Papillophlebitis Following Methamphetamine Abuse in a Middle-Aged Patient: A Case Report

Papillophlebitis Following Methamphetamine Abuse in a Middle-Aged Patient: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Papillophlebitis Following Methamphetamine Abuse in a Middle-Aged Patient: A Case Report Mojtaba Abrishami, Farid Shekarchian, Naser Shoeibi, Kian Ghasemi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7497035/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To describe a case of papillophlebitis in a middle-aged male following recent methamphetamine use, highlighting a possible causal relationship. Case Presentation: A 52-year-old male construction worker with no notable systemic or ocular history arrived at the emergency department, reporting sudden and worsening vision loss in his left eye. He mentioned smoking cigarettes and recent methamphetamine use beginning two days prior to symptoms onset. Eye examination showed optic disc swelling, venous engorgement, and peripapillary hemorrhages, indicative of papillophlebitis. No evidence of systemic illness, ocular trauma, or previous similar episodes was found. Macular edema was resolved after single intravitreal bevacizumab injection. Conclusion: This case suggests that the vascular effects of methamphetamine—such as vasospasm, endothelial damage, and hypercoagulability—may induce papillophlebitis even in healthy individuals. Clinicians should inquire about recent stimulant use when evaluating patients with sudden vision loss and monitor closely for potential progression to ischemic central retinal vein occlusion and related complications. Papillophlebitis Methamphetamine Retinal Vein Occlusion Substance-Related Disorders Figures Figure 1 Figure 2 Introduction Papillophlebitis is an uncommon retinal vascular disorder traditionally regarded as a mild, non-ischemic variant of central retinal vein occlusion (CRVO), mainly affecting healthy young adults, especially women ( 1 ). Clinically, it features unilateral optic disc swelling, venous dilation and tortuosity, and peripapillary hemorrhages, with visual acuity often better preserved than expected given the severity of fundoscopic findings ( 2 ). The exact cause remains unclear, but localized venous inflammation, immune-mediated mechanisms, and temporary disruptions in retinal venous outflow have been suggested as contributing factors ( 3 ). Although most cases resolve on their own with a good outlook, some may develop into ischemic CRVO, causing complications like macular edema or retinal neovascularization. This highlights the importance of prompt recognition and careful follow-up ( 4 ). Known risk factors include hypercoagulable states, systemic inflammatory disorders, and rarely, external exposures such as medications or recreational drugs ( 5 ). Methamphetamine abuse has become an escalating global public health concern ( 6 ). In addition to its well-documented neuropsychiatric effects, methamphetamine exerts strong cardiovascular and vasculotoxic effects through mechanisms such as vasospasm, endothelial injury, oxidative stress, and the promotion of a prothrombotic state ( 7 ). While methamphetamine-related ischemic strokes, myocardial infarctions, and retinal vascular occlusions have been reported ( 8 ), its connection with papillophlebitis remains undocumented ( 9 ). Here, we present what appears to be one of the first documented cases of papillophlebitis following recent methamphetamine use in a middle-aged man. This case emphasizes the importance of increased clinical awareness of unusual ocular vascular presentations in patients with a history of stimulant use. Case Report A 52-year-old male construction worker presented to the emergency department with a two-day history of sudden-onset, progressively worsening visual impairment in his left eye. He had no past medical history of diabetes mellitus, hypertension, or systemic illness. Blood pressure at presentation was 122/82 mmHg. The patient reported recent methamphetamine use beginning two days before symptom onset and a remote history of cigarette smoking. He denied ocular trauma, previous visual disturbances, or similar episodes. On ophthalmic examination, best-corrected visual acuity was 20/20 in the right eye and 10/20 in the left eye. Pupillary responses were normal without a relative afferent pupillary defect. Anterior segment examination was unremarkable except for mild nuclear sclerosis in both eyes. Fundus examination of the left eye revealed optic disc edema, venous engorgement and tortuosity, and scattered peripapillary hemorrhages consistent with papillophlebitis. The right eye fundus appeared normal. Imaging Findings Color fundus photography of the left eye confirmed optic disc edema with blurred margins, venous engorgement, and multiple peripapillary flame-shaped and blot hemorrhages, predominantly in the superior and temporal quadrants, with sparing of the macula (Fig. 1 ). The right eye was normal. Optical coherence tomography (OCT) demonstrated marked optic disc edema and thickening of the retinal nerve fiber layer (RNFL) in the left eye, with values ranging from 204–215 µm in the superior and nasal quadrants (p < 5%). Ganglion cell