October 2020


Ocular effects related to opioid epidemic, polysubstance abuse

by Liz Hillman Editorial Co-Director

Patients with opioid/polysubstance abuse tend to present with a corneal ulcer in the lower half of their cornea.
Source: Matilda Chan, MD

In 2017, the U.S. Department of Health and Human Services declared opioid misuse a public health emergency. While there are a host of negative health effects related to drug abuse, perhaps not widely recognized are ocular effects.
“We have been seeing the opioid epidemic affecting the eye as part of the larger issue of polysubstance abuse,” said Matilda Chan, MD, and Gerami Seitzman, MD.
The main condition these ophthalmologists are seeing related to this drug abuse is severe corneal ulcers.
“It is very clear that cocaine and methamphetamine can lead to harmful ocular side effects. Both substances can cause hypertensive crises and when this occurs can result in damaging changes in the blood vessels in the back of the eye. In addition, both of these substances are known to have an anesthetic effect on the front of the eye. When this happens, patients can damage their corneas and not feel it. The area of damage turns into a large infection and we only meet them when they are aware [of] their decreased vision,” Drs. Chan and Seitzman said. “Specific to opioid use, we know from prior published research studies, there is a relationship between opioids and corneal wound healing. The opioid antagonist naltrexone, for example, has been shown to restore re-epithelialization in a diabetic cornea rat model. Therefore, it can be reasoned that opioids can also impair corneal healing.”
There have been several papers over the last few decades describing the ocular effects of these drugs.1–4 Crack eye syndrome was coined in 1993 to describe the corneal defects associated with crack cocaine use.5 Luong et al. recently detailed endophthalmitis and other ocular manifestations associated with injected drug use.6
Social issues (homelessness, poor access to healthcare, and poor overall health) often compound the situation, Drs. Chan and Seitzman said. The doctors also said cognitive impairment that can be associated with opioid use is another factor that often delays seeking of treatment. “In these instances, they do not enter the medical system until the ocular disease is quite severe,” they said. The doctors noted, however, that opioid and substance abuse affects every demographic.
For the past year, the doctors said they’ve seen 1–2 new patients per month presenting at the public hospital for corneal ulcers associated with polysubstance abuse.
“This is a rise from just a few years ago,” they said.
The doctors said these patients generally present to the emergency department or are referred to them through the psychiatry department as part of a 5150 psychiatric hospitalization. Treating patients with severe corneal ulcers that are associated with polysubstance abuse can be difficult because the patient might be experiencing drug withdrawal symptoms or might be incapable of caring for themselves due to addiction, they said.
“We normally admit them to the hospital for hourly administration of antibiotic drops,” Drs. Chan and Seitzman continued. “Sometimes, they will leave the hospital against medical advice to return to their habit and return 1–2 days later for continued eye treatment.”
Drs. Chan and Seitzman advised ophthalmologists who care for the cornea to be mindful that opioid and polysubstance abuse can be “underlying predisposing factors that can contribute to the severity of and slow healing of cornea pathology.”

Opioid prescriptions in ophthalmology

There have been several recent studies about opioid prescriptions for ophthalmic procedures.
•Kolomeyer et al. found 1.9% of incisional ocular surgeries included an opioid prescription.7 The rate of getting these prescriptions filled increased over time.
•Woodward et al. described how after updating opioid prescribing guidelines, patients who had corneal surgery received fewer pills and still had adequate pain control.8
•Wladis et al. found that IV ketorolac adequately and safely reduced pain and opioid analgesic use in orbital surgeries.9

About the doctors

Matilda Chan, MD, PhD

Associate Professor of Ophthalmology
University of California,
San Francisco
San Francisco, California

Gerami Seitzman, MD
Medical Director
Francis I. Proctor Foundation for Research in Ophthalmology
University of California,
San Francisco


1. Miller AD, Sherman SC. Crack eye. J Emerg Med. 2009;37:75–76.
2. Pilon AF, Scheiffle J. Ulcerative keratitis associated with crack-cocaine abuse. Cont Lens Anterior Eye. 2006;29:263–267.
3. Chuck RS, et al. Recurrent corneal ulcerations associated with smokable methamphetamine abuse. Am J Ophthalmol. 1996;121:571–572.
4. Sachs R, et al. Corneal complications associated with the use of crack cocaine. Ophthalmology. 1993;100:187–191.
5. Colatrella N, Daniel TE. Crack eye syndrome. J Am Optom Assoc. 1999;70:193–197.
6. Luong PM, et al. Endogenous endophthalmitis and other ocular manifestations of injection drug use. Curr Opin Ophthalmol. 2019;30:506–512.
7. Kolomeyer AM, et al. Association of opioids with incisional ocular surgery. JAMA Ophthalmol. 2019;137:1283–1291.
8. Woodward MA, et al. Association of limiting opioid prescriptions with use of opioids after corneal surgery. JAMA Ophthalmol. 2019;138:76–80.
9. Wladis EJ, et al. Intravenous ketorolac reduces pain score and opioid requirement in orbital surgery. Ophthalmic Plast Reconstr Surg. 2020;36:132–134.


Chan: Matilda.Chan@ucsf.edu
Seitzman: Gerami.Seitzman@ucsf.edu

Ocular effects related to opioid epidemic, polysubstance abuse Ocular effects related to opioid epidemic, polysubstance abuse
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