ASRS’s Journal of Vitreoretinal Diseases (JVRD) Author’s Forum

Tractional Retinal Detachment in a Patient With a History of Methamphetamine Use

• American Society of Retina Specialists (ASRS)

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On this episode of the JVRD Author’s Forum podcast, Dr. John Kitchens of Retina Associates of Kentucky discusses 'Tractional Retinal Detachment in a Patient With a History of Methamphetamine Use,' published in the March/April 2025 issue of JVRD.

Host Dr. Timothy Murray and Dr. Kitchens discuss a complex case of tractional retinal detachment initially thought to be a complication of diabetes. Despite good glycemic control (A1c 6.7), further investigation revealed the underlying cause was severe vascular damage from methamphetamine use, not diabetes. Dr. Kitchens shares insights on the importance of thorough history-taking, recognizing when clinical findings don’t align with expectations, and the value of timely surgery in achieving favorable outcomes even in complex cases. 

For more information, visit www.ASRS.org/JVRDForum.

Welcome to ASRS’s Journal of Vitreoretinal Diseases (JVRD) Author’s Forum. JVRD is the official scientific peer-reviewed journal of the American Society of Retina Specialists (ASRS), offering the highest quality and most impactful research and clinical information in the field. Join host Dr. Timothy Murray, Editor-in-Chief of JVRD, as he discusses cutting-edge developments featured in JVRD with the lead authors, who share clinical pearls and explore their significance in advancing patient care.

SPEAKER_00:

Welcome to ASRS's Journal of Veterinal Diseases Authors Forum. I'm your host, Dr. Timothy Murray, editor-in-chief of JVRD. On each episode of the JVRD Authors Forum, I will interview innovative retinal researchers on their studies featured only in JVRD and how these studies will impact our patients' care in our clinics. Tune in to hear directly from investigators about the clinical implications of the newest and highest quality research in the field of retina. Welcome to JVRD's Author Forum Podcast. It's a pleasure to be joined by my colleague and friend, Dr. John Kitchens of Redden Associates of Kentucky. Dr. Kitchens and his team had a unique presentation of tractional retinal detachment in a patient with a history of methamphetamine use, and we're going to discuss some of the clinical pearls from his manuscript. Dr. Kitchens, thank you. Thanks, Tim. Thanks for having me. It's always a pleasure. So can you tell me a little bit about this case and some of the factors that were so unique?

SPEAKER_01:

Yeah, so this is a patient that actually had seen one of my partners and was managed in one of our satellite offices and was basically diagnosed with having diabetic retinopathy, proliferative disease, tractional retinal detachment. And despite a series of lasers and treatments with anti-VEGF, the patient had progressive traction and then was referred to me for definitive surgical care when the traction started to involve the macula. What was so unique about this case, though, is that surgery took off. We did an anti-VEGF injection before the surgery, which I think is absolutely critical. Had a very nice surgical outcome with significant improvement in the vision from like one foot, two foot, 200 to 2150. But somewhere along the line, it's been several years since I actually saw this patient. It turned up that the patient's A1c was actually 6.7 when we talked to him and he had good sugar control. And so this was just at odds with what we were seeing

SPEAKER_00:

clinically. And so what do you do? Because I think that we all make a presumptive diagnosis based on the imaging and the history. So now you get this unique piece of information that doesn't fit with your clinical story. what what are your next steps

SPEAKER_01:

yeah i think the first thing is and this is something that i've learned from this case is is just because you see a patient that doesn't look healthy and looks like they would have an a1c of 12 or 15 and not take care of themselves you still have to ask and and i looked at this guy and i looked mainly at his eyes and i thought oh he's probably a wreck he's someone who hasn't controlled his sugars And I never really asked until we were a couple of visits into this thing. And so then once we found that out, it was like, well, wait a second, how long has your A1C been this good? And it was years that he had had excellent control. And so then we started to think, well, okay, wait a second, is this really diabetic retinopathy or could this be something else? And then about 10 days after surgery, he was admitted to the hospital for a stroke.

SPEAKER_00:

And so what are you thinking now? You take him to the OR, you've operated, you've had a good one day and one week result, and your patient's in the hospital. That's got to be a little bit of a heartache there for you.

SPEAKER_01:

Yeah, it's a real kick to the gut. Obviously, we're very worried about the patient and feeling a lot of, oh my gosh, A, could my surgery have done this? Could something with the anesthesia have resulted in this? And then B, what could we have done to preempt this and stop this from happening? And that's when that A1C comes back to kind of, you know, in my mind to say, wait a second, is something else going on here? The patient was admitted to the university hospital here in town, the University of Kentucky. excellent, amazing doctors. And I love the fact that on this paper, I've co-authored it with three of our fellows, which I think is just an awesome thing. But by having fellows, they were actually able to check on the patient and follow along the patient. And it was really interesting what we found.

