Anterior Chamber Hypopyon Rinsing in Keratitis
Anterior chamber irrigation (rinsing) for hypopyon in bacterial keratitis is NOT routinely indicated, as hypopyon is typically sterile and does not require drainage unless there is high suspicion for microbial endophthalmitis following intraocular surgery, perforating trauma, or sepsis. 1
Primary Management Principle
The hypopyon associated with bacterial keratitis represents an inflammatory response rather than an infectious process within the anterior chamber itself. Aqueous or vitreous taps should not be performed for routine bacterial keratitis with hypopyon 1. The presence of hypopyon alone does not constitute an indication for anterior chamber intervention.
Specific Indications for Anterior Chamber Intervention
Anterior chamber irrigation or paracentesis should be considered ONLY in these specific circumstances:
- High suspicion of microbial endophthalmitis following intraocular surgery 1
- Perforating ocular trauma with concern for intraocular infection 1
- Systemic sepsis with potential hematogenous seeding 1
- Severe suppurative keratitis with significant endothelial plaque that obscures visualization of the lesion edge during therapeutic keratoplasty 2
Therapeutic Keratoplasty Context
When performing penetrating or lamellar keratoplasty for severe corneal ulcer with hypopyon, anterior chamber irrigation combined with corneal transplantation is safe and effective 2. This approach is particularly valuable when:
- Significant corneal endothelial plaque makes it difficult to determine lesion margins intraoperatively 2
- The hypopyon is severe (>3 mm) and interferes with surgical visualization 2, 3
- There is concern about residual inflammatory material affecting graft survival 2
Standard Management Without Irrigation
For typical bacterial keratitis with hypopyon, appropriate management focuses on:
- Intensive topical fortified antibiotics for large central infiltrates with hypopyon 1
- Cycloplegic agents to reduce synechiae formation and pain when substantial anterior chamber inflammation is present 1
- Monitoring for clinical improvement including reduction in anterior chamber cells, fibrin, or hypopyon as markers of therapeutic response 1
Critical Pitfalls to Avoid
Do not confuse hypopyon presence with need for surgical drainage. The key distinction is whether the infection has extended beyond the cornea into the intraocular space 1. Clinical features suggesting true endophthalmitis requiring intervention include:
- Recent intraocular surgery with worsening inflammation 1
- Penetrating injury with retained foreign body 1
- Vitritis or posterior segment involvement 1
- Progressive worsening despite appropriate antimicrobial therapy for keratitis 1
The presence of hypopyon alone, even if large (>2 mm), does not mandate anterior chamber irrigation in uncomplicated bacterial keratitis 1. Medical management with appropriate antibiotics and anti-inflammatory therapy typically results in hypopyon resolution as the keratitis improves 1, 2.