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

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.

Episode Transcript

SPEAKER_00 (00:00):
Welcome to ASRS's Journal of Veterinal Diseases
Authors Forum.
I'm your host, Dr.
Timothy Murray, editor-in-chiefof JVRD.
On each episode of the JVRDAuthors Forum, I will interview
innovative retinal researcherson their studies featured only

(00:22):
in JVRD and how these studieswill impact our patients' care
in our clinics.
Tune in to hear directly frominvestigators about the clinical
implications of the newest andhighest quality research in the
field of retina.
Welcome to JVRD's Author ForumPodcast.

(00:44):
It's a pleasure to be joined bymy colleague and friend, Dr.
John Kitchens of ReddenAssociates of Kentucky.
Dr.
Kitchens and his team had aunique presentation of
tractional retinal detachment ina patient with a history of
methamphetamine use, and we'regoing to discuss some of the
clinical pearls from hismanuscript.
Dr.
Kitchens, thank you.

(01:05):
Thanks, Tim.
Thanks for having me.
It's always a pleasure.
So can you tell me a little bitabout this case and some of the
factors that were so unique?

SPEAKER_01 (01:13):
Yeah, so this is a patient that actually had seen
one of my partners and wasmanaged in one of our satellite
offices and was basicallydiagnosed with having diabetic
retinopathy, proliferativedisease, tractional retinal
detachment.
And despite a series of lasersand treatments with anti-VEGF,

(01:34):
the patient had progressivetraction and then was referred
to me for definitive surgicalcare when the traction started
to involve the macula.
What was so unique about thiscase, though, is that surgery
took off.
We did an anti-VEGF injectionbefore the surgery, which I
think is absolutely critical.
Had a very nice surgical outcomewith significant improvement in

(01:56):
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'sA1c was actually 6.7 when we
talked to him and he had goodsugar control.
And so this was just at oddswith what we were seeing

SPEAKER_00 (02:17):
clinically.
And so what do you do?
Because I think that we all makea presumptive diagnosis based on
the imaging and the history.
So now you get this unique pieceof information that doesn't fit
with your clinical story.
what what are your next steps

SPEAKER_01 (02:35):
yeah i think the first thing is and this is
something that i've learned fromthis case is is just because you
see a patient that doesn't lookhealthy and looks like they
would have an a1c of 12 or 15and not take care of themselves
you still have to ask and and ilooked at this guy and i looked
mainly at his eyes and i thoughtoh he's probably a wreck he's

(02:55):
someone who hasn't controlledhis sugars And I never really
asked until we were a couple ofvisits into this thing.
And so then once we found thatout, it was like, well, wait a
second, how long has your A1Cbeen this good?
And it was years that he had hadexcellent control.
And so then we started to think,well, okay, wait a second, is

(03:16):
this really diabetic retinopathyor could this be something else?
And then about 10 days aftersurgery, he was admitted to the
hospital for a stroke.

SPEAKER_00 (03:27):
And so what are you thinking now?
You take him to the OR, you'veoperated, you've had a good one
day and one week result, andyour patient's in the hospital.
That's got to be a little bit ofa heartache there for you.

SPEAKER_01 (03:40):
Yeah, it's a real kick to the gut.
Obviously, we're very worriedabout the patient and feeling a
lot of, oh my gosh, A, could mysurgery have done this?
Could something with theanesthesia have resulted in
this?
And then B, what could we havedone to preempt this and stop
this from happening?
And that's when that A1C comesback to kind of, you know, in my

(04:02):
mind to say, wait a second, issomething else going on here?
The patient was admitted to theuniversity hospital here in
town, the University ofKentucky.
excellent, amazing doctors.
And I love the fact that on thispaper, I've co-authored it with
three of our fellows, which Ithink is just an awesome thing.
But by having fellows, they wereactually able to check on the

(04:24):
patient and follow along thepatient.
And it was really interestingwhat we found.

SPEAKER_00 (04:30):
Well, you know, it starts off with what would be
essentially a prettystraightforward case, diabetic
patient, you know, complexproliferative disease,
progressive detractiondetachment.
but what is actually going onaround that is really what
defines this.
So history is so important.
We talk about taking a goodhistory all the time, but you

(04:51):
know, sometimes patients don'talways tell us exactly what's
going on.
So, Getting them in the hospitaltends to motivate them, I find,
to be a little bit more focusedon their history.
So this patient has somesurprising history for us.
Is that right?

