Sniffing up the wrong tree
Intranasal abuse of dexmethylphenidate (Focalin) can lead to neurotrophic keratopathy
A 37-year-old Caucasian male was referred from an outside provider for severe bilateral dry eye disease and a new corneal ulcer in the left eye. On initial exam at Washington University, best-corrected visual acuity (BCVA) measured 20/50 in the right eye and 20/60 in the left eye. Biomicroscopic exam revealed marked diffuse superficial keratopathy in both eyes accompanied by multiple areas of concern for ulceration. Ocular surface cultures were obtained and the patient’s antibiotic regimen was adjusted to hourly dosing of topical moxifloxacin. The etiology of the keratopathy remained unclear, although there was suspicion that it might be related to a Vitamin A deficiency given this patient’s history of celiac disease and alcohol abuse. Subsequent workup for this proved to be negative.
At a later office visit, however, the patient revealed regular intranasal dexmethylphenidate (Focalin) abuse for many years. Based on the presentation of his neurotrophic ulcer combined with this social history, the diagnosis of a pharmacologic-induced neurotrophic keratopathy was made.
The patient presented initially to an outside provider where he was diagnosed with filamentary keratitis and dry eye syndrome. In addition to bandage contact lenses, the patient was treated with a combination of a topical antihistamine medication, two different antibiotic and steroid combination medications, as well as preservative-free artificial tears. After 5 weeks of aggressive therapy, the patient returned with worsening of his blurry vision, tearing, and photophobia. Repeat exam showed new corneal ulceration in the left eye. At that time, the patient was urgently referred to the ophthalmology service at Washington University in St. Louis, Missouri. His past ocular history was only significant for dry eye syndrome, first noted about 2.5 years ago. His past medical history included bipolar disorder, alcohol and substance abuse, attention deficit hyperactivity disorder, and celiac disease.
On initial examination, BCVA was 20/50 in the right eye and 20/60 in the left eye. There was bilateral diffuse lid edema with periocular erythema, and moderate injection of the conjunctival vessels bilaterally.