complex (GCC) analysis revealed abnormal thickening up to 212 µm (p < 1%), consistent with optic nerve head edema. Macular OCT of the left eye demonstrated severe cystoid macular edema, with a central foveal thickness of 537 µm and parafoveal thickness of 427 µm, along with intraretinal fluid pockets on cross-sectional imaging (Fig. 1 ). The right eye demonstrated normal RNFL, GCC, and macular parameters. Fluorescein angiography and perimetry could not be performed due to poor patient compliance and loss to follow-up, limiting further assessment of retinal perfusion and functional deficits. Laboratory Workup A thorough systemic evaluation was conducted to rule out secondary causes of retinal venous occlusion. Coagulation tests (PT, INR, PTT), inflammatory markers (ESR, CRP), complete blood count, fasting blood glucose, and serum proteins were all within normal limits. Autoimmune screening, including RF, ANA, and ANCA, was negative. Thrombophilia screening, which included protein C, protein S, antithrombin III, fibrinogen, homocysteine, and Factor V Leiden mutation, showed no abnormalities. Antiphospholipid and anticardiolipin antibodies were absent. Serum angiotensin-converting enzyme levels were normal, suggesting sarcoidosis is unlikely. Overall, these findings exclude systemic, hematologic, and autoimmune predispositions. (Table 1 ) Management: Given the presence of vision-threatening cystoid macular edema, the patient received an intravitreal injection of bevacizumab (Stivant, CinnaGen Co., Tehran, Iran) (1.25 mg/0.05 mL). One month later, visual acuity improved to 20/20 in the affected eye, and there was significant improvement in the fundus examination. Macular and RNFL OCT were performed for the affected eye. The macular profile shows restoration of the foveal contour with marked resolution of intraretinal cystic changes and subretinal fluid that were previously evident (Fig. 2 ). The RNFL distribution demonstrates relative normalization compared to baseline. Table 1 Results of the laboratory test evaluation for the patient. patient Normal range unit PT 10 8–11 PTT 24 20–35 INR 1 ESR 2 < 20 mm WBC 6.9 4–10 10*3/µL RBC 5.0 4.2–5.6 10*6/µL Hemoglobin 14.9 13.1–17.2 g/dL Hematocrit 45.1 41.5–51 % platelets 163 150–400 10*3/µL FBS 92 74–106 mg/dL Protein 6.1 6.4–8.3 g/dL CRP 4.4 0–22 mg/dL RF 8.6 0–24 IU/mL ANA 0.1 < 0.9 Anti Ds DNA 27.8 < 30 IU/mL Factor V Leiden 5.0 < 10% % Fibrinogen 362 100–450 mg/dL Hemocysteine 7.8 3.7–13.9 micM/L ACE 76.4 8–65 U/L ANCA < 1:20 < 1:20 U/mL Anti Cardiolipin G 0.6 < 10 U/mL Anti Phospholipid (IgG) 1.1 < 10 U/mL Anti Phospholipid (IgM) 0.5 < 10 U/mL Anti-Thrombin III 118 70–120 Protein C 98 70–140 % Protein S 66 70–140 % Discussion This report describes an unusual case of papillophlebitis in a 52-year-old man who recently used methamphetamine and presents with cystoid macular edema. Usually, papillophlebitis occurs in healthy young adults, mostly women, and is considered a self-limiting condition ( 1 , 2 ). The clinical features of this patient match the typical signs of papillophlebitis—optic disc swelling, venous engorgement, and peripapillary hemorrhages—with optical coherence tomography (OCT) showing thickening of the retinal nerve fiber layer (204–215 µm), edema of the ganglion cell complex (up to 212 µm), and severe cystoid macular edema (central foveal thickness 537 µm) ( 3 ). The patient's unusual age, sex, and risk factors, along with the timing of methamphetamine use, suggest a possible new trigger for the condition ( 6 , 7 , 9 ). Methamphetamine is a potent psychostimulant known to exert systemic vasculotoxic effects. Its pathophysiologic mechanisms include catecholamine-mediated vasospasm, endothelial injury, oxidative stress, and promotion of a hypercoagulable state ( 7 ). These mechanisms may trigger localized venous inflammation or compromise retinal venous outflow, aligning with current hypotheses regarding the pathogenesis of papillophlebitis ( 3 ). Although methamphetamine has been associated with ischemic strokes, myocardial infarction, and retinal arterial occlusions ( 8 ), reports of venous occlusive disorders, including papillophlebitis, are sparse ( 9 ). The absence of systemic risk factors in this patient, confirmed through an extensive negative laboratory workup, further supports a drug-induced vascular event. However, a latent predisposition cannot be excluded entirely ( 4 , 5 ). Macular edema is an infrequent complication of papillophlebitis, yet it constitutes a significant cause of visual impairment when it manifests. In this instance, the intensity of cystoid macular edema suggests a more substantial vascular injury, likely exacerbated by methamphetamine-related alterations in retinal blood flow ( 3 , 7 ). Intravitreal bevacizumab was selected to diminish macular edema through the reduction of vascular permeability. Whilst anti-VEGF therapy is routinely employed in cases of central retinal vein occlusion with macular involvement, its efficacy in the context of papillophlebitis remains less well-established ( 5 ). Alternative options, such as corticosteroids aimed at mitigating inflammation, or observation alone—which may suffice in mild, self-limiting cases—were