Ocular manifestations of injection drug use

Early Lifetime Substance Use and Development of Visual Impairment: Analysis of the National Survey on Drug Use and Health Data

Purpose

To investigate the association between early lifetime substance use on the development of severe visual acuity impairment or blindness on a national level.

Methods

National Survey of Drug Use and Health data was used to identify cases of substance use before 21* years of age, within the past year, and cases of self-reported blindness or visual impairment. Univariable and multivariable binary logistic regression with time-dependency was performed to evaluate odds of visual impairment influenced by 16 substances separated into three classes: prescription, non-prescription, and illicit drugs. Adjusted variables of interest included gender, marital status, race, level of education, total family income, poverty level, population density, and history of chronic disease.

Results

55,824 total responses were analyzed with 2577 (4.6%) cases of self-reported blindness or significant visual impairment. All early-use substance categories, including prescription, non-prescription, and illegal substances, were significantly associated with self-reported VI (OR 2.068, CI 1.451-2.949, p<0.001; OR 1.352, CI 1.227-1.489, p<0.001); OR 1.211, CI 1.086-1.352, p<0.001), respectively). Non-prescription substances displayed parallel significances amongst all constituents (alcohol, cigarettes, inhalants, and marijuana) (OR=1.227, CI 1.12-1.344, p<0.001; OR 1.363, CI 1.243-1.495, p<0.001; OR 1.418, CI 1.134-1.774; OR 1.388, CI 1.27-1.518, p<0.001, respectively). Univariable and multivariable analysis revealed several significant demographical and clinical adjustors.

Conclusion

Early lifetime use of all three classes of substances is associated with enhanced odds of subsequent visual impairment or blindness. Several readily available and commonly used substances have a greater risk. These findings may help clinicians and public health agencies in mitigation ventures including education, prevention, and rehabilitation efforts.

Vision health perspectives on Breaking Bad: Ophthalmic sequelae of methamphetamine use disorder

Methamphetamine use has become a rampant public health issue that not only causes devastating consequences to the user but also poses a burden to surrounding communities. A spectrum of ophthalmic sequelae is associated with methamphetamine use and includes episcleritis, scleritis, corneal ulceration, panophthalmitis, endophthalmitis, retinal vasculitis, and retinopathy. In many instances, prompt recognition of the condition and associated infectious process and early initiation of antimicrobial therapy are crucial steps to preventing vision loss. In this review, we summarize the reported ocular complications that may result from methamphetamine use in addition to several postulated mechanisms regarding the ocular toxicity of methamphetamine. The increasing prevalence of methamphetamine use as a public health threat highlights the need for continued investigation of this ophthalmologic issue.

Long-term effects of methamphetamine abuse on visual evoked potentials

PURPOSE

To compare visual evoked potential (VEP) components in normal individuals and those with long-term methamphetamine and crystal methamphetamine use.

METHODS

In this study, monocular pattern-reversal VEPs were recorded in 40 methamphetamine and crystal methamphetamine users and 38 normal individuals. Visual stimuli were high-contrast (99%) checkerboard patterns at 15 and 60 min of arc with a reversal rate of 1.53 reversals per second.

RESULTS

A significant difference was seen between the two groups for the P100 peak time for the 60 min of arc checks (p = 0.002, d = 0.75, 4.61% higher peak time in the addicted group) and the 15 min of arc checks (p = 0.004, d = 0.73, 4.78% higher peak time in the addicted group). However, other VEP components were not significantly different between the two groups.

CONCLUSIONS

The higher P100 peak time at both 15 and 60 min of arc in methamphetamine-dependent users reveals that VEPs are highly sensitive for the diagnosis of retinal and visual pathway lesions.

Vitreous and Chorioretinal Lesions in People Who Inject Drugs and Are Hospitalized with Bloodstream and Related Infections

PURPOSE

To determine the prevalence of and to characterize vitreous and chorioretinal lesions, to identify causative organisms, and to correlate symptoms with ophthalmic involvement in people who inject drugs and are hospitalized with bloodstream infection (BSI), related metastatic foci of infection (MFI), or both.

DESIGN

An academic hospital-based cross-sectional study.

PARTICIPANTS

Patients admitted with BSI or MFI related to injection drug use (IDU).

METHODS

Patients underwent a complete eye examination within 72 hours of enrollment. Characteristics including gender; age; race; injection drug of choice (DOC); presence of coinfection with hepatitis B, hepatitis C, or human immunodeficiency virus; pathogen causing systemic infection and type of infection; and history of prior infection related to IDU were recorded.

MAIN OUTCOME MEASURES

Presence of vitreous or chorioretinal findings, or both.

