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Show ]. Clin. Neuro-ophth.lln1ll1. 1: 110-121.1981. Embolic Retinopathy from Carotid Artery Self-injection A Case of True "Mainline" Talc Retinopathy JAMES R. KEANE. M.D. Abstract A 38-year-old chronic drug abuser inadvertently injected the contents of codeine tablets into his left carotid artery, resulting in an acute left cerebral hemisphere stroke and multiple retinal branch artery embolic occlusions. Punctate retinal emboli are a well-known complication of severe and prolonged intravenous Ritalin abuse. The repeated injection of crushed tablets containing talc and other fillers eventually causes sufficient damage to the pulmonary capillaries to allow talc crystals to pass into the systemic arterial circulation. Within the eyes, the tiny glistening talc emboli lodge principally in the perifoveal retinal capillaries and are surprisingly asymptomatic in most patients. I -: l In contrast to the usual insidious talc retinopathy, the following dramatic instance of true "mainline" injection occurred when a patient inadvertently injected the contents of codeine tablets directly into his left carotid artery. Case Report A 38-year-old man with a long history of drug abuse had been using his neck veins for intravenous injections after more convenient veins had become occluded. His current practice was to crush codeine tablets and inject the powder, mixed with a little water, into the left side of his neck, directing a llh-in. needle toward his carotid pulse. Immediately following such an injection, he developed weakness of his right side and had difficulty in speaking. On admission to the hospital, he was lethargic and had a moderate right hemiparesis, mild dysphasia, a right homonymous hemianopia, and an From the Dep.Htment of Neurology. lo' An~c1es County-University of Southern California Medical Center. lo' An~c1es. California. June 1981 absence of fast optokinetic responses to the right. His right eye was completely normal; no talc emboli were present. Multiple petechiae were present in the palpebral conjunctivae of the left eyelids (Fig. 1). On funduscopic examination several small perifoveal refractile emboli were seen (Fig. 2). There were mul- Figure 1. Multiple conjunctival petechiae. Figure 2. Several talc emboli templH.ll to the nucula. 119 tiple I.Hger embclli with surrllunding Iwmllrrh.1ges .1t bifun·.lt1clIls llf the superillr tempcH.11 .Htery. Immedi.1tely belllw the prllxim.11 emblllus, .1 white p.111h clf inf.Hded rdin.1 W.IS evident (figs. 3 .1Ild -l). A singll' subhy.1lclid Iwnlllrrh.1ge W.1S present infl'nltempclr.11 tcl the m.1nd.1 (fig. 5). The YiSU.11 .1l'uity W.1S 20/20 in e.llh eye, .Jnd .1side from .1 SCOtOI~l.l Cllrrespllnding tll the rdin.J1 inf.Hct, his ViSU.11 fields were nllrm.11. Screening tests for drugs of pCltential .1buse were pClsitive hH Clldeine .1Ild morphine. A cllmputerized tC1mogr.1phic x-r.1Y sC.Jn W.1S norm.Jl, .Jnd .1 lumb.u puncture revealed 20 gr.lIlulocytes, 12 mcll1ocytes, 200 red blood cells, .1 protein content llf 51 ~g/ 100 ml, and a glucose value of 53 mg/ 100 ml. Within -l days, the patient's neurologic state and his cerebrospinal fluid values had returned to normal. Prior to discharge he was instructed in the dangers of direct carotid artery injections. Figure 3. Embolic occlusicln ~t the third blfurc~lIl>n of the supenor tempor~1 ~rtery With ~dl~cent hemorrh~!,es ~nd relln~1 Inf.,Hctlon ri~ur(' ,1. ~\lcl[I' tll'.Ld hlllJJI.ltlllll ('Illbpil III the '>url'rJor ~Hlli '11\1 \l 1"1 \' 1'1.1111 11.", Figure 5. Subhyalold hemorrh~!,e overlying onferior temporal ve"els lust temporal to the macul~ Discussion This patient's instantaneous stroke and acute retinal artery embolization were undoubtedly the result of his injecting the contents of codeine tablets directly into the left carotid artery. It is not uncommon for addicts with sclerosed extremity veins to use other veins, including the superfici'al ones of the neck, for drug injections. This patient, however, was exceptional in injecting deeply into his neck, aiming for the carotid artery pulse. Presumably, until the day of admission he had been fortunate enough to enter the jugular vein during this maneuver. The optic fundus dramatically illustrates the effect of a concentrated bolus of embolic particles. His cerebrospinal fluid cellular response indirectly reflects a similar picture of multiple small hemorrhages and infarcts in the left cerebral hemisphere. Inadvertent intra-arterial injection of crushed tablets is .111 uncommon but not rare occurrence, judging from the report of five patients with this problem seen in one hospital during a single year.4 The injections typically involve arteries of the upper extremities and lead to variable ischemic damage of the hand and forearm. 4. ,; The relative importance of V.lsospasm, arteritis, and embolization in causing such ischemia is unknown,4 but our case, .111owing direct visualization of the circulation, suggests that embolization alone is a sufficient cause for ischemia following arterial injections of crushed tablets. References I. Atlee, W.E.: Talc and cornstarch emboli in eyes of drug users. /.A.M.A. 219: 49-51, 1972. 2. Schatz, H., and Drake, M.: Self-injected retinal emboli. Ophthalmology 86: 468-483,1979. Journal of Clinical Neuro-ophthalmo}ogy 3. Tse, D.T., 'lnd Ober, R.R.: T,11c rl'til1op.lthy. Am. , Ophthdlmo/. 90: 1:'24-1:'40, 10 1\0. 4. Begg, E.J., McGr.lth, M.A..•1I1d W.Ilil', D.N.: 111.ldvertant intr,I-Mteri.ll injel"!il)l1. A pn>bll'l1l l,f drug abuse. Med. , Au!'t. 2: 51:' 1-51:'3, 10 1\0 5. Lindell, T.D., Pl)rter. I.M ...1I1d Lll1gS!<'I1. C.: Il1tr,larteri. ll injectil)I1S l)f or,11 I1ll'di(.lti"I1S. N. rJl~1. I. Med. 287: 1132-1133. 10 72. June 1981 KeJne Acknowledgment Fundus photogr,lphs Wl'rl' tJkl'n by WilliJm A. Ludwid... Write for reprint!' to: /Jml's R. KCdnc, M.D., 1200 Nl.rth St,ltC Strcct, Los Ang(·lcs, Cdlifornid 00033. 121 |