contemplated but deemed less appropriate given the severity of the edema ( 5 ). The lack of fluorescein angiography and perimetry, due to patient non-compliance, further limited the assessment of retinal perfusion and functional outcomes. This is a significant limitation, as up to 30% of papillophlebitis cases may develop into ischemic CRVO with complications such as macular edema or neovascularization ( 4 ). Despite these challenges, this case highlights the importance of considering recreational drug use in atypical retinal vascular presentations. With the global increase in stimulant abuse, ophthalmologists and emergency physicians should stay vigilant and take detailed substance use histories when assessing patients with sudden vision loss ( 6 , 7 , 9 ). Future studies are needed to clarify the potential role of methamphetamine in precipitating retinal venous disorders and to define optimal management strategies, particularly for cases complicated by macular edema. While this single case does not establish causality, it contributes to the limited body of evidence suggesting a possible association between methamphetamine exposure and papillophlebitis. Conclusion This report highlights a possible link between recent methamphetamine use and papillophlebitis with cystoid macular edema in a middle-aged male, an atypical demographic for this condition ( 1 ). The findings suggest that methamphetamine’s vascular effects may precipitate retinal venous inflammation and complications. Clinicians should inquire about stimulant use in patients presenting with acute visual loss, closely monitor for potential progression, and consider targeted therapy in cases with vision-threatening macular involvement. Further research is warranted to characterize this association better and guide evidence-based management. Declarations Ethics approval and consent to participate: Not applicable. This study describes a single patient case report. Institutional ethics approval was not required according to the policies of Mashhad University of Medical Sciences. Consent for publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials: The datasets used and analyzed in this report are available from the corresponding authors upon reasonable request. Competing interests: The authors declare that they have no competing interests Funding: The authors received no funding. It is the author’s work, not funded by the government or academic institutes. Authors’ contributions: KG collected the clinical data, reviewed the literature, and drafted the manuscript. MA was responsible for the clinical management and treatment of the patient, and provided supervision. FS contributed to the diagnosis of the condition, assisted with the interpretation of clinical findings, and helped draft and revise sections of the manuscript. NS assisted with the diagnosis, provided imaging tools free of charge, performed imaging acquisition and analysis, and contributed to the interpretation of imaging results. Acknowledgments: It is a pleasure to acknowledge the ophthalmic technicians who helped us with patient evaluations and imaging, MohammadReza Taheri-Kalate, Elham Sadat Montazeri, Atefeh Ramezanpour, Fahime Alimirzaei. References Zhang XT, Zhong YF, Xue YQ, Li SQ, Wang BY, Zhang GQ, Hidasa I, Zhang H (2022) Clinical Features of Central Retinal Vein Occlusion in Young Patients. Ophthalmol Ther 11(4):1409–1422 Abdel Jalil S, Amer R (2024) The Spectrum of Papillophlebitis. Ocul Immunol Inflamm 32(10):2515–2520 Güngör İ, Konuk GE, Süllü Y, Arıtürk N, Papillophlebitis (2014) Treatment of Vision Loss Due To Subretinal Fluid with Intravitreal Ranibizumab. Neuroophthalmology 38(6):336–339 Fong AC, Schatz H, McDonald HR, Burton TC, Maberley AL, Joffe L, Zegarra H, Nadel AJ, Johnson RN (1992) Central retinal vein occlusion in young adults (papillophlebitis). Retina 12(1):3–11 Hayreh SS, Zimmerman B, McCarthy MJ, Podhajsky P (2001) Systemic diseases associated with various types of retinal vein occlusion. Am J Ophthalmol 131(1):61–77 Güngör İ, Konuk GE, Süllü Y, Arıtürk N, Papillophlebitis (2014) Treatment of Vision Loss Due To Subretinal Fluid with Intravitreal Ranibizumab. Neuroophthalmology 38(6):336–339 Kittirattanapaiboon P, Srikosai S, Wittayanookulluk A (2017) Methamphetamine use and dependence in vulnerable female populations. Curr Opin Psychiatry 30(4):247–252 Kevil CG, Goeders NE, Woolard MD, Bhuiyan MS, Dominic P, Kolluru GK, Arnold CL, Traylor JG, Orr AW (2019) Methamphetamine Use and Cardiovascular Disease. Arterioscler Thromb Vasc Biol 39(9):1739–1746 Darke S, Kaye S, McKetin R, Duflou J (2008) Major physical and psychological harms of methamphetamine use. Drug Alcohol Rev 27(3):253–262 Lee M, Leskova W, Eshaq RS, Harris NR (2021) Retinal hypoxia and angiogenesis with methamphetamine. Exp Eye Res 206:108540 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7497035","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":509184007,"identity":"e80093ba-67b8-434d-bea6-b879559ad5cc","order_by":0,"name":"Mojtaba Abrishami","email":"","orcid":"","institution":"Khatam-al-Anbia Eye