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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 437-439

Hypertensive choroidopathy with bilateral multiple ink blot fluorescein leakage similar to acute central serous chorioretinopathy in a patient using synthetic cannabinoids (Bonzai)


University of Health Sciences, Umraniye Training and Research Hospital, Eye Clinic-Retina Department, Istanbul, Turkey

Date of Submission23-Aug-2021
Date of Acceptance24-Nov-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Utku Limon
Health Sciences University, Umraniye Training and Research Hospital Eye Clinic, Elmalıkent Mahallesi Adem Yavuz Cad. No: 1 Ümraniye, Istanbul - 34000
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2105_21

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  Abstract 


We report a case of using synthetic cannabinoids (Bonzai) with hypertensive choroidopathy with bilateral multiple inkblot fluorescein leakage similar to acute central serous chorioretinopathy (CSC). The systemic blood pressure of the patient was 210/140 mm Hg. In fundus fluorescein angiography (FFA), there were multiple inkblot hyperfluorescent areas and an enlarging spot of fluorescein in the early phases and increased in the late phases similar to acute CSC in both eyes. All of the multiple focal hyperfluorescence areas in the FFA had disappeared, and hypofluorescent areas remained in their places at second month with systemic blood pressure regulation.

Keywords: Acute central serous chorioretinopathy, focal hyperfluorescence, hypertensive choroidopathy, synthetic cannabinoid, systemic hypertension


How to cite this article:
Limon U, Akçay BI. Hypertensive choroidopathy with bilateral multiple ink blot fluorescein leakage similar to acute central serous chorioretinopathy in a patient using synthetic cannabinoids (Bonzai). Indian J Ophthalmol Case Rep 2022;2:437-9

How to cite this URL:
Limon U, Akçay BI. Hypertensive choroidopathy with bilateral multiple ink blot fluorescein leakage similar to acute central serous chorioretinopathy in a patient using synthetic cannabinoids (Bonzai). Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 18];2:437-9. Available from: https://www.ijoreports.in/text.asp?2022/2/2/437/342927



Synthetic cannabinoids are psychoactive substances, and their usage is growing around the world due to their pleasurable effects.[1]


  Case Report Top


A 39-year-old male patient was admitted with headaches and sudden vision loss within the last 1 day. The patient had been using synthetic cannabinoids (Bonzai) for about 6 months. The systemic blood pressure of the patient was 210/140 mm Hg. Other vital signs (body temperature, pulse rate, and respiration rate) were normal. There was no history of hypertension in the patient's and in his family's anamnesis. He had no history of stroke or transient ischemic attack, history of coronary or peripheral vascular disease, and history of heart failure. Systemic examination (cardiac, pulmonary, neurological, and abdominal) was normal. He had no other diseases that could cause secondary hypertension, such as pheochromocytoma, primary hyperaldosteronism, Cushing's syndrome, renal parenchymal disease, renal vascular disease, coarctation of the aorta, obstructive sleep apnea, hyperparathyroidism, and hyperthyroidism. Cranial and abdominal MRI and kidney ultrasonography were normal. Laboratory tests for serological investigations, inflammation, and infection showed no abnormalities. At initial visit, his BCVA was counting fingers in the right eye and 0.05 in the left eye. Anterior segment examination was unremarkable in both eyes. Intraocular pressure was 15 mm Hg in the right eye and 17 mm Hg in the left eye. In fundus examination, there was dot blot retinal hemorrhage in the midperiferal retina, arterial narrowing, and moderate venous dilation, retinal edema, cotton wool spots, and arteriovenous crossing signs. Moreover, there were pale yellowish lesions resembling Elschnig's spots in both eyes. There was no markedly signs of chronic arterial hypertension, including widening of the arteriole reflex and copper or silver wire arterioles in the retina. In optical coherence tomography (OCT), there were serious retinal detachments in both eyes [Figure 1]. In fundus fluorescein angiography (FFA), there were multiple ink blot hyperfluorescent areas (similar to acute CSC) and enlarging spots of fluorescein in the macula, superior, and inferior retina that started in the early phases and increased in the late phases in both eyes (more in the right eye than in the left eye). Also, there were early hyperfluorescence in the region of Elschnig's spots that increased slightly in the late phases (supporting Elschnig's spots) [Figure 2]. In fundus autofluorescence, there were multiple areas of hyper- and hypoautofluorescence in the macula of both eyes [Figure 3]. After systemic tension regulation and discontinuation of synthetic cannabinoid (Bonzai) use, hemorrhages and other fundus findings in both eyes regressed substantially [Figure 4]. All of the multiple focal hyperfluorescence areas in the FFA had disappeared, and hypofluorescent areas remained in their places at 2nd month [Figure 5].
Figure 1: Images taken at initial visit (BCVA was counting fingers in the right eye and 0.05 in the left eye) (a and b) Color fundus photograph of the right and left eye. There was serous retinal detachment in the macula, dot blot retinal hemorrhages in the midperiferal retina, arterial narrowing and moderate venous dilation, and cotton wool spots (yellow arrow). In addition, there were pale yellowish lesions resembling Elschnig's spots (blue arrow). (c and d) Optical coherence tomography (OCT) imaging of the right and left eye. There was serous retinal detachment in the macula in both eyes