RESULTS

Ninety-one unique patients with 96 separate hospitalizations for systemic infection were enrolled from March 28, 2018, through March 30, 2020. Vitreous or chorioretinal involvement was identified in 16 of 96 patients (16.7%). The most common ocular findings were intraretinal or white-centered hemorrhage in 9 of 96 patients, chorioretinal infiltrate in 8 of 96 patients, endophthalmitis in 5 of 96 patients, and cotton wool spots in 3 of 96 patients. Of the patients with ocular involvement, only 7 of 16 patients (44%) were symptomatic, and 5 of these were patients with endophthalmitis; the others showed chorioretinal infiltrates or intraretinal or white-centered hemorrhage and cotton wool spots. Staphylococcus aureus was the most common causative pathogen in patients with and without ocular findings. Presence of ocular symptoms, worse visual acuity, and injection DOC of methamphetamine were correlated with the presence of ocular findings.

CONCLUSIONS

Patients without ocular symptoms with systemic infections related to IDU may have chorioretinal findings. Further study is needed to characterize better the epidemiologic features of these infections and to identify risk factors for ocular involvement in people who inject drugs.

Illicit drugs: Effects on eye

There is a myriad of changes that can be produced in the eye by toxic drugs ranging from mild/no symptoms to severe loss of vision from endophthalmitis. The routes of administration include oral ingestion, smoking, nasal inhalation, intravenous injection, topical application or application to other mucosal surfaces. It is important to recognize certain clinical signs and symptoms in the eye produced by these toxins. This article describes in brief some of the ocular effects of commonly abused drugs. For identification of a particular poisoning, in addition to the clinical presentation, pulse, blood pressure, respiration and body temperature, pupillary size, pupillary reaction to light, ocular convergence and nystagmus can be useful indicators of the type of drug the patient is exposed to. Unmasking these features help the clinician in an early and accurate diagnosis of the offending drug as well as timely management.

Endogenous endophthalmitis and other ocular manifestations of injection drug use

PURPOSE OF REVIEW

The United States has experienced a dramatic rise in opioid and injection drug use over the past 2 decades. A public health emergency was declared in 2017 and subsequently, there have been several new reports on the rise of endogenous endophthalmitis specifically associated with injection drug use. The purpose of this review is to provide a current perspective of the ocular harms posed by injection drug use.

RECENT FINDINGS

The opioid epidemic has prompted several new studies from New England, one of the US regions most heavily affected, that examine the trends and characteristics of injection drug use-associated endogenous endophthalmitis. Patients may delay seeking care and may be infected with a variety of rare and atypical microbes, and as a result clinical appearance may vary widely. Injection drug use also leads to embolic phenomena such as talc retinopathy and septic emboli from endocarditis. HIV is highly associated with injection drug use and although HAART has drastically reduced the morbidity and mortality of HIV-associated infections, a variety of ocular disease may accompany an immunocompromised patient.

SUMMARY

Healthcare providers must remain vigilant in the recognition of injection drug use patients with vision loss and ocular inflammation to ensure prompt medical and/or surgical treatment.

Ocular manifestations of drug and alcohol abuse

PURPOSE OF REVIEW

The purpose of this study is to review commonly encountered adverse ocular effects of illicit drug use.

RECENT FINDINGS

Drug and alcohol abuse can produce a variety of ocular and neuro-ophthalmic side effects. Novel, so-called 'designer', drugs of abuse can lead to unusual ocular disorders. Legal substances, when used in manners for which they have not been prescribed, can also have devastating ophthalmic consequences.

SUMMARY

In this review, we will systematically evaluate each part of the visual pathways and discuss how individual drugs may affect them.

Endogenous endophthalmitis: microorganisms, disposition and prognosis

PURPOSE

Endogenous endophthalmitis is a severe and potentially blinding complication caused by haematogenous spreading of microorganisms. We evaluated the causative microorganisms, disposition to and prognosis of the disease.

METHODS

Thirty-one eyes of 28 patients were treated between 1996 and 2006 as the result of an endogenous endophthalmitis.

RESULTS

The microorganisms responsible for infection could be identified in 94% of all eyes investigated. Candida isolates were obtained in 15, gram-positive isolates in 11, gram-negative in one and Aspergillus in two of the 29 eyes studied. The majority of patients suffered from severe general disease (immuno-deficiency, severe surgical procedures, diabetes mellitus) and one third were intravenous drug abusers. Only one patient was otherwise healthy. The prognosis depended on the causative microorganisms. Whereas none of the eyes with Candida infection became blind, all except two of the eyes with gram-positive bacteria, Nocardia or Aspergillus infection lost visual function or had to be enucleated.

