POSSIBLE FOREIGN BODY GRANULOMA OF T H E RETINA ASSOCIATED WITH INTRAVENOUS COCAINE ADDICTION J O S E P H B. M I C H E L S O N , M.D., J O H N P. W H I T C H E R , M.D., S C A R L E T T E W I L S O N , AND G. R I C H A R D O ' C O N N O R , M.D. San Francisco,
A type of retinopathy caused by talc, lactose, and cornstarch emboli has been observed in drug addicts after repeated intravenous injections of either powder or crushed tablets. Ophthalmoscopic exa mination reveals tiny glistening crystals concentrated in the posterior pole of the eye along the small end arterials of the perifoveal arcade. 1 These emboli are cur rent diluents for the intravenous adminis tration of heroin, cocaine, or methylphenidate hydrochloride (Ritalin). The pa tients, often chronic abusers of these drugs, refer to what they call a "talc flash" (the phenomenon of light flashes just seconds after intravenous injection). 1 Tablet filler for methylphenidate hydrochloride and powder filler for cocaine and heroin are made up principally of talc (magnesium silicate), but may also con tain cornstarch, lactose, cotton fibers, and other refractile and nonrefractile materi als. All of these filler materials have been reported to cause foreign body granulomas in the heart valves, lungs, liver, and other viscera and can be seen histologically as minute crystals deposited in the visceral organs of chronic intravenous drug abusers. 2 - 6 However, the only case so far reported with ocular involvement shows a type of crystalline retinopathy in which diffuse emboli are seen deposited in the posterior pole as minute glistening From the Francis I. Proctor Foundation for Re search in Ophthalmology and the Department of Ophthalmology, University of California, San Fran cisco, California. Dr. Michelson was a Heed Foun dation Fellow (1977-1978). Reprint requests to Joseph B. Michelson, M.D., Division of Ophthalmology, Scripps Clinic and Research Foundation, 10666 N. Torrey Pines Rd., La Jolla, CA 92037. 278
M.D.,
California
crystals. 1 We describe herein the case of an isolated foreign body crystal appearing in the retina and evolving into an organ ized noninfectious granulomatous pro cess over a period of time, consistent with what is reported as occurring in other visceral organs. No inflammatory signs had been seen in this patient's eye over a four-month period, ruling out a concomi tant bacterial or fungal endophthalmitis. Candida endophthalmitis is a wellrecognized entity in drug addicts who are otherwise healthy, young adults who de velop the budding yeast form in the vitre ous as a complication of intravenous drug use. 7 CASE REPORT A 27-year-old man with no history of ocular prob lems noted a bright constellation of light flashes in front of the right eye immediately after injecting intravenous cocaine. This patient had a one-year history of heroin addiction, and before that a long history of chronic lysergic acid diethylamide (LSD) abuse. At the time of examination three days later, the patient had visual acuity of 6/9 (20/30) in the right eye with a temporal hemicentral scotoma. Visual acuity in the left eye was 6/6 (20/20). The cornea was clear and the anterior chamber was free of cell and flare. The iris stroma was normal without nodules or synechiae. The lens was clear. The vitre ous was free of cells. A posterior vitreous detach ment was noted. In the fundus of the right eye, the papillomacular bundle contained a white glistening foreign body crystal that lay just above a small area of intraretinal exudate (Fig. I). This foreign body of a highly glistening and refractile nature stood out prominently from the rest of the retina. Except for the small line of intraretinal exudate superior and inferior to this crystal, there were no other signs of inflammation surrounding this foreign body embolus. The optic nerve head was normal and no collat eral vessels emanated from the disk. Over the next three weeks, the vitreous remained clear and free of cells and no anterior or posterior uveitis was noted. The retinal lesion formed a granuloma, the apex of which surrounded the refractile crystal (Fig. 2). Fi brous epiretinal bands formed around this crystal
AMERICAN JOURNAL O F OPHTHALMOLOGY 87:278-280, 1979
VOL. 87, NO. 3
RETINAL FOREIGN BODY GRANULOMA
279
Fig. 1 (Michelson and associates). Fundus of the right eye showing white, highly glistening foreign body crystal, lying above small area of intraretinal exudate in the papillomacular bundle.
Fig. 3 (Michelson and associates). Fluorescein angiogram of right eye, in the late venous phase, showing marked intraretinal accumulation of fluo rescein in the papillomacular granuloma.
and numerous collateral vessels originated from the temporal margin in the superior and inferior mar gins of the papillomacular bundle that was now grossly elevated and edematous (Fig. 3). Fluorescein angiography of the eye showed marked intraretin al accumulation and leakage of fluorescein in the papillomacular bundle. This occurred early, during the arteriovenous phase, and stained. After develop ment of the retinal granuloma as seen in Figure 2,
without any overlying vitreous cells or any other inflammatory component to the eye, the ophthalmoscopic appearance did not change. The patient maintained visual acuity of 6/9 (20/30) with a hemicentral scotoma.
