COCAINE AND CHOROIDAL INFARCTION, REVISITING THE TRIANGULAR SIGN OF AMALRIC Shantan Reddy, MD, MPH,* Darin R. Goldman, MD,† Jean-Pierre Hubschman, MD,† Andrew Kaines, MD,† David Sarraf, MD†
Purpose: To describe a case of choroidal infarction as illustrated by the ‘‘triangular sign of Amalric’’ after cocaine inhalation. Methods: Observational case report. Results: A 52-year-old male presented with an acute loss of vision in his left eye immediately after cocaine inhalation. Color photography and fluorescein angiography revealed triangular areas of choroidal ischemia following the distribution of the posterior ciliary arteries. Conclusion: Cocaine-induced vasospasm, specifically of the distal short posterior ciliary arteries, may explain the triangular wedge-shaped choroidal infarcts in our patient. A thorough drug history may circumvent unnecessary and costly investigations in such cases. RETINAL CASES & BRIEF REPORTS 5:91–93, 2011
loss in the left eye. His medical history was significant for hypertension and diabetes, which were well controlled at the time of presentation. Visual acuity was 20/25 in the right eye and no light perception in the left eye. Anterior segment examination was unremarkable. Fundus examination revealed a cotton wool spot in the right eye and wide spread retinal and choroidal ischemic whitening in the left eye (Figures 1, A and B). Fluorescein angiography revealed a triangular area of hypofluorescence early that was temporal to the fovea with its apex toward the macula and its base toward the periphery (Figure 2A). There was perfusion of the paraoptic short posterior ciliary vessels that supply the optic nerve. The triangular lesion stained in the later frames (Figure 2B). Additional triangular areas of choroidal hypofluorescence and ischemia were present more temporally that correlated to the choroidal opacifications seen on color photography (Figure 3). Watershed cerebral infarcts and abdominal infarctions were identified by computed tomography and colonoscopy. Urine toxicology screening was positive for cocaine at the time of hospital admission, and the patient was admitted for recent, frequent, and regular inhalation of cocaine.
From the *New York University Medical Center, New York, New York; and †Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, California. malric1 first described the ‘‘triangular sign’’ as a wedge-shaped area of early choroidal hypofluorescence with late staining, explained by choroidal ischemia. There have been many subsequent reports describing conditions with the triangular sign including giant cell arteritis, systemic lupus erythematosus, Raynaud’s disease, polyarteritis nodosa, sickle cell hemoglobinopathy, internal carotid artery or central retinal artery thrombosis, and contusion injury to the globe.2,3 We report a novel case in which cocaine inhalation led to vasospasm that caused multiple choroidal infarcts, as demonstrated by the triangular signs of Amalric.
A
Discussion Case Report The vascular effects of cocaine are extensive and can lead to complications that arise within several organ systems of the human body. Arterial vasoconstriction induced by cocaine mediates the ischemia that accounts for cardiovascular, cerebrovascular, pulmonary, renal, mesenteric, and even ophthalmic injuries.4 Cocaineinduced vasospasm, specifically of the distal short
A 52-year-old male presented to the emergency department complaining of right-sided weakness, abdominal pain, and vision The authors have no financial interest in the material presented in this article. Reprint requests: Shantan Reddy, MD, MPH, Retina Division, Department of Ophthalmology, Jules Stein Eye Institute, 100 Stein Plaza Box 34, Los Angeles, CA 90095; e-mail: [email protected]
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Fig. 1. A. Fundus photography demonstrated retinal and choroidal opacification in macula and peripapillary areas along with arterial boxcarring, flame-shaped hemorrhages, and cotton wool spots. B. There were additional areas of triangular opacification in the temporal retina.
posterior ciliary arteries, may explain the triangular wedge-shaped choroidal infarcts in our patient along with ischemic whitening of the retina and arterial boxcarring secondary to a central retinal arterial occlusion. However, there was sparing and perfusion of the paraoptic short posterior ciliary arteries because they arise from the ophthalmic artery to supply the optic nerve, suggesting a patent ophthalmic artery.5 The patient denied having any intravenous drug use; he did not exhibit any physical signs of intravenous drug abuse on examination of his extremities, and ophthalmoscopy and fluorescein angiogram did not demonstrate any visible retinal emboli. Rahman et al6 reported a case of presumed chorioretinal infarction after cocaine use, although fluorescein angiography was more suggestive of retinal
Fig. 2. Fluorescein angiography illustrated hypoperfusion of the triangular lesion early (A) with staining in the later frames (B). There was perfusion of paraoptic short posterior ciliary vessels that supply the optic nerve.
