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Kimberly Nolan, O.D.
Dorchester House Multi-Service Center
Dorchester, MA
Resident’s Day Submission: Academy 2008
Splenda Retinopathy: A case report
Abstract
A potential connection between excessive sucralose (Splenda) consumption and
retinopathy is witnessed in a healthy twenty-four year-old female who presents with a
“decreased sharpness” to her distance vision.
Case Report Outline
I.
Case History
a. Patient Demographics: Twenty-four year old white female
b. Chief complaint: Constant “decreased sharpness” (OD=OS) in her
distance vision x 2 yrs.
i. She first noticed the change one-year prior (August 2007) for
which she visited an optometrist who told her that her vision
changes were likely a temporary problem. She was prescribed
reading glasses at that visit. The reading glasses did not help with
the change in distance vision either immediately or over time;
therefore, the patient sought a second opinion.
c.
i. Ocular history: Migraine with aura causing a bilateral central
vision loss lasting 20 minutes.
1. Noted on two separate occasions after ingesting an
excessive amount of sucralose at one time.
2. Both instances occurred after her aforementioned
optometry appointment in August 2007 and when she
presented to our clinic in August 2008.
ii. Medical history: Migraine headaches
iii. Allergies: cats
iv. Family ocular history: cataracts.
1. No family history of glaucoma, maculopathy or blindness.
d. Medications: Ortho-Tri cyclin lo
e. Social history: 2.5 years of daily excessive Splenda consumption
i. She admitted to ingesting 50-80+ grams of Splenda / day
ii. (1 packet= 1 gram).
II.
Pertinent findings
a. Clinical
i. VA 20/20- OD and OS.
ii. Entrance testing within normal limits
iii. Slit lamp exam unremarkable OU
iv. Dilated fundus exam revealed diffuse pigment changes and the
appearance of thin, irregular pigment granules in her maculae.
v. OCT revealed thinner than average foveal and central foveal
thickness OU1
b. Physical
i. Weight: 133.2 lbs = 60.4 Kg
ii. Height: 62.5”
iii. Blood Pressure: 106/60
c. Laboratory Studies:
i. Blood work revealed a slightly fatty liver on (ALT=54 IU/L),
slightly elevated C Reactive Protein (11 Mg/L), and slightly
reduced iron saturation of 13 (Normal range= 15-55).
ii. All other blood work unremarkable including: triglycerides; serum
cholesterol, serum sodium, serum potassium, serum chloride,
serum phosphorus, BUN, serum creatinine, BUN/Creatinine ratio;
serum uric acid, bilirubin, AST, GGT, alkaline phosphate, serum
iron, iron binding capacity, serum total protein, serum albumin,
globulin, A/G ratio, Carbon dioxide total, UIBC, glomerulus
filtration rate, TSH, hemoglobin, hematocrit, RBC, MCV, MCH,
MCHC, RDW, WBC, urinalysis, vitamin D.
iii. Blood work also negative for: Lyme disease, Toxoplasmosis,
Rickettsia IgG, Rickettsia IgM, Rickettsia Typhi IgM, Rickettsia
Typhi IgM, Rickettsia Typhi IgG
III.
Differential Diagnosis
a. Inherited macular disease
i. Stargardt disease
ii. Cone dystrophy
iii. Pattern dystrophy
iv. North Carolina macular dystrophy
v. Butterfly-Shaped macular dystrophy
1. Presents in second to third decade typically by chance but
may have accompanying complaints of decreased central
vision.
b. Ocular side effects from oral contraceptive
c. Acute macular neuroretinopathy
d. Batten disease
e. Toxoplasmosis – a differential for the chorioretinal scar OD
i. Proven negative by blood work
IV.
Diagnosis and discussion
a. E.D. is a healthy 24-year-old white female with a history of migraine
headache with aura. She has no further history of ocular disease or
systemic disease (confirmed by blood work). Her family ocular history is
b.
c.
d.
e.
significant for cataracts. Her social history includes ingesting excessive
amounts of sucralose (Splenda) on a daily basis for two and a half years.