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Figure 2: Fundus fluorescein angiography (FFA) images at initial visit. (a) There were multiple inkblot hyperfluorescent areas (blue arrows) and enlarging spot of fluorescein (yellow arrows) in the macula. (b)Increased hyperfluorescent areas in the late phases (blue and yellow arrows) in the right eye. (c)There were multiple ink blot hyperfluorescent areas (blue arrows) and an enlarging spot of fluorescein (yellow arrows) in the macula, superior, and inferior retina that started in the early phases. (d) Increased hyperfluorescent areas in the late phases (blue and yellow arrows) in the left eye

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Figure 3: Fundus auto fluorescence images at initial visit (a and b) and at 2nd month (c and d). (a-d) There were hypo and hyperautofluorescence areas

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Figure 4: Images taken at 2nd month visit (BCVA increased to 1.0 in the right eye and 0.8 in the left eye) (a and b) Color fundus photograph of the right and left eye. Hemorrhages in both eyes regressed substantially. A slight pigment irregularity remained in the left fovea. (c and d) Optical coherence tomography (OCT) imaging of the right and left eye. Serous retinal detachment disappeared completely in both eyes

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Figure 5: Fundus fluorescein angiography (FFA) images at 2nd month. (a-d) All of the multiple focal hyperfluorescence areas in the FFA had disappeared and hypofluorescent areas remained in their places in the right and left eye

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  Discussion Top


Hypertensive choroidopathy is characterized by necrosis of the choroidal arterioles. As a result, the perfusion of the overlying choriocapillaris is impaired and focal ischemic damage occurs in the RPE. The patient's presentation to us with acute onset of headache and vision loss, high systemic blood pressure measured in the first examination, findings of acute hypertensive retinopathy and hypertensive choroidopathy in the fundus OCT and FFA examinations, and bilateral fundus findings and improvement within 2 months with hypertension regulation support that the ocular findings are related to hypertension. Hypertension should be considered in patients presenting to the clinic with the abovementioned findings, and the patient's systemic blood pressure should be measured.

In hypertensive choroidopathy, FFA shows delayed choroidal filling and early hyperfluorescent multifocal areas with late subretinal leakage describing Elschnig's spots.[2] Yamada et al.[3] had reported three types of angiographic patterns in acute CSC as smokestack, ink blot leakage, and minimally enlarging spot of fluorescein. In our case, there were pale yellowish lesions resembling Elschnig's spots, which is an important finding of hypertensive choroidopathy. In FFA, there was early hyperfluorescence in the region of Elschnig's spots that increased slightly in the late phases (supporting Elschnig's spots). At the same time, increasing areas of hyperfluorescence in the form of ink blots were suggestive of acute CSC. In fundus autofluorescence, there were multiple areas of hyper- and hypoautofluorescence in the macula of both eyes. Similar to hypertensive choroidopathy in CSC, a focal damage occurs in the RPE (reason not known exactly) and leakage occurs into the subretinal area. However, due to the presence of findings of hypertensive retinopathy and hypertensive choroidopathy, we did not consider CSC to be the cause of the ink blot leakages in our patient.


  Conclusion Top


Synthetic cannabinoids (Bonzai) can cause malignant (accelerated) systemic hypertension. Serous retinal detachments with multiple areas of focal leakage may develop in hypertensive choroidopathy.[4] With systemic blood pressure regulation without any ophthalmic treatment, these multiple focal leakage areas and serous retinal detachments can regress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alves VL, Gonçalves JL, Aguiar J, Teixeira HM, Câmara JS. The synthetic cannabinoids phenomenon: From structure to toxicological properties. A review. Crit Rev Toxicol 2020;50:359-82.  Back to cited text no. 1
    
2.
Sakai D, Matsumiya W, Kusuhara S, Nakamura M. The choroidal structure changes in a case with hypertensive choroidopathy. Am J Ophthalmol Case Rep 2020;18:100710.  Back to cited text no. 2
    
3.
Yamada K, Hayasaka S, Setogawa T. Fluorescein-angiographic patterns in patients with central serous chorioretinopathy at the initial visit. Ophthalmologica 1992;205:69-76.  Back to cited text no. 3
    
4.
Adamowicz P, Meissner E, Maślanka M. Fatal intoxication with new synthetic cannabinoids AMB-FUBINACA and EMB-FUBINACA. Clin Toxicol (Phila) 2019;57:1103-8.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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