Hospital, Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mojtaba","middleName":"","lastName":"Abrishami","suffix":""},{"id":509184008,"identity":"3a301d34-bc3c-4aa3-aaea-55d4a439dea0","order_by":1,"name":"Farid Shekarchian","email":"","orcid":"","institution":"Khatam-al-Anbia Eye Hospital, Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Farid","middleName":"","lastName":"Shekarchian","suffix":""},{"id":509184009,"identity":"de185c0d-a88b-4c39-a148-81879c4dfeb6","order_by":2,"name":"Naser Shoeibi","email":"","orcid":"","institution":"Khatam-al-Anbia Eye Hospital, Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Naser","middleName":"","lastName":"Shoeibi","suffix":""},{"id":509184010,"identity":"8b7f923a-a8fd-4643-89a0-472842690539","order_by":3,"name":"Kian Ghasemi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYBACCWYgwdgAYjI2PkhgsAAyEojX0myQwCBBhBYGuBYGNgkGYrRItjM/e/h1h509v9jhtooHNRJyBscTGD98zMGtRZqZzdxY9kxy4szZiW03Eo5JGBucecAsOXMbbi1yzAxm0pJtzAkGt4FaEhskEjfcSGBj5sWrhf0bUEu9vT1QSwFRWqSZecwkP7YdZtwgndjGQJQWyWaeMmnGtuOJM24nNkuA/CJ55mEzXr9InD++TfJnW7U9/+z0hx9/1NjI8R1PPvjhIx4tIMDMg8qHRhM+wPiDoJJRMApGwSgY0QAATGRPs4F1exUAAAAASUVORK5CYII=","orcid":"","institution":"Khatam-al-Anbia Eye Hospital, Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Kian","middleName":"","lastName":"Ghasemi","suffix":""}],"badges":[],"createdAt":"2025-08-30 18:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7497035/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7497035/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90904569,"identity":"3755f0cf-77c1-4677-856c-c8ba32688551","added_by":"auto","created_at":"2025-09-09 12:55:44","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":330843,"visible":true,"origin":"","legend":"\u003cp\u003eA) Fundus photo of Right Eye: Clear media, well-demarcated optic disc margins. No swelling or hemorrhage. Retinal vasculature appears normal in caliber without venous engorgement or tortuosity. Macula shows preserved foveal reflex. B) Fundus photo of Left Eye: Blurring of disc margins with disc swelling. Peripapillary region shows venous congestion. Loss of foveal reflex with suspicion of macular edema is visible. C) Macular OCT of Right Eye: Normal foveal contour, intact retinal layers, no cystoid changes or subretinal fluid. D) Macular OCT of Left Eye: Loss of normal foveal contour with intraretinal cystoid hyporeflective spaces, subfoveal fluid, and retinal thickening, consistent with cystoid macular edema. E) TSNIT Plot: Symmetry analysis shows RNFL values for the right eye within normal range, while the left eye demonstrates significant deviation above normative values, reflecting diffuse RNFL thickening in correlation with optic disc edema. F) The macular thickness map of the left eye represents a pattern of significant macular edema. The central subfield thickness is markedly elevated, and the surrounding sectors show diffuse thickening. The pattern is consistent with cystoid macular edema.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7497035/v1/4a2267f7115f73e975e0d907.jpg"},{"id":90904568,"identity":"5f1e0c12-ee12-4542-992f-34ef9de25117","added_by":"auto","created_at":"2025-09-09 12:55:44","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":232258,"visible":true,"origin":"","legend":"\u003cp\u003eA) TSNIT profile (1-month follow-up): The RNFL distribution shows relative normalization compared to baseline, with most sectors falling within the normal (green) range. Mild superior thickening remains but is less noticeable than at presentation, indicating resolution of previous optic disc edema. B) Macular OCT scan: The macular profile displays restoration of the foveal contour with significant resolution of intraretinal cystic changes and subretinal fluid that were previously observed. The central macular thickness has returned to normal, and no new exudation or hemorrhage is present.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7497035/v1/945a80eb87652ab630dd67a4.jpg"},{"id":92441400,"identity":"76dbb332-2d84-45bd-9161-b81c42ab5930","added_by":"auto","created_at":"2025-09-29 18:38:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":973867,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7497035/v1/c5d385dc-1408-4544-afb9-c7e6a4ecd354.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Papillophlebitis Following Methamphetamine Abuse in a Middle-Aged Patient: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePapillophlebitis is an uncommon retinal vascular disorder traditionally regarded as a mild, non-ischemic variant of central retinal vein occlusion (CRVO), mainly affecting healthy young adults, especially women (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Clinically, it features unilateral optic disc swelling, venous dilation and tortuosity, and peripapillary hemorrhages, with visual acuity often better preserved than expected given the severity of fundoscopic findings (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The exact cause remains unclear, but localized venous inflammation, immune-mediated mechanisms, and temporary disruptions in retinal venous outflow have been suggested as contributing factors (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough most cases resolve on their own with a good outlook, some may develop into