CONCLUSION

Compared to postoperative endophthalmitis, patients with endogenous endophthalmitis are more likely to have Candida isolates. Visual prognosis depends mainly on the underlying microorganisms, and is particularly poor in the case of infection with gram-positive bacteria or Aspergillus.

Peripheral retinal neovascularization in talc retinopathy

BACKGROUND

Neovascularization of the peripheral retina can be present in a number of systemic and ocular diseases. Very rarely, peripheral retinal neovascularization can also be manifested in intravenous drug abusers. In addition to ocular complications, intravenous drug abusers are at high risk for contracting various infections and the development of pulmonary and cardiovascular diseases. We present a case of a chronic heroin and cocaine abuser with bilateral peripheral retinal neovascularization, pulmonary complications, and a history of endocarditis.

CASE REPORT

A patient with a 20-year history of heroin and cocaine abuse initially presented for a routine eye examination. Fundus examination revealed pinpoint white deposits centered in both maculas, engorged vascular fronds with a patch of intraretinal hemorrhage in the peripheral retinal of the right eye and neovascularization of the disc as well as exudation with adjacent focal preretinal hemorrhage in the left eye. The patient underwent fluorescein angiography and was screened for diabetes, sarcoidosis, and sickle cell disease. When no systemic disease could be discovered, it was concluded that the peripheral retinal neovascularization developed as a result of vascular occlusion from heroin and cocaine abuse.

DISCUSSION

It is important to investigate the cause of neovascularization in the peripheral retina. Retinal vascular emboli such as talc are common in drug abusers, but in most cases, the retinal deposits pose only a minimal threat to vision. However, this case shows that careful retinal examination is warranted in drug abusers to rule out neovascularization of the retina. Other causes of peripheral retinal neovascularization should be ruled out as well. These conditions include sickle cell retinopathy, sarcoidosis, diabetic retinopathy, blood dyscrasias, retinal vascular occlusion, Eales' disease, and other systemic conditions, so that appropriate ocular and systemic treatment can be provided. Peripheral retinal neovascularization is best treated by pan-retinal photocoagulation.

Intraorbital Heroin Injection Resulting in Orbital Cellulitis and Superior Ophthalmic Vein Thrombosis

A 47-year-old man with decreased vision, ophthalmoplegia, proptosis, and chemosis of his right eye admitted to injecting heroin directly into his orbit. He was placed on intravenous antibiotics for orbital cellulitis, and computed tomography and magnetic resonance imaging were performed. Superior ophthalmic vein thrombosis (SOVT) was noted on magnetic resonance imaging. The patient responded well to intravenous antibiotics, and his symptoms resolved with minimal deficits. Steroids and anticoagulants were not administered. We review the pathogenesis of septic SOVT and briefly discuss the role of anticoagulants and steroids in this setting.

Phacoemulsification in isolated endogenous Candida albicans anterior uveitis with lens abscess in an intravenous methadone user

We report the clinical course of a 31-year-old former intravenous drug user on methadone substitution therapy who injected methadone mixed with orange juice. She developed isolated metastatic Candida albicans anterior uveitis, which was treated with adequate systemic and local antifungal therapy. The uveitis regressed, but despite adequate local and systemic treatment, a lens abscess developed. Phacoemulsification and endocapsular intraocular lens implantation were performed, and the patient recovered 20/20 visual acuity in the affected eye. In patients with a history of injection drug use, persisting intravenous drug or substitution therapy abuse must be considered. Quick diagnosis and adequate treatment can prevent the development of widespread C albicans endophthalmitis, which has a poor visual prognosis. Early administration of antifungal and surgical therapy is crucial for achieving good functional results.

Isolated endogenous endophthalmitis due to a sporodochial-formingPhialemonium curvatumacquired through intracavernous autoinjections

We report a case of endogenous endophthalmitis due to a sporodochial-forming species of Phialemonium curvatum. The infection led to the enucleation of the affected eye, but there was no evidence of systemic dissemination. The isolated P. curvatum produced aggregates of phialides, many occurring on coils or in verticils, which eventually develop into sporodochia. The initial and post-enucleation isolates revealed they were identical to strains of P. curvatum from Israel causing disseminated disease in patients practicing intracavernous autoinjections for the treatment of erectile dysfunction. The reported case had unusual clinical and microbiological features. Despite the route of acquisition and the lack of systemic antifungal therapy, the infection did not spread beyond the eye. The morphology of the phialides aggregates was also unique, and the distinction between Volutella and Acremonium is discussed. This case expands the spectrum of infections due to Phialemonium species, and reveals a novel way of developing fungal endophthalmitis.