Fig. 3. Fluorescein angiography of the temporal retina revealed triangular areas of choroidal hypofluorescence with hyperfluorescent borders.
COCAINE TOXICITY
occlusion, and choroidal infarction was not convincingly demonstrated. Our case is unique in that, we believe, it is the first illustrated example of multiple triangular signs of Amalric after cocaine inhalation and illustrates the susceptibility of the posterior ciliary vessels to vasospasm after cocaine use. A thorough drug history may circumvent unnecessary and costly investigations in such cases. Key words: amalric, choroidal ischemia, cocaine, infarction. References 1. Amalric P. Acute choroidal ischaemia. Trans Ophthalmol Soc U K 1971;91:305–322.
93 2. Amalric P. Choroidal vessel occlusive syndromes–clinical aspects. Trans Am Acad Ophthalmol Otolaryngol 1973;77: 291–299. 3. Hsu CT, Kerrison JB, Miller NR, Goldberg MF. Choroidal infarction, anterior ischemic optic neuropathy, and central retinal artery occlusion from polyarteritis nodosa. Retina 2001; 21:348–351. 4. Brody SL, Slovis CM, Wrenn KD. Cocaine-related medical problems: consecutive series of 233 patients. Am J Med 1990; 89:833–836. 5. Hayreh S. Posterior ciliary artery circulation in health and disease the Weisenfeld lecture. Invest Ophthalmol Vis Sci 2004; 45:749–757. 6. Rahman W, Thomas S, Wiselka M, Bibby K. Cocaineinduced chorioretinal infarction. Br J Ophthalmol 2008;92: 150–151.
Purpose: To describe a case of choroidal infarction as illustrated by the ‘‘triangular sign of Amalric’’ after cocaine inhalation. Methods: Observational case report. Results: A 52-year-old male presented with an acute loss of vision in his left eye immediately after cocaine inhalation. Color photography and fluorescein angiography revealed triangular areas of choroidal ischemia following the distribution of the posterior ciliary arteries. Conclusion: Cocaine-induced vasospasm, specifically of the distal short posterior ciliary arteries, may explain the triangular wedge-shaped choroidal infarcts in our patient. A thorough drug history may circumvent unnecessary and costly investigations in such cases. RETINAL CASES & BRIEF REPORTS 5:91–93, 2011
loss in the left eye. His medical history was significant for hypertension and diabetes, which were well controlled at the time of presentation. Visual acuity was 20/25 in the right eye and no light perception in the left eye. Anterior segment examination was unremarkable. Fundus examination revealed a cotton wool spot in the right eye and wide spread retinal and choroidal ischemic whitening in the left eye (Figures 1, A and B). Fluorescein angiography revealed a triangular area of hypofluorescence early that was temporal to the fovea with its apex toward the macula and its base toward the periphery (Figure 2A). There was perfusion of the paraoptic short posterior ciliary vessels that supply the optic nerve. The triangular lesion stained in the later frames (Figure 2B). Additional triangular areas of choroidal hypofluorescence and ischemia were present more temporally that correlated to the choroidal opacifications seen on color photography (Figure 3). Watershed cerebral infarcts and abdominal infarctions were identified by computed tomography and colonoscopy. Urine toxicology screening was positive for cocaine at the time of hospital admission, and the patient was admitted for recent, frequent, and regular inhalation of cocaine.
