An unusual vertical hypopyon.

Case report

A vertical hypopyon was noted in a 72-year old bedbound Chinese patient with a history of stroke and multiple vascular comorbidities.

The patient was consulted for right eye redness for a week. He was bedridden, lying on his left side with no voluntary head turn due to chronic immobility caused by previous stroke. Ophthalmic examination demonstrated right lagophthalmos and exposure keratopathy with secondary sterile anterior uveitis. A 3 mm slightly oblique vertical hypopyon was noted on the nasal side (Fig. 1). A hypopyon with an apparent vertical location was demonstrated when a clinical photo was taken at the anatomical position.

Fig. 1

Vertical hypopyon in a Chinese patient with reactive anterior uveitis.

When displayed in the neutral anatomical position, the gravity-dependent hypopyon in this bed bound, left head-tilted patient would be seen as vertically located.

Discussion

Hypopyon are reactive leukocytes that sediment at the site of the anterior chamber with low velocity and high resistence. Gravitational force accounts for this hypopyon variant, as leukocytes deposited at the dependent nasal side, lending to an apparent vertical location anatomically. Mahajan et al. advocated differentiation of sterile hypopyon post-intravitreal triamcinolone injection from that of an infectious cause by its ability to shift with deliberate head tilt for minutes. Nevertheless, a primary sterile vertical hypopyon in a patient without previous steroid treatment or deliberate intervention on posture has been less well documented in literature.

Conclusion

In addition to the classical teaching of common inferior hypopyon caused by deposited leukocytes in sterile and infective cases, as well as reversed hypopyon caused by emulsification of silicone oil, ophthalmologist should be vigilant about less typical hypopyon caused by the combined effect of gravitational force and abnormal patient posture and consider head-tilting test where indicated.

Patient consent

Consent to publish this case report has been obtained from the patient(s) in writing, (see attachment).

Acknowledgments and disclosures

Funding

No funding or grant support

Authorship

All authors attest that they meet the current ICMJE criteria for Authorship.

Declaration of competing interest

The following authors have no financial disclosures: CYY, YKLH.