Fig. 2 (Michelson and associates). Fundus photo graph of right eye showing evolution of lesion into a granuloma of the retina, with marked elevation of lesion, the foreign body crystal still being visualized at the apex.
DISCUSSION
Foreign body granulomata caused by talc, cornstarch, or lactose emboli derived from the diluents of heroin, cocaine, and pulverized tablets such as methylphenidate (Ritalin) used for intravenous addic tion is a well-known complication of drug abuse. Such foreign body granulomas have been noted in the lungs, heart valves, liver, spleen, and kidneys. 2 - 6 These emboli, visualized in the fundus and described as crystals in a previous patient, 1 represent a diffuse, posterior pole retinopathy. However, a solitary, or ganized retinal granuloma in the absence of this type of crystalline retinopathy has not been noted previously. While this refractile, foreign body crystal appeared to be embedded in the retinal tissue of the papillomacular bundle, we believe it was contained in a vessel originally, despite the lack of clinical confirmation.
280
AMERICAN JOURNAL OF OPHTHALMOLOGY
Patients who are chronic drug abusers are subject to showers of emboli from their intravenous drug use. Such showers of emboli, when arriving at the pulmo nary tree, cause a secondary pulmonary hypertension. 3 - 5 Pulmonary hyperten sion may even prove fatal to the patient either from a fatal embolus or secondary cardiovascular complications. 4-5 ' 8,9 Thus, crystalline emboli, when injected into the venous side of the vascular tree, may travel through the pulmonary vasculature, and as a consequence of pulmonary hypertension, be shunted to the left side of the vascular tree. They are then embolized to the eye or to the other visceral «£gans, as has been reported previously. Retinal foreign body granuloma may now be listed with crystalline retinopathy and fungal endophthalmitis 7 as another con sequence of emboli resulting from chron ic intravenous drug abuse. When a for eign body granuloma is seen in the fundus of an otherwise healthy, and espe cially young patient, a concomitant his tory of intravenous drug use should be suspected as a possible cause of emboli. SUMMARY
A 27-year-old man who was a heroin addict had light flashes in front of the right eye and a hemicentral scotoma im mediately after intravenous cocaine. The initial ophthalmoscopic appearance was of a white foreign body lying over the papillomacular bundle of the retina in the right eye. This ophthalmoscopic finding was consistent with intraocular talc, cornstarch, or lactose, common diluting
MARCH, 1979
agents that are present in intravenous injections of heroin, cocaine, or methylphenidate hydrochloride, and are known to cause systemic embolic phenomena in chronic drug abusers. This glistening crystal on the surface of the retina changed and evolved into a noninfectious but inflammatory organization of retinal granuloma, in which the foreign body crystal could still be visualized at the apex of the lesion. The anterior and pos terior segments of the eye remained free of inflammatory signs throughout the course of the organization of the retinal granuloma. REFERENCES 1. Atlee, W. E., Jr.: Talc and cornstarch emboli in eyes of drug abusers. J.A.M.A. 219:49, 1972. 2. Hahn, H. H., Schweid, A., and Beatty, H.: Complications of injecting dissolved methylphenidate tablets. Arch. Intern. Med. 123:656, 1969. 3. Hopkins, G. B., and Taylor, D.: Pulmonary talc granulomatosis. A complication of drug abuse. Am. Rev. Respir. Dis. 101:101, 1970. 4. Wendt, V. E., Puro, H. E., Shapiro, J., Mathews, W., and Wolf, P. L.: Angipthrombotic pulmo nary hypertension in addicts. "Blue velvet" addic tion. J.A.M.A. 188:755, 1964. 5. Robertson, C. H., Jr., Reynolds, R. C , and Wilson, J. E.: Pulmonary hypertension and foreign body granulomas in intravenous drug abusers docu mentation by cardiac catheterization and lung biop sy. Am. J. Med. 61:657, 1976. 6. Min, K. W., Gyorkey, F., and Cain, G. D.: Talc granulomata in liver disease in narcotic addicts. Arch. Pathol. 98:33, 1974. 7. Getnik, R. A., and Rodrigues, M. M.: Endoge nous fungal endophthalmitis in a drug addict. Am. J. Ophfhalmol. 77:680, 1974. 8. Vientara, M., and Moore, S.: Fatal talc embo lism in a drug addict. Hum. Pathol. 1:324, 1970. 9. Bainborough, A. R., and Jericho, K. W. F.: Core pulmonale secondary to talc granulomata in the lungs of a drug addict. Can. Med. Assoc. J. 103:1297, 1970.
