Although drug overdose fatalities have declined markedly in the US in recent years, overdose still remains a leading cause of death in American adults. The drug epidemic shows no signs of abating in the country any time soon, and opioids – including prescription pills, heroin, and synthetic opioids like fentanyl – continue to act as the main driving factor behind many of these fatalities.
Amid this ongoing public health emergency, ophthalmologists – clinicians on the frontlines of the epidemic – have an extraordinary position to be able to facilitate early intervention for patients suffering from substance abuse issues, particularly those presenting with injection drug use–associated endogenous endophthalmitis (IDU-EE).
In an attempt to better identify potential opportunities for earlier intervention with opioid patients, a group of multi-institutional researchers analysed data gathered from Mass General Brigham over a six-year period, examining recent substance use disorder (SUD) care in the Boston-based integrated healthcare system.
To learn more about their study findings, The Ophthalmologist sat down with co-authors Jared T. Sokol, Assistant Professor of Ophthalmology at the Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, and Eric Gaier, Assistant Professor of Ophthalmology at Harvard Medical School and Neuro-Ophthalmologist at the Department of Ophthalmology, Massachusetts Eye and Ear, Massachusetts.
What were you investigating in this study?
We examined injection drug use–associated endogenous endophthalmitis in the modern era to understand both visual outcomes and how often patients receive evidence-based addiction care during hospitalization. Our goal was to identify missed opportunities where treating the eye could also prevent future harm.
Fentanyl is generally associated with worse visual outcomes than other drugs – why do you think it might be linked to more severe ocular disease?
In our cohort, fentanyl use was associated with worse vision outcomes. In honesty, this was not a predefined hypothesis but one that jumped out when we started looking at the data. Fentanyl’s high potency, short duration, and chaotic use patterns may increase infection risk, delay care, and disrupt follow-up. However, after conducting several subgroup analyses, we could not pinpoint a clear explanation. Additionally, fentanyl may be mixed with other injection drugs without the user knowing, so its use is likely under reported. Further research on this important finding is clearly needed.
What key signs might clinicians/emergency departments look out for when inspecting for IDU-EE?
Any person who injects drugs and presents with acute vision loss, floaters, eye pain, or photophobia should raise concern for endogenous endophthalmitis. On exam, vitritis is nearly universal, and chorioretinal lesions – often involving the macula – are common. Diagnosis often requires a combination of slit lamp and indirect ophthalmoscopy examination techniques, which can be difficult to obtain in some emergency departments due to limited accessibility to ophthalmic equipment. If a diagnosis cannot be made, further urgent specialized referral is required to prevent severe vision loss.
Ideally, how would ophthalmologists treat patients with substance abuse issues presenting with endogenous endophthalmitis?
IDU-associated endophthalmitis should be treated as a dual emergency: a vision-threatening infection and a manifestation of severe substance use disorder. Our study supports aggressive ophthalmic treatment (usually with bedside vitreous tap/intravitreal antimicrobials, surgery, or both) alongside inpatient admission and standardized involvement of addiction consultation specialists where available.
What opportunities for intervention were highlighted in your study?
Hospitalization is a critical window. IDU-EE offers a rare touchpoint to connect patients with substance use disorders to evidence-based addiction treatments. We found common opportunities to initiate medications for opioid use disorder, standardize addiction consult involvement, and connect patients to harm-reduction and follow-up care – steps that could reduce both vision loss and overdose risk.
One of the most striking findings is that no opioid use disorder medication was given to patients unless addiction consult services were involved. What do you think this reveals about current inpatient systems of care?
It shows that addiction treatment is still siloed in inpatient care. Even when opioid use disorder is recognized, treatment often doesn’t happen unless a specialist team is consulted – highlighting a system-level gap and opportunity to improve care for these patients.
For ophthalmologists who may feel addiction care is outside their scope, what practical role can they play in triggering addiction consult involvement?
Ophthalmologists don’t need to deliver addiction treatment themselves – but they can normalize and trigger addiction consult involvement, just as they would infectious disease or surgery. Simply making the consult routine can change outcomes.
Do you see future guidelines recommending routine addiction consult service involvement for IDU-EE the way some institutions currently do for injection drug use–associated endocarditis?
Yes. IDU-associated endophthalmitis signals high medical risk. Our findings support routine addiction consult involvement as part of standard inpatient care when resources allow, just like in the treatment of injection drug use–associated endocarditis.
Ophthalmologists are often the first specialists these patients see. That creates a powerful opportunity – not just to save vision, but to intervene at a moment that could change the patient’s long-term health and survival. Although facilitating addiction medicine consultation may require additional steps on the part of the ophthalmologist, such efforts have the potential to meaningfully alter the clinical course of a patient’s substance use disorder.
