Abstract
Purpose
To use new adaptive optics scanning laser ophthalmoscopy (AOSLO) technology to better image macular pathology in poppers maculopathy.
Observations
A 40-year-old patient was found to have poppers maculopathy. Best corrected visual acuity was decreased to 20/40 OD and 20/50 OS, spectral domain optical coherence tomography found outer retinal disruption of the fovea, and AOSLO imaging showed significant decrease in cone density of the fovea of both eyes.
Conclusions and importance
Poppers maculopathy is a rare, but visually significant, complication of popper abuse. AOSLO technology demonstrates significant cone damage in poppers maculopathy. The striking loss of cones revealed by AOSLO imaging shows how AOSLO imaging can elucidate macular pathology.
Highlights
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Poppers maculopathy can cause a significant decrease in BCVA despite relatively minimal changes observed on DFE and SD-OCT.
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AOSLO imaging in this case of poppers maculopathy reveals a striking decrease in central cone density.
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This report demonstrates that AOSLO can elucidate macular pathology not seen in more widely used retinal imaging modalities.
1
Introduction
Poppers are recreational drugs used for their psychoactive effects and are particularly common among men having sex with men (MSM) because of their ability to induce euphoria and myorelaxation. The most common type of poppers inhalant is amyl nitrite. One study revealed popper use among the general population in the UK, Australia, USA and Eurozone was around 7.6 % within the past year, whereas a study in Ireland showed that 35 % of MSM have used poppers in the same period. , Importantly, poppers use amongst MSM is also associated with increased incidence of unprotected sex and HIV transmission.
Historically, poppers were thought to be relatively benign, with transient side effects including presyncope, syncope, hypotension, and flushing due to vasodilation. More recently, poppers have been implicated as a cause of vision loss commonly characterized by central scotomas. , Our report describes a case of poppers maculopathy using newer generation adaptive optics scanning laser ophthalmoscopy (AOSLO; Apaeros System, Boston Micromachines, Boston USA).
2
Case report
A 40-year-old male with HIV disease well controlled on HAART was referred to our retina service with a 6 month history of progressive blurring of vision OU. He had no prior ocular or relevant family history. On presentation, the patient’s best corrected visual acuity (BCVA) was 20/40 OD and 20/50 OS. Anterior segment exam was unremarkable. A complete dilated eye examination revealed no obvious pathology ( Fig. 1 A), however, spectral-domain optical coherence tomography (SD-OCT) of the macula showed a small, central defect in the ellipsoid zone OU ( Fig. 1 B). Autofluorescence (AF), near infrared reflectance (NIR), and fluorescein angiography (FA) were all normal. Humphrey visual field 10–2 was without focal deficits.
Further history was elucidated inquiring about environmental exposures and the patient denied any sun-gazing but did endorse using “poppers” most days for the past 2 years. Given the relatively mild SD-OCT findings, yet significant decrease in best corrected visual acuity, we used AOSLO as an additional modality to assess the extent of retinal damage. Notably, AOSLO revealed extensive damage to the central cones of both eyes. In these images, the central dark elliptical zone denotes an area with absent cone outer segment signal. This is surrounded by normal reflecting outer segments in the perifovea ( Fig. 2 B and C). This is more apparent when compared to the central high density of cones that is seen in a healthy control ( Fig. 2 A).