A type of retinopathy caused by talc, lactose, and cornstarch emboli has been observed in drug addicts after repeated intravenous injections of either powder or crushed tablets. Ophthalmoscopic exa mination reveals tiny glistening crystals concentrated in the posterior pole of the eye along the small end arterials of the perifoveal arcade. 1 These emboli are cur rent diluents for the intravenous adminis tration of heroin, cocaine, or methylphenidate hydrochloride (Ritalin). The pa tients, often chronic abusers of these drugs, refer to what they call a "talc flash" (the phenomenon of light flashes just seconds after intravenous injection). 1 Tablet filler for methylphenidate hydrochloride and powder filler for cocaine and heroin are made up principally of talc (magnesium silicate), but may also con tain cornstarch, lactose, cotton fibers, and other refractile and nonrefractile materi als. All of these filler materials have been reported to cause foreign body granulomas in the heart valves, lungs, liver, and other viscera and can be seen histologically as minute crystals deposited in the visceral organs of chronic intravenous drug abusers. 2 - 6 However, the only case so far reported with ocular involvement shows a type of crystalline retinopathy in which diffuse emboli are seen deposited in the posterior pole as minute glistening From the Francis I. Proctor Foundation for Re search in Ophthalmology and the Department of Ophthalmology, University of California, San Fran cisco, California. Dr. Michelson was a Heed Foun dation Fellow (1977-1978). Reprint requests to Joseph B. Michelson, M.D., Division of Ophthalmology, Scripps Clinic and Research Foundation, 10666 N. Torrey Pines Rd., La Jolla, CA 92037. 278
M.D.,
California
crystals. 1 We describe herein the case of an isolated foreign body crystal appearing in the retina and evolving into an organ ized noninfectious granulomatous pro cess over a period of time, consistent with what is reported as occurring in other visceral organs. No inflammatory signs had been seen in this patient's eye over a four-month period, ruling out a concomi tant bacterial or fungal endophthalmitis. Candida endophthalmitis is a wellrecognized entity in drug addicts who are otherwise healthy, young adults who de velop the budding yeast form in the vitre ous as a complication of intravenous drug use. 7 CASE REPORT A 27-year-old man with no history of ocular prob lems noted a bright constellation of light flashes in front of the right eye immediately after injecting intravenous cocaine. This patient had a one-year history of heroin addiction, and before that a long history of chronic lysergic acid diethylamide (LSD) abuse. At the time of examination three days later, the patient had visual acuity of 6/9 (20/30) in the right eye with a temporal hemicentral scotoma. Visual acuity in the left eye was 6/6 (20/20). The cornea was clear and the anterior chamber was free of cell and flare. The iris stroma was normal without nodules or synechiae. The lens was clear. The vitre ous was free of cells. A posterior vitreous detach ment was noted. In the fundus of the right eye, the papillomacular bundle contained a white glistening foreign body crystal that lay just above a small area of intraretinal exudate (Fig. I). This foreign body of a highly glistening and refractile nature stood out prominently from the rest of the retina. Except for the small line of intraretinal exudate superior and inferior to this crystal, there were no other signs of inflammation surrounding this foreign body embolus. The optic nerve head was normal and no collat eral vessels emanated from the disk. Over the next three weeks, the vitreous remained clear and free of cells and no anterior or posterior uveitis was noted. The retinal lesion formed a granuloma, the apex of which surrounded the refractile crystal (Fig. 2). Fi brous epiretinal bands formed around this crystal
AMERICAN JOURNAL O F OPHTHALMOLOGY 87:278-280, 1979
VOL. 87, NO. 3
RETINAL FOREIGN BODY GRANULOMA
279
Fig. 1 (Michelson and associates). Fundus of the right eye showing white, highly glistening foreign body crystal, lying above small area of intraretinal exudate in the papillomacular bundle.
Fig. 3 (Michelson and associates). Fluorescein angiogram of right eye, in the late venous phase, showing marked intraretinal accumulation of fluo rescein in the papillomacular granuloma.
and numerous collateral vessels originated from the temporal margin in the superior and inferior mar gins of the papillomacular bundle that was now grossly elevated and edematous (Fig. 3). Fluorescein angiography of the eye showed marked intraretin al accumulation and leakage of fluorescein in the papillomacular bundle. This occurred early, during the arteriovenous phase, and stained. After develop ment of the retinal granuloma as seen in Figure 2,
without any overlying vitreous cells or any other inflammatory component to the eye, the ophthalmoscopic appearance did not change. The patient maintained visual acuity of 6/9 (20/30) with a hemicentral scotoma.
