Delhi Journal of Ophthalmology

Crystalline Pseudo-hypopyon

Pawan Prasher
Department of Ophthalmology, Sri Guru Ram Das Institute of Medical Science and Research, Amritsar, Punjab, India

Corresponding Author:

Pawan Prasher
Department of Ophthalmology, Sri Guru Ram Das Institute of Medical Science and Research, Amritsar, Punjab, India
Email id: pawanprasher@yahoo.com

Received: 28-AUG-2019

Accepted: 16-SEP-2019

Published Online: 27-FEB-2020

DOI:http://dx.doi.org/10.7869/djo.514

Abstract
Crystalline pseudohypopyon is a rare condition which may present a dilemma to the ophthalmologists both in terms of establishing the diagnosis as well as in deciding the appropriate management. Reported herein, is an unusual case of a 70 year old male presenting with acute crystalline pseudohypopyon in the presence of an old retinal detachment in his right eye. The microscopic examination of the aqueous aspirate was consistent with the diagnosis of Cholesterolosis bulbi.

Keywords :Crystalline pseudohypopyon, Cholesterolosis bulbi, Synchysis scintillans

A 70 years old male presented with gradually increasing “whiteness” in his right eye for over one week along with mild irritation and redness. Examination showed right exotropia with no perception of light in the right eye (a). Intraocular pressure was 12 mm of Hg. Slit lamp examination showed dense hypopyon involving more than one third of anterior chamber along with floating, glittering, yellowish white crystals in the upper part (b and c). There was associated extensive iris neovascularization and presence of a dense white cataract. Hypopyon was shifting in nature i.e. changed position on lying on one side (d). B-scan ultrasonography showed cataractous lens, highly echogenic vitreous and funnel shaped retinal detachment (e). Anterior chamber wash with cataract extraction was done after explaining the prognosis to the patient, to prevent possible corneal decompensation and to address patient’s concern about unusual whiteness. Initially the crystals appeared to come from lens, so an extracapsular cataract extraction was attempted to eradicate the source; however, during capsulorhexis, a large zonular dehiscence was observed which necessitated its conversion to intracapsular cataract extraction. Anterior chamber was meticulously cleaned to remove the residual crystals and the patient was left aphakic. Examination at post-op week one showed recurrence of few crystals in the anterior chamber indicating their source to be from the vitreous cavity and not the lens (f). The fundus examination was significant for a long standing retinal detachment. The examination of the other eye was unremarkable. Microscopic analysis of aqueous aspirate showed transparent rhomboid crystals with notched borders suggestive of cholesterol crystals (g), consistent with the diagnosis of Cholesterolosis bulbi.


Figure 1: Gross photo showing right exotropia (a). Slit lamp photo showing hypopyon (b) and Refaractile Crystals (c). Hypopyon shifted on head tilt (d). USG Showing Retinal dettacment (e). Post-operative photo showing few crystals (f). Microscopy showing transparent rhomboid crystals (g) of Cholesterolosis bulbi.

Discussion
The term “cholesterolosis bulbi” also known as synchysis scintillans in ophthalmic literature refers to the presence of highly refractile and free floating crystals in the liquefied vitreous and is usually present in eyes with severe intraocular disease.1-3 The source of crystals can be lens or from cholesterol in the cell walls of RBCs present in the vitreous haemorrhage.1-2 Management of pseudohypopyon can be a dilemma to the ophthalmologists because of poor visual potential. However, intervention may be necessary for cosmetic reasons as well as to prevent endothelial decompensation of the cornea. Ophthalmologists should be aware of this rare entity which is a chronic, non-infective pathology with poor visual prognosis and should not be confused with hypopyon of infectious origin. 

References
  1. Kennedy CJ. The pathogenesis of polychromatic cholesterol crystals in the anterior chamber. Aust N Z J Ophthalmol 1996; 24:267-273.
  2. Evereklioglu C. Shifting crystalline pseudohypopyon secondary to lens absorption with spontaneous openings in the anterior lens capsule. J Cataract Refract Surg 2006; 32:1971-1973. 
  3. Hurley IW, Brooks AM, Reinehr DP, Grant GB, Gillies WE. Identifying anterior segment crystals. Br J Ophthalmol 1991; 75:329-331.

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Prasher PCrystalline Pseudo-hypopyon.DJO 2019;30:76-77

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Prasher PCrystalline Pseudo-hypopyon.DJO [serial online] 2019[cited 2020 Apr 7];30:76-77. Available from: http://www.djo.org.in/articles/30/2/Crystalline-Pseudo-hypopyon.html