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Rare disease

CASE REPORT

Poppers retinopathy
Joshua Luis, Meena Virdi, Shahriar Nabili

Department of Ophthalmology, SUMMARY

Hairmyres Hospital, East We present a case of a 52-year-old man with sudden,
Kilbride, UK
bilateral central loss of vision as a result of inhalation of
Correspondence to ‘poppers’. He was found to have characteristic changes
Dr Joshua Luis, on optical coherence tomography. With conservative
joshua.luis@nhs.net treatment, the patient’s vision improved marginally at
Accepted 9 February 2016
3 months follow-up. An overview of previous published
cases is also included.

BACKGROUND Figure 1 Spectral domain OCT on presentation,

‘Poppers’ are a group of alkyl nitrite chemicals. showing symmetrical disruption of the inner/outer
segment layers (red arrows) top—right eye, bottom—left
They cause euphoria, sexual arousal and relaxation
eye. OCT, optical coherence tomography.
of smooth muscles including the anal sphincter. As
a result, they are particularly popular in the gay
partying community. Numerous recent reports have
DISCUSSION
associated the use of poppers with disruption in
Alkyl nitrites, colloquially known as ‘poppers’, are
vision, we present such a case in a 52-year-old
recreational substances frequently used in the club-
man.
bing community due to their euphoric effects. They
also cause sexual arousal and smooth muscle relax-
CASE PRESENTATION ation, being therefore especially popular among the
A 52-year-old bisexual man presented to the oph- homosexual population.1 Poppers are not con-

by copyright.
thalmology acute referral clinic with a 10-day trolled under the Misuse of Drugs Act2 and are
history of central visual blurring and metamor- therefore readily available from a variety of
phopsia. He reported normal peripheral vision, sources.
and had no other visual symptoms of note. The Despite the high prevalence of poppers, there
deterioration was noted immediately following a have only been around 30 published cases of
night of clubbing, during which time the patient poppers retinopathy/maculopathy. The actual inci-
inhaled ‘poppers’ for the first time. He was HIV dence is likely to be much higher, although the
negative and systemically well. majority of these are asymptomatic.3 All cases
Slit-lamp examination was unremarkable, with present with bilaterally symmetrical central field
normal fundal views. His best corrected visual loss or distortion, with preservation of peripheral
acuity was 6/15 in the left eye and 6/12 in the fields. Other symptoms such as loss in colour
right, improving to 6/12 and 6/9.5, respectively, vision, photopsias and positive scotomas are more
with pinhole. His pupil reactions and colour vision variable.4–6
were normal. Spectral domain optical coherence SD-OCT provides the most valuable diagnostic
tomography (SD-OCT) showed disruption of the test, showing pathognomonic disruption of the
inner and outer segment layers, confined to the inner and outer segment layers in both foveae.7–9
fovea. These findings were identical in both eyes Fundus fluorescein angiograms (FFAs), when
(figure 1). carried out, are invariable normal.
The patient was treated conservatively, with The SD-OCT findings are similar to those
advice regarding cessation of drug use. At 3 months observed in photic injury.10 However, some recent
follow-up, the patient’s best corrected visual acuity cases have shown abnormalities in full-field
improved marginally to 6/9.5 bilaterally. OCT
showed improvement in the photoreceptor layer,
although some mild changes in the foveal area
remained (figure 2).

DIFFERENTIAL DIAGNOSIS
Differential diagnoses for poppers retinopathy
include photic injury, central serous retinopathy
To cite: Luis J, Virdi M,
Nabili S. BMJ Case Rep
and vitreoretinal traction. Photic injury can gener-
Published online: [please ally be differentiated by history, while other condi-
include Day Month Year] tions are all very unlikely to present symmetrically.
doi:10.1136/bcr-2016- This therefore highlights the importance of relevant
214442 drug history and examining both eyes. Figure 2 Improvement at 3 months follow-up.
Luis J, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-214442 1
 BMJ Case Reports: first published as 10.1136/bcr-2016-214442 on 7 March 2016. Downloaded from http://casereports.bmj.com/ on 12 August 2021 at Cote d'Ivoire:BMJ-PG Spon. Protected
Rare disease

electroretinography.5 This supports the presence of diffuse tening control over substances similar to and including poppers,
retinal damage, and is not limited to the maculae as previously in the UK.
thought. The current proposed mechanism of injury for
poppers is that of free radical release from the nitrite chemi- Competing interests None declared.
cals.3 11 As a consequence, these studies advocate the use of the Patient consent Obtained.
term ‘poppers retinopathy’ over ‘poppers maculopathy’.12 Provenance and peer review Not commissioned; externally peer reviewed.
In poppers retinopathy, disease progression is successfully
halted following abstinence from the substance in all cases. REFERENCES
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11 Vignal-Clermont C, Audo I, Sahel JA, et al. Poppers-associated retinal toxicity.
▸ Poppers retinopathy presents as bilateral, symmetrical, N Engl J Med 2010;363:1583–5.
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reaction to recreational substance abuse. Eye (Lond) 2012;26:888.

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2 Luis J, et al. BMJ Case Rep 2016. doi:10.1136/bcr-2016-214442