A case of maculopathy from rush poppers

第二，加快民生水利建設(shè)進(jìn)程。一是加強(qiáng)以高效節(jié)水為重點的農(nóng)田水利建設(shè)。新建農(nóng)業(yè)高效節(jié)水面積300萬畝。二是完成剩余142項定居興牧配套骨干水利工程建設(shè)；再解決60萬農(nóng)村人口的飲水安全問題，推進(jìn)城鄉(xiāng)一體化供水；加快大中型灌區(qū)節(jié)水改造、大中型病險水閘除險加固建設(shè)；加快13個水電新農(nóng)村電氣化縣、小水電代燃料和水電增效擴(kuò)容工程建設(shè)；繼續(xù)加強(qiáng)水產(chǎn)工作。

W e present the first Chinese case of poppers maculopathy.Poppers are a recreational substance of abuse which composes of a series of volatile alkyl nitrite. “Rush” is a kind of poppers, which was born in the United States and has been in existence for more than 30y. Inhalation of poppers provides a brief rush of euphoria, sexual arousal and relaxation of smooth muscles including the anal sphincter. There are approximate 20% male homosexual using poppers to enhance sexual pleasure in our country.

現(xiàn)階段，慢性心力衰竭臨床治療的主要措施便是抗心衰，以此減少患者出現(xiàn)心血管危象的風(fēng)險，提高患者的存活率。細(xì)胞生物學(xué)的快速發(fā)展，幫助人們進(jìn)一步明確了慢性心力衰竭的主要誘發(fā)因素，即心肌能量代謝異常。健康人心肌代謝能量為葡萄糖、脂肪酸生物氧化產(chǎn)生的三磷酸腺苷，而慢性心衰患者心肌長期血氧不足，代謝較差，糾正臨床癥狀，必須保證心肌代謝能量充足。磷酸肌酸鈉經(jīng)人體可以向三磷酸腺苷轉(zhuǎn)化，補充患者心肌代謝能量[3] 。本次研究結(jié)果顯示，觀察組患者的心功能以及運動耐量明顯優(yōu)于對照組患者，差異有統(tǒng)計學(xué)意義（P＜0.05）?？梢?，磷酸肌酸鈉可以改善患者的心功能，提高患者的運動耐量，為病情抑制奠定較好的基礎(chǔ)條件。

It is previously considered that the risk of poppers is low both physically and psychologically. However, a global drug survey showed that 12% respondents who were using or had used poppers believed that the use of poppers may have or definitely affected their eyesight. Here we present, to our knowledge,the first reported case of poppers maculopathy in China. We obtained the written informed consent from the patient.

筆者在廣泛調(diào)研國內(nèi)外掘進(jìn)機(jī)工作特點的基礎(chǔ)上，設(shè)計了用于掘進(jìn)機(jī)模擬試驗平臺且可對掘進(jìn)機(jī)所有狀態(tài)與參數(shù)進(jìn)行動態(tài)顯示的監(jiān)控系統(tǒng)，另外搭建了可對各種掘進(jìn)機(jī)位姿檢測方法進(jìn)行驗證與對比的高精度掘進(jìn)機(jī)位姿測量精度驗證系統(tǒng)。選取了具有代表性的位姿測量方法開展掘進(jìn)機(jī)位姿測量試驗，對系統(tǒng)的功能進(jìn)行驗證，并分析了位姿測量精度驗證系統(tǒng)的實用性。

After poppers inhalation, patients present with similar symptoms such as blurred vision, fluctuating vision, central scotoma, photophobia, and phosphenes, and most of them have both eyes suffered. The fundus manifestations are varied, which can be normal, yellowish-white spots, or even vitelliform lesions at the fovea. OCT provides the most valuable diagnostic test, showing disruption or attenuation of the ellipsoid zone in both foveae. All patients with pathognomonic changes on OCT imaging should be asked about inhalation of poppers.