SPEAKER_01 (05:09):
Yeah, and absolutely.
You're right.
That honesty is a matter of lifeor death for some patients,
especially this patient.
So turns out after a thoroughneurological evaluation and a
more thorough history, thispatient had what looked like
Moya Moya disease, but inactuality, it was caused by
methamphetamine.
Which basically hismethamphetamine use, and I have

(05:32):
to say, I didn't even know thathe 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 justin his eyes, but also in his
brain.
And it was what was responsiblefor his pseudo-diabetic
tractional retinal detachments.

SPEAKER_00 (05:51):
Well, even if he had controlled diabetes to have the
vascular compromise, like wetalk about with other diseases,
you know, that can really alterthe manifestation of the ocular
disease.
So to me, I look at this and Idon't see that I would have
thought to do anything differentthan what you guys did.
And I'm curious if the course ofthis gave you any insight as to

(06:17):
how you might alter yourapproach to a patient like this.

SPEAKER_01 (06:21):
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 forsurgery.
We have medical retina doctorsthat don't operate, and we have
surgeons that operate.
And I think sometimes when youjust see that patient that shows
up for a preoperativeevaluation, it's very easy to
just say, yes, you have amacular hole, or yes, you have a

(06:43):
traction retinal detachment.
Let's just fix this.
And I think taking time to stepback, 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 alittle more history of the
patient and talk to the patienta little bit more.
I don't know if it would havechanged the course of this

(07:03):
gentleman, but I think taking astep back and saying, hey, wait
a second, I can't just treatthis as a, yes, I would operate
on this patient, let's go.
It's talking and learning alittle bit more about that
patient and diving in more intowhat's going on in their lives
and their history and theirexpectations too.

SPEAKER_00 (07:21):
Yeah, that's so easy to say while you see 80 patients
in your clinic, right?
You're in that unique situationof focused referral since we're
more a standalone clinic.
I get to see them from start tofinish.
My thing with this is that, youknow, if I had a better
understanding of the history, Imay have been more aggressive in

(07:41):
our follow-up and sort of timelyintervals for analysis of the
patient and giving them a betteridea of what was going on.
So it's kind of one discussionin somebody that you already
know what's going to happenwith.
It's another discussion whensomebody's out of that typical
clinical course.
And those are the patients Ifind I need to spend that extra

(08:04):
time with.

SPEAKER_01 (08:05):
Yeah.
And I think just also havingthat sort of intuition that
says, wait a second, somethinghere just doesn't fit.
And I've learned it from you andfrom the great clinicians that I
trained under.
There's just a sixth sense thatpeople have that's like, hold
on, something's not makingsense.
And it's not just green lightthem straight to the operating
room.

SPEAKER_00 (08:25):
And I think that this case really highlights how
important that history is andthinking outside of the box and
getting the information that youneed, right?
So I want to thank you forsharing that with us.
The outcome, at least in theshort term for this patient,
looks excellent.
But again, you have that problemwith patients of this caliber,

(08:46):
sometimes where follow-up can bedifficult and patients get lost.
So I really was glad to see thatyou were able to operate because
I think that you and I wouldagree that if you can operate on
these eyes and they go well inthe postoperative period, then a
lot of times these patients canbe long-term stable as opposed
to doing things like ongoinganti-VEGF or even laser.

SPEAKER_01 (09:07):
Yeah, and I think you're absolutely right, Tim.
If he had ended up having thisstroke before the surgery, it
might have been months or yearsbefore we got him to the
operating room.
And then you're dealing with aneovascular anterior segment, a
total tractional retinaldetachment that's not
repairable.
So I agree with you.
I think getting him to theoperating room actually ended up
being fortuitous.
And I just hate that he had tohave this bad systemic event you

(09:31):
know, less than two weeks aftersurgery, he is still alive and
he does still have vision.
So those are both some reallygood things for this patient.

SPEAKER_00 (09:40):
For sure.
Good things for you and I alsofor our patients.
So Dr.
Kitchens, thanks so much forjoining us.
It's a pleasure to have you.
And I direct our listeners tothe full manuscript, Traction
Retinal Detachment in a Patientwith History of Methamphetamine
Use.
Thank you, John.
Thanks, Tim.
Thanks for tuning in to the JVRDAuthors Forum You can watch and

(10:03):
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(10:24):
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