Patient Presentation: A 23-year-old obese female was diagnosed with idiopathic intracranial hypertension (IIH) and referred to neurosurgery for ventriculoperitoneal shunt. A baseline ocular examination was performed prior to the procedure.
On examination, vision was 20/200 in the right eye, and 20/40 in the left eye. There was a right relative afferent pupillary defect. Slit lamp examination was normal.
A dilated fundus examination was performed demonstrating the following:
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Retina
Case 82
Contributors: Dr. David Rabinovitch, Dr. Nupura Bakshi
Patient presentation: A 30-year-old man was referred to a tertiary ophthalmology clinic with a 6-month history of intermittent blurred vision and central scotoma OD. His medical history included HIV with an undetectable viral load, T1DM, dyslipidemia, hypertension, and multiple diagnoses of primary syphilis. His medications included metformin, ramipril, rosuvastatin, and Genvoya (elvitegravir/cobicistat/emtricitabine/tenofovir). He had a history of IV drug use, but stopped 6 months prior to presentation, and recreationally used inhalant alkyl nitrites.
On examination, his visual acuity was 20/200 OD and 20/20 OS, with no improvement on pinhole testing OD. There was no RAPD, and his IOP was within normal limits. The anterior segment examination was unremarkable.
Additional investigations, including fundus photography, fundus autofluorescence (FAF), and optical coherence tomography (OCT) images were taken and are presented below:
Question 2: What are the key features on the OCT imaging?
Question 3: What is the most likely diagnosis?
Question 4: What is in the differential for isolated subfoveal ellipsoid zone loss?
References:
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Docherty G, Eslami M, O'Donnell H. "Poppers Maculopathy": a case report and literature review. Can J Ophthalmol. 2018 Aug;53(4):e154-e156.
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Vignal-Clermont C, Audo I, Sahel JA, Paques M. Poppers-associated retinal toxicity. N Engl J Med. 2010 Oct 14;363(16):1583-5.
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Bral, N. O., Marinkovic, M., Leroy, B. P., Hoornaert, K., Lint, M., & Tusscher, M. P. (2016). Do not turn a blind eye to alkyl nitrite (poppers)!. Acta Ophthalmologica (1755375X), 94(1).
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Davies, A. J., Kelly, S. P., Naylor, S. G., Bhatt, P. R., Mathews, J. P., Sahni, J., Haslett, R., & McKibbin, M. (2012). Adverse ophthalmic reaction in poppers users: case series of 'poppers maculopathy'. Eye (London, England), 26(11), 1479–1486.
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Mrejen S, Khan S, Gallego-Pinazo R, Jampol LM, Yannuzzi LA. Acute zonal occult outer retinopathy: a classification based on multimodal imaging. JAMA Ophthalmol. 2014 Sep;132(9):1089-98.
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Abdellah, M. M., Mostafa, E. M., Anber, M. A., El Saman, I. S., & Eldawla, M. E. (2019). Solar maculopathy: prognosis over one year follow up. BMC ophthalmology, 19, 1-9.
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Melles, R. B., & Marmor, M. F. (2014). The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA ophthalmology, 132(12), 1453-1460.
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Marmor, M. F., Kellner, U., Lai, T. Y., Melles, R. B., & Mieler, W. F. (2016). Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 revision). Ophthalmology, 123(6), 1386-1394.
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Kim, H. A., Lee, S., Eah, K. S., & Yoon, Y. H. (2020). Prevalence and risk factors of tamoxifen retinopathy. Ophthalmology, 127(4), 555-557.
Learning Objectives:
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To identify key OCT features of poppers maculopathy.
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To differentiate retinal pathologies with isolated EZ disruption.