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EDUCATION

Case Study: I Can’t Feel My K When I’m With You

Greer Randleman
Presenter: Christine Greer, MD Discussant: J. Bradley Randleman, MD
 

History

  • Consulted by medicine for a white “dot” on patient’s right eye. Patient in-house for ETOH withdrawal/psychosis; currently homeless and pending placement x three months
  • Patient has no ocular complaints at this time
  • Past ocular history: Decreased vision OU for four years. Patient unwilling to provide additional history
  • Social history: crack cocaine abuse

Exam Findings

  • VA: hand motions OU
  • Pupils: unable OD, round and reactive OS
  • IOP: deferred OD; 17 OS
  • EOM: Full
  • External exam OD
    • Unable to fully close right eye
    • Anterior staphyloma
    • Corneal scarring with iris apposition to cornea
    • No view posteriorly due to degree of scarring
  • External exam OS
    • Lids and Lashes: Within Normal Limits (WNL)
    • Conjunctiva/Sclera: WNL
    • Cornea: clear
    • Anterior Chamber: deep and quiet
    • Lens: dense cataract
    • Retina/Vitreous: no view
Figure 1
Figure 1: External photograph of patient’s right eye depicting severe degree of extrusion of ocular surface.
Figure 2
Figure 2: External photograph of patient’s right eye. Note anterior staphyloma with iris apposition to thin, scarred cornea.

 

Differential Diagnosis

  • Neoplasms
    • Conjunctival or uveal melanoma
  • Anterior staphyloma caused by:
    • Corneal trauma
    • Infectious keratitis
    • Drug related
      • Crack eye syndrome
      • Methamphetamine use

Additional Investigations

  • Posterior exam with ultrasound B scan OU
    • Retina flat, no detachments, no masses OU

Diagnosis

  • Crack eye syndrome characterized by:
    • Epitheliopathy/epithelial trauma
    • Superficial punctate keratitis
    • Epithelial defects
    • Microbial keratitis
    • Stromal melt and corneal perforation
    • Neurotrophic keratopathy
Figure 3
Figure 3: Neurotropic keratitis demonstrating ulceration with classic rolled borders.

 

Pathophysiology

  • Direct toxic effect of crack cocaine on the cornea; damaging epithelial plasma membranes and microvilli
  • Decreased corneal sensation leading to decreased blink mechanism and exposure keratopathy predisposing to infection
  • Cutting substances damage the nerves leading to a neurotrophic keratitis
  • Crack smoke causing subclinical alkali burn leading to decreased epithelial barrier function, persistent epithelial defects, predisposing to corneal infection
  • Mechanical trauma due to rubbing because of irritation from smoke causes epithelial devitalization and corneal epithelial defects
  • Probable mechanism
    • Crack smoke-induced neuropathy and corneal irritation stimulated an intense eye rubbing with epithelial trauma. Recurrent use led to recurrent intermittent epithelial trauma, which stimulates collagen breakdown leading to progressive corneal ectasia. The recurrent nature of this trauma results in extensive corneal scarring and neovascularization from repeated corneal remodeling and thinning.

Treatment

  • Treatments vary based on stage of disease/degree of ulceration if infectious keratitis develops

Prognosis and Future Directions

  • Crack eye syndrome is multifactorial in etiology
  • Results in extensive and chronic corneal changes
    • Repeated corneal trauma and epithelial devitalization
    • Increased risk of neurotrophic keratopathy
    • Epithelial defects/corneal ulcers
    • It is likely an underreported clinical entity and addressing drug use with patients may optimize treatment and facilitate healing

References

  • Müller LJ, Marfurt CF, Kruse F, Tervo TMT. Corneal nerves: structure, contents and function. Exp Eye Res. 2003 May;76(5):521-42.
  • Tomás-Juan J, Murueta-Goyena Larrañaga A, Hanneken L. Corneal Regeneration After Photorefractive Keratectomy: A Review. J Optom. 2015 Jul-Sep;8(3):149-69.
  • Poulsen EJ, Mannis MJ, Chang SD. Keratitis in Methamphetamine Abusers. Cornea. 1996 Oct;15(5):477-82.
  • Sachs R, Zagelbaum BM, Hersh PS. Corneal complications associated with the use of crack cocaine. Ophthalmology. 1993 Feb;100(2):187-91.
  • Pilon AF, Scheiffle J. Ulcerative keratitis associated with crack-cocaine abuse. Cont Lens Anterior Eye. 2006 Dec;29(5):263-7.
  • Ghosheh FR, Ehlers JP, Ayres BD, Hammersmith KM, Rapuano CJ, Cohen EJ. Corneal ulcers associated with aerosolized crack cocaine use. Cornea. 2007 Sep;26(8):966-9
  • Sacchetti M, Lambiase A. Diagnosis and management of neurotrophic keratitis. Clin Ophthalmol (Auckland, N.Z.). 2014;8:571-579.

Contact

Section Editors

 

Produced by: Monica Chavez, John Daniel, Joseph Yim and Dr. Vivek Patel
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