Abstract
Photo courtesy of Kevin Caldwell Photography.
Occupational hazards and preoccupations afflict every profession. Rapid typists are prone to carpal tunnel syndrome, careless divers get the bends, farmers endlessly scrutinize the clouds for rain, and hatters go mad by curing their brims with mercury. Retinal specialists are not immune from warped, or informed, perspectives. For example, our years of experience dealing with serious ocular trauma have certainly affected our thinking, and we can all complete these seemingly ordinary sentences with inevitable and frightening conclusions: “I was just securing the bungee cord to the car roof when…,” “The nail hit a knot in the board so I gave it a good whack and then…,” “I just lifted my mask at the paintball course for just a second when…,” and countless others. Although most people will live their lives without a serious eye injury, the risk of one will always be with us. Our knowledge and experience as ophthalmology’s trauma surgeons can both shield us and unnerve us, and we can be forgiven if we see risks where others do not. Indeed, even something as commonplace as rubbing one’s eyes becomes an object of fear as a potential cause of keratoconus.
In this vein, a question arises: have you ever worried about the retinal effects of sleeping with your pillow pressing into your eye? We must all be resting in this position almost nightly, but the eye is so tough, and our protective reactions so strong, that we routinely awake with our sight intact. Of course, we really do not know whether some of the sporadic events we observe in our clinics—the grandfather with a central retinal vein occlusion, the accountant with disc damage due to low tension glaucoma, etc—are the result of seemingly innocuous retinal vascular compromise that occurred during sleep. In fact, there are dramatic examples of retinal and choroidal pressure-related circulatory damage such as that induced by inappropriate Honan balloon application, severe intraocular pressure increase with intraocular gas expansion, retro-orbital hemorrhage, and many other assaults to the posterior circulation of the eye.
This issue of JVRD presents a unique example of another: Saturday Night Retinopathy After Intranasal Heroin. Drs Nguyen, North, Oellers, and Husain document the profound retinal, choroidal, and orbital circulatory damage and permanent visual loss presumably induced by unremitting pressure on one eye with continued face-down position during a drug-induced near coma. The patient described is also remarkable for the association of lid swelling, corneal changes, ocular motility deficits, optic nerve abnormalities, and also hippocampal ischemia associated with amnesia. With the opioid crisis showing no signs of abating but rather worsening, ophthalmologists are increasingly likely to encounter this condition in the future. While the vision loss is permanent at present, increased awareness will guide the systemic workup and differential diagnosis and perhaps prepare us for attempts at a future effective therapy. In the meantime, we are burdened with yet another man-made loss of sight.
This issue also features a highly readable review of, in contrast, an utterly positive development from the hand of man: gene therapy. The ability to strongarm the genetic machinery of retinal and RPE cells in restorative ways is here, as an FDA-approved therapy for Leber’s congenital amaurosis, and the race is on for other targets amenable to this miraculous intervention. In addition, there are many other clinically important and scientifically intriguing offerings in the present issue, and it is hoped they will add to the reader’s knowledge, and not to the reader’s anxiety, as an increasingly aware retinal specialist.
