Vision Loss Associated With the Opioid Epidemic

The United States experienced a tripling in the number of opioid overdose deaths from 2000 to 2014. In particular, the Northeast region has the highest age-adjusted rate of deaths associated with drug use, at 16.1 per 100 000 persons.¹ In New Hampshire, the rate is even higher, at 26.2 per 100 000 persons.¹

A devastating sequela of injection drug use (IDU) is endogenous endophthalmitis (EE).² Injection drug use can lead to transient microbial bloodstream infection from use of a nonsterile injection apparatus, which can seed ocular infection.³ The prognosis of EE is poor, with nearly 50% of affected eyes having no light perception despite treatment.² We investigated clinical characteristics of IDU vs non-IDU EE at Dartmouth-Hitchcock Medical Center (DHMC), Lebanon, New Hampshire, during the opioid epidemic.

A retrospective, manual medical record review identified EE cases from January 1, 2012, through December 5, 2016, at DHMC with codes 360.0 and 360.1 from the International Classification of Diseases, 9th Revision, and codes H44.0 and H44.1 from the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Patient demographics, IDU history, microbial data, and clinical courses were recorded. Patients were classified as having EE if they had intraocular inflammation without recent eye surgery, had trauma with a positive intraocular microbial culture or concurrent positive blood culture, or experienced clinical resolution after treatment with intraocular antibiotics or antifungals. The study was approved by the committee for protection of human subjects at DHMC with adherence to Declaration of Helsinki tenets.⁴ The committee waived the need for informed consent for this medical record review. Statistical analysis was performed using χ² and paired and unpaired t tests, with no adjustment to the P values to take into account multiple comparisons.

From 2012 through 2016, 15 patients with EE were identified (5 male and 10 female; age range, 24-83 years), of whom 9 (56.3%) had a history of IDU. During the study period, the number of non-IDU EE cases remained at 0 to 2 cases per year, whereas the number of IDU EE cases per year ranged from 0 to 4 per year, with the most IDU cases occurring in 2016.

Reduced vision was the most common presenting symptom, including all 9 patients with IDU EE and 5 of 6 patients with non-IDU EE. Less common symptoms included pain, floaters, photophobia, and conjunctival injection. The patients with IDU were younger, had fewer comorbidities, and tended to delay seeking medical care (Table). Patients without IDU were more likely to be encountered during hospitalization or shortly after discharge and less likely to warrant surgical intervention because of more frequent resolution of vitritis. More negative intraocular and blood culture findings for EE occurred among patients with IDU, and patients with IDU experienced significantly more improvement in visual acuity after intervention than did patients without IDU (Figure).

The peak in IDU EE cases observed in 2016 mirrors the increased in IDU-related deaths in New Hampshire. Patients with IDU EE were young and ambulatory and presented later but were more likely to experience improved vision with treatment compared with patients with non-IDU EE, who fared worse likely because of more chronic comorbidities and advanced age. In addition, microbes were less likely to be recovered in patients with IDU. These observations support the notion that patients with IDU subvert typical patterns of self-care by normalizing injection-related harms and delaying medical treatment until emergencies occur.⁶ This delay also makes microbial diagnosis challenging, because the injection-induced transient bacteremia may have resolved by the time of presentation. Furthermore, organisms may be sequestered in tissues difficult to access even with repeated sampling, which may contribute to the frequent nonclearing vitritis seen in patients with IDU and account for the observed higher need for surgical intervention.⁷ Although further interpretation is limited by the small sample size at a single hospital, the contrast in initial clinical impression between patients with and without IDU was substantial. The patients with IDU represent a younger and healthier subset of the population with EE and may regain vision with prompt recognition and treatment.

Corresponding Author: Michael E. Zegans, MD, Section of Ophthalmology, Department of Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756 (michael.e.zegans@hitchcock.org).

Accepted for Publication: September 22, 2017.

Published Online: November 16, 2017. doi:10.1001/jamaophthalmol.2017.4868

Author Contributions: Mr Luong had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Luong, Batra, Zegans.

Statistical analysis: Luong, Tsui.

Obtained funding: Luong.

Administrative, technical, or material support: Zegans.

Study supervision: Batra, Chapman, Zegans.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This study was supported by the Francis A. L’Esperance Jr, MD, Visual Sciences Scholar Fund (Dr Zegans) and the Geisel School of Medicine at Dartmouth Summer Research Fellowship (Mr Luong).

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: John Higgins, MS, Dartmouth-Hitchcock Medical Center, performed the queries for International Classification of Disease codes in the electronic medical record. He did not receive extra compensation for this work.