Fig. 2 (Michelson and associates). Fundus photo graph of right eye showing evolution of lesion into a granuloma of the retina, with marked elevation of lesion, the foreign body crystal still being visualized at the apex.
DISCUSSION
Foreign body granulomata caused by talc, cornstarch, or lactose emboli derived from the diluents of heroin, cocaine, and pulverized tablets such as methylphenidate (Ritalin) used for intravenous addic tion is a well-known complication of drug abuse. Such foreign body granulomas have been noted in the lungs, heart valves, liver, spleen, and kidneys. 2 - 6 These emboli, visualized in the fundus and described as crystals in a previous patient, 1 represent a diffuse, posterior pole retinopathy. However, a solitary, or ganized retinal granuloma in the absence of this type of crystalline retinopathy has not been noted previously. While this refractile, foreign body crystal appeared to be embedded in the retinal tissue of the papillomacular bundle, we believe it was contained in a vessel originally, despite the lack of clinical confirmation.
280
AMERICAN JOURNAL OF OPHTHALMOLOGY
Patients who are chronic drug abusers are subject to showers of emboli from their intravenous drug use. Such showers of emboli, when arriving at the pulmo nary tree, cause a secondary pulmonary hypertension. 3 - 5 Pulmonary hyperten sion may even prove fatal to the patient either from a fatal embolus or secondary cardiovascular complications. 4-5 ' 8,9 Thus, crystalline emboli, when injected into the venous side of the vascular tree, may travel through the pulmonary vasculature, and as a consequence of pulmonary hypertension, be shunted to the left side of the vascular tree. They are then embolized to the eye or to the other visceral «£gans, as has been reported previously. Retinal foreign body granuloma may now be listed with crystalline retinopathy and fungal endophthalmitis 7 as another con sequence of emboli resulting from chron ic intravenous drug abuse. When a for eign body granuloma is seen in the fundus of an otherwise healthy, and espe cially young patient, a concomitant his tory of intravenous drug use should be suspected as a possible cause of emboli. SUMMARY
A 27-year-old man who was a heroin addict had light flashes in front of the right eye and a hemicentral scotoma im mediately after intravenous cocaine. The initial ophthalmoscopic appearance was of a white foreign body lying over the papillomacular bundle of the retina in the right eye. This ophthalmoscopic finding was consistent with intraocular talc, cornstarch, or lactose, common diluting
MARCH, 1979
agents that are present in intravenous injections of heroin, cocaine, or methylphenidate hydrochloride, and are known to cause systemic embolic phenomena in chronic drug abusers. This glistening crystal on the surface of the retina changed and evolved into a noninfectious but inflammatory organization of retinal granuloma, in which the foreign body crystal could still be visualized at the apex of the lesion. The anterior and pos terior segments of the eye remained free of inflammatory signs throughout the course of the organization of the retinal granuloma. REFERENCES 1. Atlee, W. E., Jr.: Talc and cornstarch emboli in eyes of drug abusers. J.A.M.A. 219:49, 1972. 2. Hahn, H. H., Schweid, A., and Beatty, H.: Complications of injecting dissolved methylphenidate tablets. Arch. Intern. Med. 123:656, 1969. 3. Hopkins, G. B., and Taylor, D.: Pulmonary talc granulomatosis. A complication of drug abuse. Am. Rev. Respir. Dis. 101:101, 1970. 4. Wendt, V. E., Puro, H. E., Shapiro, J., Mathews, W., and Wolf, P. L.: Angipthrombotic pulmo nary hypertension in addicts. "Blue velvet" addic tion. J.A.M.A. 188:755, 1964. 5. Robertson, C. H., Jr., Reynolds, R. C , and Wilson, J. E.: Pulmonary hypertension and foreign body granulomas in intravenous drug abusers docu mentation by cardiac catheterization and lung biop sy. Am. J. Med. 61:657, 1976. 6. Min, K. W., Gyorkey, F., and Cain, G. D.: Talc granulomata in liver disease in narcotic addicts. Arch. Pathol. 98:33, 1974. 7. Getnik, R. A., and Rodrigues, M. M.: Endoge nous fungal endophthalmitis in a drug addict. Am. J. Ophfhalmol. 77:680, 1974. 8. Vientara, M., and Moore, S.: Fatal talc embo lism in a drug addict. Hum. Pathol. 1:324, 1970. 9. Bainborough, A. R., and Jericho, K. W. F.: Core pulmonale secondary to talc granulomata in the lungs of a drug addict. Can. Med. Assoc. J. 103:1297, 1970.