To our knowledge, nitric oxide (NO) regulates photoreceptor metabolism in rods and cones primarily through activation of guanylate cyclase, a key enzyme of phototransduction. It is widely suspected that the potential cause of retinal damage linked to inhalation of poppers is high concentration of NO.Experimental studies showed that high doses of NO induce apoptotic cell death in photoreceptors. There is another hypothesis that poppers cause rapid widespread dilation of blood vessels, as well as blood vessels in the eye, which causes an increase in intraocular pressure and damage to retina.

mfERG is also a useful tool for detecting the location and extent of retinal dysfunction, particularly in the diagnosis of retinal toxicity confined to the central retina. In some drug-reduced retinopathies, such as chloroquine and hydroxychloroquine, mfERG is considered an objective examination of retinal function that can provide earlier detection of retinal damage. As a case reported that OCT abnormality appeared 3mo later than visual symptoms and acuity loss following poppers inhalation, mfERG can be a significant method for early screening of poppers retinal toxicity and monitoring of disease progression or recovery after drug cessation.

礦區(qū)范圍內(nèi)未見到巖漿巖出露。礦區(qū)內(nèi)發(fā)現(xiàn)的蝕變有硅化、碳酸鹽化、絹云母化、黃鐵礦化、葉臘石化、炭化及高嶺石化等。其中，硅化、碳酸鹽化、絹云母化和炭化與礦化關(guān)系較密切。

A 37-year-old Chinese man presented with blurred vision and central scotoma in both eyes for 7d. He admitted to regular use (at least twice or 3 times per month) rush poppers for the previous 7y. After inhaling the rush poppers, he had multiple transient blurred visions, and the symptom did not disappear since his last inhalation of rush poppers 7d ago. He did not smoke or drink and had no significant past medical, ophthalmic or family history. Slit-lamp examination was unremarkable,with normal fundus (Figure 1). Best-corrected visual acuity(BCVA) was 0.7 in the right eye and 0.5 in the left. His pupil reactions and color vision (Farnsworth D-15 test) were normal.Optical coherence tomography (OCT) revealed disruption of the ellipsoid zone confined to the fovea in both eyes (Figure 2A). Full-field electroretinography (ERG) showed normal.Multifocal electroretinography (mfERG) showed amplitude reduced at macular fovea of both eyes (Figure 3A). Visual field testing showed normal on the 5day of the onset, while there was central scotoma of the left eye on the 17day, the other eye was normal (Humphrey 24-2; Figure 4A).

The patient was advised to stop drug inhalation. With 2mo follow-up, the patient complained that the scotoma was disappeared. At the same time, his BCVA improved to 1.0 in the right eye and 0.8 in the left. OCT showed the photoreceptor layer of both eyes was return to normal (Figure 2B). mfERG showed improvement in both central regions, especially in the right eye (Figure 3B). The central scotoma on the left visual field was disappeared (Figure 4B).

Some other ancillary testings should be considered, such as visual field examination that central or paracentral scotomas are possibly seen with normal peripheral fields, but these abnormalities may not appear in the early stage of the disease.Color vision examination is also helpful to distinguish macular diseases from optic nerve diseases.

Clinical features and ellipsoid zone disruption on OCT of poppers macular lesions are similar to photic injury, the two conditions can only be reliably distinguished by the history of excess light. Therefore, it is crucial to document the relevant drug history and light exposure. Adult-onset occult macular dystrophy should be another differential diagnosis as the normal fundus and similar structural changes in the ellipsoid zone, but the patients with occult macular dystrophy usually have progressive decrease of visual acuity and red-green color defect. If the patient has yolk-like lesions at the fovea,it needs to be differentiated from best vitelliform macular dystrophy.

The prognosis of poppers maculopathy is variable. When they ceased using poppers, most patients may achieve complete or partial resolution, while others experience no improvement.The final results may be related to the duration, frequency and type of drug inhalation.

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