Quiz

Macular Diseases

Middle-aged Man With Foveal Photoreceptor Loss

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA Ophthalmology

November 1, 2019

JAMA Ophthalmology Clinical Challenge

Article Information and Disclosures

Enrico Borrelli, MD, FEBO¹; Riccardo Sacconi, MD, FEBO¹; Giuseppe Querques, MD, PhD¹ Author Affiliations

¹Department of Ophthalmology, Hospital San Raffaele, University Vita Salute San Raffaele, Milan, Italy

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A 38-year-old man was referred to the medical retina service for evaluation of bilateral macular lesions noted by his general ophthalmologist. Medical history was otherwise unremarkable. On examination, his best-corrected visual acuity was 20/20 OU, although his vision was slightly eccentric. His pupils were round and reactive. The slitlamp examination of the anterior segment was unremarkable. Dilated fundus examination revealed subtle bilateral yellow foveal spots. Optical coherence tomography (OCT) displayed the presence of a bilateral foveal defect of the external limiting membrane and ellipsoid zone bands (Figure).

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Poppers maculopathy

C. Obtain an in-depth medical and personal history, including drug history

Poppers is a term for the chemical class of alkyl nitrites, which are inhaled for recreational drug purposes, typically for the high or rush that the drug may produce. Poppers have also been historically used by men who have sex with men for their ability to relax the anal sphincter. Although poppers are illegal, they can be purchased in some countries as alternative products, which include room deodorizers or video head cleaners.¹ The use of poppers is thought to be high and ranges between 5% to 6% in French teenagers² and up to 10% of adults in the United Kingdom.¹ However, their use may be higher in certain groups and is estimated to be about 60% in Australia’s gay community.³

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Article Information

Corresponding Author: Giuseppe Querques, MD, PhD, Department of Ophthalmology, Hospital San Raffaele, University Vita Salute San Raffaele, Via Olgettina 60, Milan 20132, Italy (giuseppe.querques@hotmail.it).

Published Online: September 19, 2019. doi:10.1001/jamaophthalmol.2019.3643

Conflict of Interest Disclosures: Dr Querques reports personal fees from Alimera Sciences, Allergan, Bayer, KBH, LumiThera, Novartis, Zeiss, Topcon, Roche, Heidelberg Pharma, SIFI, Bausch + Lomb, Sooft-Fidia, and Sandoz outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

Davies AJ, Kelly SP, Naylor SG, et al. Adverse ophthalmic reaction in poppers users: case series of ‘poppers maculopathy’. Eye (Lond). 2012;26(11):1479-1486. doi:10.1038/eye.2012.191 PubMed Google Scholar

Audo I, El Sanharawi M, Vignal-Clermont C, et al. Foveal damage in habitual poppers users. Arch Ophthalmol. 2011;129(6):703-708. doi:10.1001/archophthalmol.2011.6 PubMed Google Scholar

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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 PubMed Google Scholar

Davies AJ, Borschmann R, Kelly SP, Ramsey J, Ferris J, Winstock AR. The prevalence of visual symptoms in poppers users: a global survey. BMJ Open Ophthalmol. 2017;1(1):e000015. doi:10.1136/bmjophth-2016-000015 Google Scholar

Vignal-Clermont C, Audo I, Sahel J-A, Paques M. Poppers-associated retinal toxicity. N Engl J Med. 2010;363(16):1583-1585. doi:10.1056/NEJMc1005118 PubMed Google Scholar

Prascina F, Querques G, Russo V, Iaculli C, Noci ND. Morphologic and functional changes in solar retinopathy: a study by optical coherence tomography and fundus-related perimetry. Retin Cases Brief Rep. 2007;1(4):267-270. doi:10.1097/01.iae.0000243418.63583.b2 PubMed Google Scholar

10.

Mainster MA, Turner PL. Photic retinal injuries: mechanisms, hazards, and prevention. In: Ryan SJ, Sadda WR, Hinton DR, et al, eds. Retina. 5th ed. Philadelphia, PA: Saunders;2012.

Middle-aged Man With Foveal Photoreceptor Loss

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