SPEAKER_00:

Well, you know, it starts off with what would be essentially a pretty straightforward case, diabetic patient, you know, complex proliferative disease, progressive detraction detachment. but what is actually going on around that is really what defines this. So history is so important. We talk about taking a good history all the time, but you know, sometimes patients don't always tell us exactly what's going on. So, Getting them in the hospital tends to motivate them, I find, to be a little bit more focused on their history. So this patient has some surprising history for us. Is that right?

SPEAKER_01:

Yeah, and absolutely. You're right. That honesty is a matter of life or death for some patients, especially this patient. So turns out after a thorough neurological evaluation and a more thorough history, this patient had what looked like Moya Moya disease, but in actuality, it was caused by methamphetamine. Which basically his methamphetamine use, and I have to say, I didn't even know that he was a meth user. He didn't admit to that to us. He didn't say anything about it, but it had caused severe vascular obliteration, not just in his eyes, but also in his brain. And it was what was responsible for his pseudo-diabetic tractional retinal detachments.

SPEAKER_00:

Well, even if he had controlled diabetes to have the vascular compromise, like we talk about with other diseases, you know, that can really alter the manifestation of the ocular disease. So to me, I look at this and I don't see that I would have thought to do anything different than what you guys did. And I'm curious if the course of this gave you any insight as to how you might alter your approach to a patient like this.

SPEAKER_01:

You know, I I think in our practice, and we've got a great practice with 10 doctors, we have doctors that refer patients all the time for surgery. We have medical retina doctors that don't operate, and we have surgeons that operate. And I think sometimes when you just see that patient that shows up for a preoperative evaluation, it's very easy to just say, yes, you have a macular hole, or yes, you have a traction retinal detachment. Let's just fix this. And I think taking time to step back, sit down in the chair, and cross your legs and say, okay, tell me what's going on with you and get a little rapport and a little more history of the patient and talk to the patient a little bit more. I don't know if it would have changed the course of this gentleman, but I think taking a step back and saying, hey, wait a second, I can't just treat this as a, yes, I would operate on this patient, let's go. It's talking and learning a little bit more about that patient and diving in more into what's going on in their lives and their history and their expectations too.

SPEAKER_00:

Yeah, that's so easy to say while you see 80 patients in your clinic, right? You're in that unique situation of focused referral since we're more a standalone clinic. I get to see them from start to finish. My thing with this is that, you know, if I had a better understanding of the history, I may have been more aggressive in our follow-up and sort of timely intervals for analysis of the patient and giving them a better idea of what was going on. So it's kind of one discussion in somebody that you already know what's going to happen with. It's another discussion when somebody's out of that typical clinical course. And those are the patients I find I need to spend that extra time with.

SPEAKER_01:

Yeah. And I think just also having that sort of intuition that says, wait a second, something here just doesn't fit. And I've learned it from you and from the great clinicians that I trained under. There's just a sixth sense that people have that's like, hold on, something's not making sense. And it's not just green light them straight to the operating room.

SPEAKER_00:

And I think that this case really highlights how important that history is and thinking outside of the box and getting the information that you need, right? So I want to thank you for sharing that with us. The outcome, at least in the short term for this patient, looks excellent. But again, you have that problem with patients of this caliber, sometimes where follow-up can be difficult and patients get lost. So I really was glad to see that you were able to operate because I think that you and I would agree that if you can operate on these eyes and they go well in the postoperative period, then a lot of times these patients can be long-term stable as opposed to doing things like ongoing anti-VEGF or even laser.

SPEAKER_01:

Yeah, and I think you're absolutely right, Tim. If he had ended up having this stroke before the surgery, it might have been months or years before we got him to the operating room. And then you're dealing with a neovascular anterior segment, a total tractional retinal detachment that's not repairable. So I agree with you. I think getting him to the operating room actually ended up being fortuitous. And I just hate that he had to have this bad systemic event you know, less than two weeks after surgery, he is still alive and he does still have vision. So those are both some really good things for this patient.

SPEAKER_00:

For sure. Good things for you and I also for our patients. So Dr. Kitchens, thanks so much for joining us. It's a pleasure to have you. And I direct our listeners to the full manuscript, Traction Retinal Detachment in a Patient with History of Methamphetamine Use. Thank you, John. Thanks, Tim. Thanks for tuning in to the JVRD Authors Forum You can watch and listen to more episodes on the ASRS YouTube channel and on popular podcast directories including Apple Podcasts and Spotify. Visit www.asrs.org forward slash JVRD forum on the ASRS website to learn more. See you soon.