A Case Report of Acute Esotropia in a Young Woman following Heroin Withdrawal

Abstract

Introduction. Esotropia is a form of strabismus that can give the affected individual a “cross-eyed” appearance. Acute onset of esotropia is an uncommon form; in the vast majority of cases, no underlying neurological etiology is found. Case Presentation. A 22-year-old female with a long history of opiate abuse presented with acute onset of diplopia. She noted her eyes were crossing and started seeing double. She stopped using heroin 11 days prior to presentation. There was large inward deviation of her left eye. Convergence was difficult and accompanied by horizontal nystagmus. Diplopia resolved by covering each eye. Further investigations including imaging studies were normal. Discussion. Acute onset esotropia is rare and must be investigated right away to exclude central nervous system pathologies, where no opiates use is reported. Diplopia in the form of acute esotropia may manifest in up to 30% of individuals undergoing heroin withdrawal. Evaluating acute esotropia requires detailed information of medical history with an emphasis on drug use. Conclusion. Acute onset esotropia with double vision can be caused by abrupt withdrawal of opiates. This case should serve to raise awareness among health care professionals, to avoid costly and unnecessary diagnostic evaluations and interventions.

Emerging and Underrecognized Complications of Illicit Drug Use

“…There have been several outbreaks of black tar heroin-related tetanus and botulism in California, China, Saudi Arabia, and Western Europe [66][67][68][69]. Withdrawal from heroin can cause acute esotropia, or strabismus, which typically resolves after the withdrawal period is over [70]. In persons who injected crush-resistant opiates, 2 cases have been reported of opiate-associated hearing loss, thought to be secondary to cochlear ischemia [71].…”

Acute Esotropia in the Setting of Heroin Withdrawal

“…1 This phenomenon was first observed in soldiers returning from Vietnam. 4 In fact, vision problems including diplopia were reported with many drugs of abuse.…”

“…myasthenia gravis), but can also be idiopathic. 1 The onset of esotropia can be very relevant in patients with brain tumors as it sometimes suggests a rise in intracranial pressure. 2 Ocular deviations resulting from nerve palsies or a defect of extraocular muscles that vary with the direction of gaze are called 'incomitant', while those that don't change with the direction of gaze are called 'comitant'.…”

Heroin-Induced Exodeviation Masking a Baseline Decompensated Esophoria

“…The majority of the cases are of an induction of acute-onset comitant esotropia from heroin withdrawal, which typically occurs 3 to 8 days after heroin cessation. [1][2][3][4][5][6][7][8][9][10] The effects of heroin withdrawal were systematically evaluated by Firth et al 4 where they examined 66 patients undergoing heroin detoxification and found 16 patients had esotropia and 5 had intermittent esotropia after 5 days of detoxification, which was not present prior to detoxification. 1 Studies of strabismus during acute heroin intake are less prevalent, but acute use of heroin has been reported to cause comitant exotropia without underlying neurologic or ocular pathology in a few cases.…”

“…[1][2][3][4][5][6][7][8][9][10] There are also rare reports of acute heroin ingestion causing exotropia. 8,10 We report a patient presenting with a decompensated esophoria who had transient improvement in her diplopia from heroin-induced exodeviation.…”