A rise in fungal infections of the retina is linked to the nation’s opioid crisis, according to researchers at Bascom Palmer Eye Institute. Physicians treating intravenous drug users should be aware of this dangerous complication and screen their patients for recent changes in their vision.
“Using a needle to inject drugs can introduce fungal contaminants to the bloodstream,” said Harry W. Flynn, Jr., M.D., professor of ophthalmology and The J. Donald M. Gass Distinguished Chair in Ophthalmology. “When the blood carries the fungi to the eye, they begin to grow in the retina, a condition called endogenous fungal endophthalmitis (EFE), which can cause severe vision loss and blindness, even with early diagnosis and treatment.”
Flynn was co-author of a commentary, “Endogenous Fungal Endophthalmitis: An Increasing Problem Among Intravenous Drug Users,” published recently in JAMA, the Journal of the American Medical Association, with Stephen G. Schwartz, M.D., M.B.A., associate professor of clinical ophthalmology and medical director of Bascom Palmer Eye Institute at Naples, and Nidhi Relhan Batra, M.D., a clinical retina fellow at Bascom Palmer.
“This dangerous visual complication represents a new perspective on the opioid problem, and our commentary presented an update on the characteristics, management and visual outcomes in patients with EFE,” said Schwartz. He noted that Bascom Palmer researchers have conducted a number of studies in the past few years on bacterial and fungal infections related to intravenous drug use.
A recent report from the U.S. Centers for Disease Control and Prevention found that drug overdose deaths nearly tripled between 1999 and 2014. In 2014, about 61 percent of the 47,055 drug overdose deaths involved opioids such as heroin. A separate study by Pittsburgh researchers indicated there are approximately 30 nonfatal overdoses for every death.
In May, Florida Gov. Rick Scott officially declared the opioid crisis a public health emergency, allowing the state to accept a $54 million federal grant for prevention, treatment and recovery services. However, the opioid crisis appears to be most severe in New England, which has reported a significant increase in heroin-related deaths since 2014. Because EFE is closely associated with opioid use, a collaborative team of researchers conducted a medical records review evaluating all patients with EFE referred to the New England Eye Center at Tufts Medical Center in Massachusetts from May 1, 2014 to May 1, 2016.
Their study Outbreak of Endogenous Fungal Endophthalmitis among Intravenous Drug Abusers in New England, “An Outbreak of Endogenous Fungal Endophthalmitis among Intravenous Drug Abusers in New England” in JAMAOphthalmology, reported 10 patients (five men and five women) with EFE related to intravenous drug use, compared with only three patients from May 2012 to April 2014.
In their commentary, the Bascom Palmer researchers urged physicians and other health care professionals to ask IV drug-using patients about recent changes to their vision.
“When these patients report vision loss, EFE should be considered,” said Schwartz. “The external eye may appear normal to a penlight examination, making it unlikely that the correct diagnosis will be made unless a formal, dilated eye examination is performed.”
Other challenges to identifying EFE include the need to prioritize treatment for concurrent life-threatening medical problems, said Schwartz. Also, young children and drug users with mental problems may not be able to report changes to their vision.
A typical EFE infection results in white, elevated lesions on the retina or the vitreous, abscesses below the retina, or retinal detachment. “A prompt diagnosis is important for identifying the infectious agent, which could be fungi, bacteria or other pathogens,” said Schwartz. “Otherwise, the infection can lead to severe visual loss, blindness or loss of the eye.”
Treatment for EFE generally includes systemic antimicrobial medications to attack the pathogens in the blood stream, as well as injections into the vitreous (the jelly-like ball of the eye). In the most serious cases of infection, the vitreous is surgically removed — a procedure called pars plana vitrectomy — and replaced with saline. Five of the patients with EFE in the New England study required vitreous eye surgery.
“In view of the increasing worldwide prevalence of intravenous drug use, EFE is an important challenge for all of medicine,” Flynn said.
Miller School of Medicine