IMAGE OF THE MONTH: December 2022
A Patient with Bilateral Central Blurred Vision
Description
A 37-year-old male presented to clinic with a 2 week history of bilateral central blurred vision. His vision changed overnight and he woke up with a constant central fixed blurred spot. He denied any other ocular complaints. He works for Uber and drives during the day in direct sunlight. He denied any family ocular history. BCVA was 20/40 OD (PH 20/20) and 20/50 OS (PH 20/20). Anterior and posterior examination were unremarkable with exception of a blunted foveal reflex. Macular OCT is seen below.
Diagnosis
Popper's maculopathy
Discussion
The OCT images above reveal a focal area of ellipsoid disruption subfoveally that appears worse in the left eye than the right eye. The differential diagnosis includes: drug induced maculopathy, solar retinopathy, white dot syndrome, pattern dystrophy, central serous retinopathy, macular telangiectasia, acute retinal pigment epitheliitis, popper's maculopathy. Patient endorsed taking “amyl nitrates” the night before. Given the temporal history of amyl nitrate use and no other significant past medical history, diagnosis of Popper's Maculopathy was made.
Poppers are inhaled for recreational reasons and are known to have a euphoric effect and cause sexual arousal.1 Physician, Sir Thomas Lauder Brunton, first used amyl nitrite medically for treating angina pectoris in 1867.2 It was later discovered that direct inhalation of amyl nitrites resulted in smooth muscle dilation and thus blood vessel dilation. Recreational use of Poppers become popular during the disco age around the mid-1970s.3
The pathogenesis for maculopathy as a result of Poppers are believed to be similar to photic injury with nitric oxide resulting in increased photosensitivity. Another theory is that nitric oxide results in changes in ocular vasodilation that results in ocular perfusion pressure that results in retinal injury.4 OCT is the most useful diagnostic test for cases of popper maculopathy. Classic OCT findings show pathognomonic alterations of the outer foveal retina with an interruption of the ellipsoid zone. Other OCT findings can include hyperreflectivity of the ellipsoid zone and foveal detachments.5,6
Management is to observe and dissuade further popper use. Recovery may take as long as 3-6 months after cessation of popper use. Patients typically recover normal, functional vision. However, in severe cases the central scotoma may persist especially in chronic popper use.7 The patient described herein was observed for 3 months and returned with resolution of symptoms. VA was 20/20 OU. OCT findings (shown below) remained unchanged.
References
1. Davies AJ, Kelly SP, Bhatt PR. 'Poppers maculopathy'--an emerging ophthalmic reaction to recreational substance abuse. Eye (Lond). 2012;26(6):888. doi:10.1038/eye.2012.37
2. Fye, W B (August 1986). "T. Lauder Brunton and amyl nitrite: a Victorian vasodilator". Circulation. 74 (2): 222–229.
3. Newell, GR; Spitz, MR; Wilson, MB (1988). "Nitrite inhalants: historical perspective". NIDA Research Monograph. 83: 1–14
4. Docherty G; Eslami M; O’Donnell H. “Poppers Maculopathy”: a case report and literature review. Canadian Journal of Ophthalmology. Vol. 53(4), 154-156.
5. Milena Pahlitzsch, Christian Mai, Antonia M. Joussen & Richard Bergholz (2016) Poppers Maculopathy: Complete Restitution of Macular Changes in OCT after Drug Abstinence, Seminars in Ophthalmology, 31:5, 479-484
6. Julio González-Martín-Moro, Elena Guzmán Almagro, Nestor Ventura Abreu & Fernando Neria Serrano (2022) Poppers maculopathy: A quantitative review of previous literature, Seminars in Ophthalmology, 37:3, 391-398
7. Hui, Michelle MD; Galvin, Justin BSc; et al. POPPER MACULOPATHY: LONG-TERM FOLLOW-UP AND CASE SERIES. Retinal Cases & Brief Reports: Spring 2020, Vol 14 (2):195-199
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