ischemic CRVO, causing complications like macular edema or retinal neovascularization. This highlights the importance of prompt recognition and careful follow-up (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Known risk factors include hypercoagulable states, systemic inflammatory disorders, and rarely, external exposures such as medications or recreational drugs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMethamphetamine abuse has become an escalating global public health concern (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In addition to its well-documented neuropsychiatric effects, methamphetamine exerts strong cardiovascular and vasculotoxic effects through mechanisms such as vasospasm, endothelial injury, oxidative stress, and the promotion of a prothrombotic state (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). While methamphetamine-related ischemic strokes, myocardial infarctions, and retinal vascular occlusions have been reported (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), its connection with papillophlebitis remains undocumented (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHere, we present what appears to be one of the first documented cases of papillophlebitis following recent methamphetamine use in a middle-aged man. This case emphasizes the importance of increased clinical awareness of unusual ocular vascular presentations in patients with a history of stimulant use.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 52-year-old male construction worker presented to the emergency department with a two-day history of sudden-onset, progressively worsening visual impairment in his left eye. He had no past medical history of diabetes mellitus, hypertension, or systemic illness. Blood pressure at presentation was 122/82 mmHg. The patient reported recent methamphetamine use beginning two days before symptom onset and a remote history of cigarette smoking. He denied ocular trauma, previous visual disturbances, or similar episodes.\u003c/p\u003e\u003cp\u003eOn ophthalmic examination, best-corrected visual acuity was 20/20 in the right eye and 10/20 in the left eye. Pupillary responses were normal without a relative afferent pupillary defect. Anterior segment examination was unremarkable except for mild nuclear sclerosis in both eyes. Fundus examination of the left eye revealed optic disc edema, venous engorgement and tortuosity, and scattered peripapillary hemorrhages consistent with papillophlebitis. The right eye fundus appeared normal.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eImaging Findings\u003c/h2\u003e\u003cp\u003eColor fundus photography of the left eye confirmed optic disc edema with blurred margins, venous engorgement, and multiple peripapillary flame-shaped and blot hemorrhages, predominantly in the superior and temporal quadrants, with sparing of the macula (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The right eye was normal.\u003c/p\u003e\u003cp\u003eOptical coherence tomography (OCT) demonstrated marked optic disc edema and thickening of the retinal nerve fiber layer (RNFL) in the left eye, with values ranging from 204\u0026ndash;215 \u0026micro;m in the superior and nasal quadrants (p\u0026thinsp;\u0026lt;\u0026thinsp;5%). Ganglion cell complex (GCC) analysis revealed abnormal thickening up to 212 \u0026micro;m (p\u0026thinsp;\u0026lt;\u0026thinsp;1%), consistent with optic nerve head edema. Macular OCT of the left eye demonstrated severe cystoid macular edema, with a central foveal thickness of 537 \u0026micro;m and parafoveal thickness of 427 \u0026micro;m, along with intraretinal fluid pockets on cross-sectional imaging (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The right eye demonstrated normal RNFL, GCC, and macular parameters.\u003c/p\u003e\u003cp\u003eFluorescein angiography and perimetry could not be performed due to poor patient compliance and loss to follow-up, limiting further assessment of retinal perfusion and functional deficits.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eLaboratory Workup\u003c/h3\u003e\n\u003cp\u003eA thorough systemic evaluation was conducted to rule out secondary causes of retinal venous occlusion. Coagulation tests (PT, INR, PTT), inflammatory markers (ESR, CRP), complete blood count, fasting blood glucose, and serum proteins were all within normal limits. Autoimmune screening, including RF, ANA, and ANCA, was negative. Thrombophilia screening, which included protein C, protein S, antithrombin III, fibrinogen, homocysteine, and Factor V Leiden mutation, showed no abnormalities. Antiphospholipid and anticardiolipin antibodies were absent. Serum angiotensin-converting enzyme levels were normal, suggesting sarcoidosis is unlikely. Overall, these findings exclude systemic, hematologic, and autoimmune predispositions. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eManagement:\u003c/h3\u003e\n\u003cp\u003eGiven the presence of vision-threatening cystoid macular edema, the patient received an intravitreal injection of bevacizumab (Stivant, CinnaGen Co., Tehran, Iran) (1.25 mg/0.05 mL). One month later, visual acuity improved to 20/20 in the affected eye, and there was significant improvement in the fundus examination. Macular and RNFL OCT were performed for the affected eye. The macular profile shows restoration of the foveal contour with marked resolution of intraretinal cystic changes and subretinal fluid that were previously evident (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The RNFL distribution demonstrates relative normalization compared to baseline.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults of the laboratory test evaluation for the patient.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003epatient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNormal range\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eunit\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u0026ndash;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePTT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u0026ndash;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eINR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eESR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003emm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWBC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10*3/\u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRBC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.2\u0026ndash;5.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10*6/\u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.1\u0026ndash;17.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eg/dL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHematocrit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.5\u0026ndash;51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eplatelets\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e163\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e150\u0026ndash;400\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10*3/\u0026micro;L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFBS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74\u0026ndash;106\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003emg/dL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProtein\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.4\u0026ndash;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eg/dL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCRP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u0026ndash;22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003emg/dL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIU/mL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eANA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnti Ds DNA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIU/mL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFactor V Leiden\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFibrinogen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e362\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100\u0026ndash;450\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003emg/dL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemocysteine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.7\u0026ndash;13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003emicM/L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eACE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u0026ndash;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eU/L\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eANCA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1:20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;1:20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eU/mL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnti Cardiolipin G\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eU/mL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnti Phospholipid (IgG)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eU/mL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnti Phospholipid (IgM)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eU/mL\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnti-Thrombin III\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e118\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u0026ndash;120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProtein C\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u0026ndash;140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProtein S\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u0026ndash;140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis report describes an unusual case of papillophlebitis in a 52-year-old man who recently used methamphetamine and presents with cystoid macular edema. Usually, papillophlebitis occurs in healthy young adults, mostly women, and is considered a self-limiting condition (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The clinical features of this patient match the typical signs of papillophlebitis\u0026mdash;optic disc swelling, venous engorgement, and peripapillary hemorrhages\u0026mdash;with optical coherence tomography (OCT) showing thickening of the retinal nerve fiber layer (204\u0026ndash;215 \u0026micro;m), edema of the ganglion cell complex (up to 212 \u0026micro;m), and severe cystoid macular edema (central foveal thickness 537 \u0026micro;m) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The patient's unusual age, sex, and risk factors, along with the timing of methamphetamine use, suggest a possible new trigger for the condition (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMethamphetamine is a potent psychostimulant known to exert systemic vasculotoxic effects. Its pathophysiologic mechanisms include catecholamine-mediated vasospasm, endothelial injury, oxidative stress, and promotion of a hypercoagulable state (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These mechanisms may trigger localized venous inflammation or compromise retinal venous outflow, aligning with current hypotheses regarding the pathogenesis of papillophlebitis (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Although methamphetamine has been associated with ischemic strokes, myocardial infarction, and retinal arterial occlusions (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), reports of venous occlusive disorders, including papillophlebitis, are sparse (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The absence of systemic risk factors in this patient, confirmed through an extensive negative laboratory workup, further supports a drug-induced vascular event. However, a latent predisposition cannot be excluded entirely (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMacular edema is an infrequent complication of papillophlebitis, yet it constitutes a significant cause of visual impairment when it manifests. In this instance, the intensity of cystoid macular edema suggests a more substantial vascular injury, likely exacerbated by methamphetamine-related alterations in retinal blood flow (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Intravitreal bevacizumab was selected to diminish macular edema through the reduction of vascular permeability. Whilst anti-VEGF therapy is routinely employed in cases of central retinal vein occlusion with macular involvement, its efficacy in the context of papillophlebitis remains less well-established (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Alternative options, such as corticosteroids aimed at mitigating inflammation, or observation alone\u0026mdash;which may suffice in mild, self-limiting cases\u0026mdash;were contemplated but deemed less appropriate given the severity of the edema (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe lack of fluorescein angiography and perimetry, due to patient non-compliance, further limited the assessment of retinal perfusion and functional outcomes. This is a significant limitation, as up to 30% of papillophlebitis cases may develop into ischemic CRVO with complications such as macular edema or neovascularization (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Despite these challenges, this case highlights the importance of considering recreational drug use in atypical retinal vascular presentations. With the global increase in stimulant abuse, ophthalmologists and emergency physicians should stay vigilant and take detailed substance use histories when assessing patients with sudden vision loss (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFuture studies are needed to clarify the potential role of methamphetamine in precipitating retinal venous disorders and to define optimal management strategies, particularly for cases complicated by macular edema. While this single case does not establish causality, it contributes to the limited body of evidence suggesting a possible association between methamphetamine exposure and papillophlebitis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis report highlights a possible link between recent methamphetamine use and papillophlebitis with cystoid macular edema in a middle-aged male, an atypical demographic for this condition (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The findings suggest that methamphetamine\u0026rsquo;s vascular effects may precipitate retinal venous inflammation and complications. Clinicians should inquire about stimulant use in patients presenting with acute visual loss, closely monitor for potential progression, and consider targeted therapy in cases with vision-threatening macular involvement. Further research is warranted to characterize this association better and guide evidence-based management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u003cbr\u003e\u0026nbsp;Not applicable. This study describes a single patient case report. Institutional ethics approval was not required according to the policies of Mashhad University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003cbr\u003e\u0026nbsp;Written informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and analyzed in this report are available from the corresponding authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors received no funding. It is the author’s work, not funded by the government or academic institutes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u0026nbsp;\u003c/strong\u003eKG collected the clinical data, reviewed the literature, and drafted the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMA was responsible for the clinical management and treatment of the patient, and provided supervision. