Int Ophthalmol
DOI 10.1007/s10792-016-0399-9
CASE REPORT
Acute visual loss and intraretinal hemorrhages associated
to energy drink consumption
Christina W. Pagano . Max Wu . Lihteh Wu
Received: 27 October 2015 / Accepted: 25 November 2016
Ó Springer Science+Business Media Dordrecht 2016
Abstract
Purpose To report the association of acute visual
loss secondary to intraretinal hemorrhages and energy
drink consumption.
Methods Case report and literature review.
Results A 48-year-old hypertensive man developed
an elevation in systemic blood pressure, tachycardia,
and acute visual loss secondary to intraretinal hemor-
rhages shortly after drinking several cans of energy
drinks.
Conclusion High consumption of energy drinks may
lead to intraretinal hemorrhages and acute visual loss.
Keywords Energy drinks
Caffeine
Intraretinal
hemorrhages
Guarana
Visual loss
Introduction
Energy drinks have been marketed to improve mental
and physical stamina [1]. They typically contain a
mixture of vitamins, amino acids, sugar, herbal
derivatives, and varying amounts of caffeine [1, 2].
Over the past several years, the consumption of energy
drinks has grown exponentially worldwide. At the
C. W. Pagano
M. Wu
L. Wu (&)
Asociados de Macula, Vitreo y Retina de Costa Rica,
Apdo 144-1225 Plaza Mayor, San José, Costa Rica
e-mail: LW65@cornell.edu
same time, the number of emergency room (ER) visits
in the United States associated with energy drink
consumption has also exploded, exceeding 20,000
visits in 2011 [3]. Most of these adverse events have
been attributed to caffeine toxicity [4].
To the best of our knowledge, there have not been
any reports of ophthalmic adverse events associated
with the ingestion of energy drinks. We report a case
of acute visual loss secondary to intraretinal hemor-
rhages associated to energy drink consumption.
Case report
A 48-year-old warehouse watchman presented to the
ER complaining of a sudden decrease in vision in his
right eye. He had been working during the nightshift
and had drank three large cans (473 mL each) of an
energy drink over 30–40 min. Thirty min after he
finished his last can, he developed malaise, palpita-
tions, headache, and loss of vision. In the ER, his blood
pressure was 180/120 mm Hg and his heart rate was
100 beats per min. No carotid bruit was detected
during the physical examination. His visual acuity was
hand motions and 20/20, respectively. There was no
afferent pupillary defect and the slit-lamp examination
was unremarkable for both eyes. The intraocular
pressure was 16 mm Hg OU. Funduscopic examina-
tion revealed deep intraretinal hemorrhages in a
petalloid pattern in the right eye (Fig. 1). The left
fundus was unremarkable. His past medical history
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 Int Ophthalmol

Fig. 1 Fundus photographs

and fluorescein angiography
of the right eye. a Fundus
photograph of the right eye
depicting deep intraretinal
hemorrhages in a petalloid
pattern. b Late frame of the
fluorescein angiogram
showing blockage from the
hemorrhages. There is no
evidence of fluorescein
leakage

Fig. 2 Multimodality imaging of the right fundus 3 weeks after
the acute event. Notice the petalloid pattern of the remaining
hemorrhages. a Infrared reflectance of the right fundus. Notice
the wedge-shaped hyporeflective areas pointing toward the
fovea. b Blue fundus autofluorescence of the right fundus
showing similar wedge-shaped hypoautofluorescent areas.
c Blue reflectance of the right fundus also depict wedge-shaped
hyporeflective areas that correspond to the intraretinal hemor-
rhages. d Spectral domain OCT of the right fovea. Notice the
disruption of the ellipsoid line. In addition, there are hyper-
reflective lesions that correspond to the intraretinal hemorrhages

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Int Ophthalmol
was significant for systemic hypertension for which he
was taking 20 mg of enalapril daily. The patient
denied any use of illicit drugs or substances. He also
denied vigorous sexual activities. He had an extensive
work-up in the ER that included a CT scan of his head,
ESR, VDRL, CBC, and PT/PTT. All of these tests
were within normal limits. A fluorescein angiogram
revealed only blockage from the hemorrhages. Three
weeks after this acute event, his visual acuity in the
OD had improved to 20/200. The intraocular hemor-
rhages started to clear as well (Fig. 2). The patient was
then lost to follow-up.
Discussion
Most if not all of the ER visits associated with energy
drink consumption are probably related to caffeine
toxicity [4]. Clinical manifestations of caffeine toxi-
city include anxiety, restlessness, tachycardia, insom-
nia, gastrointestinal upset, and nervousness [1]. In
addition, several cardiovascular adverse effects,
including cardiac arrest, arrhythmias, and death,
associated to energy drink ingestion have been
reported [3]. On top of the caffeine that is accounted
for in the label, energy drinks also contain guarana
extract [2]. Paullinia cupana, more commonly known
as guarana, is a climbing plant from the maple family,
native to the Amazon basin. The seeds of the guarana
plant contain the highest caffeine content of any plant
in the world (2–7.5%) [5]. Guarana seeds also contain
related substances such as theophylline and theo-
bromine that can potentiate the effects of caffeine [6].
Worthley et al. [7] compared platelet and endothe-
lial function in normal volunteers before and after
energy drink consumption. They found endothelial
dysfunction, platelet hyperaggregability, and an
increase in blood pressure 1 h after energy drink
ingestion.
In our particular case, the differential diagnosis
included hypertensive retinopathy, Valsalva retinopa-
thy, Purtcher-like retinopathy, ocular decompression
retinopathy, central retinal vein occlusion, trauma,
blood dyscrasia, Terson-like retinopathy, vigorous
sexual activity [8], or idiopathic unilateral deep retinal
hemorrhages [9]. Based on the temporal sequence of
events and laboratory results, the most likely cause of
our patient’s ailment is somewhat related to the energy
drink ingestion. The unilaterality of the findings was
rather peculiar. Patients with stenosis of the internal
carotid artery proximal to the origin of the ophthalmic
artery or carotid insufficiency on the unaffected side
have been reported to develop asymmetric or unilat-
eral retinopathy. No carotid bruit was detected during
the physical examination of our patient; therefore
carotid dopplers were not performed. Alternatively,
the fundus findings are very similar to those described
as idiopathic unilateral deep retinal hemorrhages [9].
In summary, we have reported a case of a sudden
increase in systemic blood pressure, tachycardia, and
acute visual loss secondary to the development of
intraocular hemorrhages associated to ingestion of
energy drinks.
Compliance with ethical standards
Conflict of interest The authors have no financial interests in
the subject matter presented.
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