From the *New York University Medical Center, New York, New York; and †Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, California. malric1 first described the ‘‘triangular sign’’ as a wedge-shaped area of early choroidal hypofluorescence with late staining, explained by choroidal ischemia. There have been many subsequent reports describing conditions with the triangular sign including giant cell arteritis, systemic lupus erythematosus, Raynaud’s disease, polyarteritis nodosa, sickle cell hemoglobinopathy, internal carotid artery or central retinal artery thrombosis, and contusion injury to the globe.2,3 We report a novel case in which cocaine inhalation led to vasospasm that caused multiple choroidal infarcts, as demonstrated by the triangular signs of Amalric.
A
Discussion Case Report The vascular effects of cocaine are extensive and can lead to complications that arise within several organ systems of the human body. Arterial vasoconstriction induced by cocaine mediates the ischemia that accounts for cardiovascular, cerebrovascular, pulmonary, renal, mesenteric, and even ophthalmic injuries.4 Cocaineinduced vasospasm, specifically of the distal short
A 52-year-old male presented to the emergency department complaining of right-sided weakness, abdominal pain, and vision The authors have no financial interest in the material presented in this article. Reprint requests: Shantan Reddy, MD, MPH, Retina Division, Department of Ophthalmology, Jules Stein Eye Institute, 100 Stein Plaza Box 34, Los Angeles, CA 90095; e-mail: [email protected]
91
92
RETINAL CASES & BRIEF REPORTS´ 2011 VOLUME 5 NUMBER 1
Fig. 1. A. Fundus photography demonstrated retinal and choroidal opacification in macula and peripapillary areas along with arterial boxcarring, flame-shaped hemorrhages, and cotton wool spots. B. There were additional areas of triangular opacification in the temporal retina.
posterior ciliary arteries, may explain the triangular wedge-shaped choroidal infarcts in our patient along with ischemic whitening of the retina and arterial boxcarring secondary to a central retinal arterial occlusion. However, there was sparing and perfusion of the paraoptic short posterior ciliary arteries because they arise from the ophthalmic artery to supply the optic nerve, suggesting a patent ophthalmic artery.5 The patient denied having any intravenous drug use; he did not exhibit any physical signs of intravenous drug abuse on examination of his extremities, and ophthalmoscopy and fluorescein angiogram did not demonstrate any visible retinal emboli. Rahman et al6 reported a case of presumed chorioretinal infarction after cocaine use, although fluorescein angiography was more suggestive of retinal
Fig. 2. Fluorescein angiography illustrated hypoperfusion of the triangular lesion early (A) with staining in the later frames (B). There was perfusion of paraoptic short posterior ciliary vessels that supply the optic nerve.
Fig. 3. Fluorescein angiography of the temporal retina revealed triangular areas of choroidal hypofluorescence with hyperfluorescent borders.
COCAINE TOXICITY
occlusion, and choroidal infarction was not convincingly demonstrated. Our case is unique in that, we believe, it is the first illustrated example of multiple triangular signs of Amalric after cocaine inhalation and illustrates the susceptibility of the posterior ciliary vessels to vasospasm after cocaine use. A thorough drug history may circumvent unnecessary and costly investigations in such cases. Key words: amalric, choroidal ischemia, cocaine, infarction. References 1. Amalric P. Acute choroidal ischaemia. Trans Ophthalmol Soc U K 1971;91:305–322.
93 2. Amalric P. Choroidal vessel occlusive syndromes–clinical aspects. Trans Am Acad Ophthalmol Otolaryngol 1973;77: 291–299. 3. Hsu CT, Kerrison JB, Miller NR, Goldberg MF. Choroidal infarction, anterior ischemic optic neuropathy, and central retinal artery occlusion from polyarteritis nodosa. Retina 2001; 21:348–351. 4. Brody SL, Slovis CM, Wrenn KD. Cocaine-related medical problems: consecutive series of 233 patients. Am J Med 1990; 89:833–836. 5. Hayreh S. Posterior ciliary artery circulation in health and disease the Weisenfeld lecture. Invest Ophthalmol Vis Sci 2004; 45:749–757. 6. Rahman W, Thomas S, Wiselka M, Bibby K. Cocaineinduced chorioretinal infarction. Br J Ophthalmol 2008;92: 150–151.