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFS contributed to the diagnosis of the condition, assisted with the interpretation of clinical findings, and helped draft and revise sections of the manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNS assisted with the diagnosis, provided imaging tools free of charge, performed imaging acquisition and analysis, and contributed to the interpretation of imaging results. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eIt is a pleasure to acknowledge the ophthalmic technicians who helped us with patient evaluations and imaging, MohammadReza Taheri-Kalate, Elham Sadat Montazeri, Atefeh Ramezanpour, Fahime Alimirzaei.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhang XT, Zhong YF, Xue YQ, Li SQ, Wang BY, Zhang GQ, Hidasa I, Zhang H (2022) Clinical Features of Central Retinal Vein Occlusion in Young Patients. Ophthalmol Ther 11(4):1409\u0026ndash;1422\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdel Jalil S, Amer R (2024) The Spectrum of Papillophlebitis. Ocul Immunol Inflamm 32(10):2515\u0026ndash;2520\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eG\u0026uuml;ng\u0026ouml;r İ, Konuk GE, S\u0026uuml;ll\u0026uuml; Y, Arıt\u0026uuml;rk N, Papillophlebitis (2014) Treatment of Vision Loss Due To Subretinal Fluid with Intravitreal Ranibizumab. Neuroophthalmology 38(6):336\u0026ndash;339\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFong AC, Schatz H, McDonald HR, Burton TC, Maberley AL, Joffe L, Zegarra H, Nadel AJ, Johnson RN (1992) Central retinal vein occlusion in young adults (papillophlebitis). Retina 12(1):3\u0026ndash;11\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHayreh SS, Zimmerman B, McCarthy MJ, Podhajsky P (2001) Systemic diseases associated with various types of retinal vein occlusion. Am J Ophthalmol 131(1):61\u0026ndash;77\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eG\u0026uuml;ng\u0026ouml;r İ, Konuk GE, S\u0026uuml;ll\u0026uuml; Y, Arıt\u0026uuml;rk N, Papillophlebitis (2014) Treatment of Vision Loss Due To Subretinal Fluid with Intravitreal Ranibizumab. Neuroophthalmology 38(6):336\u0026ndash;339\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKittirattanapaiboon P, Srikosai S, Wittayanookulluk A (2017) Methamphetamine use and dependence in vulnerable female populations. Curr Opin Psychiatry 30(4):247\u0026ndash;252\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKevil CG, Goeders NE, Woolard MD, Bhuiyan MS, Dominic P, Kolluru GK, Arnold CL, Traylor JG, Orr AW (2019) Methamphetamine Use and Cardiovascular Disease. Arterioscler Thromb Vasc Biol 39(9):1739\u0026ndash;1746\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDarke S, Kaye S, McKetin R, Duflou J (2008) Major physical and psychological harms of methamphetamine use. Drug Alcohol Rev 27(3):253\u0026ndash;262\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee M, Leskova W, Eshaq RS, Harris NR (2021) Retinal hypoxia and angiogenesis with methamphetamine. Exp Eye Res 206:108540\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Papillophlebitis, Methamphetamine, Retinal Vein Occlusion, Substance-Related Disorders","lastPublishedDoi":"10.21203/rs.3.rs-7497035/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7497035/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose: To describe a case of papillophlebitis in a middle-aged male following recent methamphetamine use, highlighting a possible causal relationship.\u003c/p\u003e\n\u003cp\u003eCase Presentation: A 52-year-old male construction worker with no notable systemic or ocular history arrived at the emergency department, reporting sudden and worsening vision loss in his left eye. He mentioned smoking cigarettes and recent methamphetamine use beginning two days prior to symptoms onset. Eye examination showed optic disc swelling, venous engorgement, and peripapillary hemorrhages, indicative of papillophlebitis. No evidence of systemic illness, ocular trauma, or previous similar episodes was found. Macular edema was resolved after single intravitreal bevacizumab injection.\u003c/p\u003e\n\u003cp\u003eConclusion: This case suggests that the vascular effects of methamphetamine—such as vasospasm, endothelial damage, and hypercoagulability—may induce papillophlebitis even in healthy individuals. Clinicians should inquire about recent stimulant use when evaluating patients with sudden vision loss and monitor closely for potential progression to ischemic central retinal vein occlusion and related complications.\u003c/p\u003e","manuscriptTitle":"Papillophlebitis Following Methamphetamine Abuse in a Middle-Aged Patient: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 12:55:39","doi":"10.21203/rs.3.rs-7497035/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"437d7136-25b8-47b1-81aa-5f14dc28c1b7","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-29T18:38:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 12:55:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7497035","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7497035","identity":"rs-7497035","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}