Purpose

Cocaine use continues to rise worldwide. Levamisole is an increasingly common cutting agent mixed with cocaine, and both substances result in local and systemic effects. However, their effects on ophthalmic structures are not fully characterised. We sought to explore the adnexal presentations which may arise through cocaine use.

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Methods

Retrospective case series of patients presenting with cocaine-related adnexal damage to a specialist tertiary centre, and review of literature was performed.

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Results

Five cases were identified in our patient records, and 47 cases in the literature. In total, 65% of cases were male (34/52) with median age 45 (range 23-80) years.
Four phenotypes are associated with cocaine abuse: eyelid and ocular surface involvement, orbital involvement (infiltrate with mass effect or inflammatory with bony destruction) with/without systemic pseudo-vasculitis, paranasal sinus disease and dacryocystitis, and vascular events resulting in optic neuropathy or paralytic strabismus, highlighted in our case series:
Case 1: Severe bilateral cicatricising conjunctivitis and unilateral ankyloblepharon.
Case 2: Orbital bony destruction and restrictive strabismus due to medial recti-nasal mucosal adhesion.
Cases 3 and 4: Orbital extension of infiltrative inflammatory masses, causing restrictive strabismus.
Case 5: Extensive destruction of the nasal septum, orbital walls and paranasal sinuses resulting in sino-nasal fistulae. Later visual loss presumed secondary to a vascular event.

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Conclusion

Cocaine is a potent vasoconstrictor capable of local and systemic ischaemia. The devastating adnexal inflammatory responses seen are a likely by-product of levamisole-induced pseudo-vasculitis. Given the rising abuse of levamisole-adulterated cocaine, it is essential that ophthalmologists are aware of the clinical manifestations of this uncommon presentation. Prompt diagnosis, treatment adherence and cocaine abstinence are crucial to overall therapeutic success, and a multi-disciplinary approach should be taken to optimise outcomes.

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Additional Authors

First name	Last name	Base Hospital / Institution
Ken	Kawamoto	Moorfields Eye Hospital, London, United Kingdom
Mohsan	Malik	Moorfields Eye Hospital, London, United Kingdom
Allan	Nghiem	Moorfields Eye Hospital, London, United Kingdom
Simon	Gane	Royal National Throat, Nose, and Ear Hospital, London, United Kingdom
David	Verity	Moorfields Eye Hospital, London, United Kingdom

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