondary to hypogammaglobulinemia. Computed tomography scan 2 months prior exhibited reactivation and she started treatment with clarithromycin (1000 mg/d), ethambutol (15 mg/kg/d), and rifabutin (300 mg/d).

Best-corrected visual acuity was hand motions OD and 20/20 OS. Intraocular pressures were 4 mm Hg ODand 13 mm Hg OS. Anterior segment examination of the right eye showed substantial conjunctival hyperemia and substantial cellular response in the anterior chamber (2 to 3+) along with a 1-mm hypopyon. There was no leak at the trabeculectomy bleb (negative Seidel test). B-scan ultrasonography showed no retinal detachment or mass. Presumed diagnosis of bleb-related infectious endophthalmitis was made and she was referred for treatment. Pars plana vitrectomy was performed, including vitreous sampling, and showed very light growth of Staphylococcus aureus in 1 colony on 1 plate, which was highly suspicious for contaminant. Intravitreal amikacin and vancomycin were administered after vitreous sampling was performed. Postoperatively, the patient initiated treatment with topical antibiotics and corticosteroids. Her visual acuity returned to 20/30.

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Article Information

Corresponding Author: Lesya Shuba, MD, PhD, Department of Ophthalmology and Visual Sciences, Dalhousie University, Two West, 1276 S Park St, Halifax, NS B3H 2Y9, Canada (lesya.shuba@dal.ca).

Published Online: October 28, 2021. doi:10.1001/jamaophthalmol.2021.1447

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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