Average daily consumption was estimated to be 50-80 grams of Splenda /
day (1 packet= 1 gram). She presented to an optometrist one year ago with
complaints of a “decrease in sharpness” to her central distance vision. She
was subsequently given reading glasses. The vision changes persisted and
only after re-evaluating her dietary habits did she begin to question her
excessive Splenda consumption as being related not only to the dimming
of her vision but also as a trigger to her migraine headaches.
Our patient began excessive sucralose consumption when she started the
South Beach diet. She reports enjoying her beverages “extremely sweet”
and was also using sucralose in place of sugar for any cooking or baking
she did.
There have been no published articles that suggest a connection between
excessive sucralose consumption and retinopathy; however, countless
personal accounts of blurred vision have been reported with high daily
intake of sucralose. An article has been published in Headache that
discusses a case report of a patient whose migraines were attributed to
sucralose consumption.2
Sucralose (Splenda) toxicity
i. Sucralose (trichlorogalactosucrose or Splenda) is an artificial
sweetener that has been used for the past ten years, after FDA
approval was granted in April 1998. FDA and manufacturer
studies indicate that sucralose is a safe alternative to sugar; 3
however, not all consumers agree.
ii. It is made from sucrose in a five-step process that includes
replacing hydroxyl groups with three chlorine molecules.
iii. Estimated daily intake (EDI) in humans is 1.1 mg/kg/day.
Acceptable daily intake is 16 mg/kg/day. Highest no adverse
effects limit in is 1500 mg/kg/day 4. The latter two quoted daily
intakes were determined with animal (rat) studies and have not
been duplicated in humans.
1. Our patient was consuming approximately 827- 1324.50
mg/kg/day
iv. While studies have proven that sucralose is safe in animals, there
have been no long-term studies with high daily intake of the
chemical in either animals or humans.
Chloroquine retinopathy
i. Well-known and clinically proven Chloroquine retinopathy is
related to the dose a patient is taking. Symptoms and retinal
changes include: altered color vision, Scotoma: central,
paracentral, or peripheral, bulls-eye macular lesion, arteriolar
narrowing, vascular sheathing.
ii. Other known drug-induced maculopathies:
1. Chlorpromazine, thioridazine (anti-psychotic), tamoxifen
(breast cancer treatment), canthaxanthin (carotenoid used to
enhance sun tanning), methoxyflurane (inhalant anesthetic),
nitrofurantoin (antibiotic), nicotinic acid (cholesterollowering medication), desferrioxamine mesylate (iron
overload treatment).
V.
Treatment, management
a. Discontinue Splenda
b. Further blood-work to rule out other causes
c. Monitor and patient education to report changes in vision and/or color
vision after Splenda is discontinued.
d. Monitor retinal changes with fundus photos and OCT
VI.
Conclusion
a. There have been no long-term studies performed on the safety profile of
sucralose when consumed in excess as occurred in our patient. This case
proves a potential link between long-term, high-dose daily intake of
sucralose and retinopathy. Further investigation and research should be
performed to determine potential side effects of excessive sucralose
consumption.
VII.
References
1. Chan, Annie, MD; Ducker, Jay S.; Ko, Tony H.; Fujimoto, PhD; Schuman, Joel S.,
MD. Normal Macular Thickness Measurements in Healthy Eyes Using Stratus Optical
Coherence Tomography. Archives of Ophthalmology. 2006; 124: 193-198.
2. Patel, Rajendrakumar et al. Popular Sweetener Sucralose as a Migraine Trigger.
Headache. 2006. Pg. 1303,1304.
3. Department of Health and Human Services. Food and Drug Administration. Food
Additives Permitted for Direct Addition to Food for Human Consumption; Sucralose.
Docket number 87F-0086. April 3, 1998.
4. Frank, Genevieve. Sucralose: An Overview. Undergraduate Research Journal for the
Human Sciences. 2001.
5. Kanski, Jack J. Clinical Ophthalmology. 6th edition. 2007. Pg.505, 844, 672
6. Kaiser, Peter K; Friedman, Neil et. al. The Massachusetts Eye and Ear Infirmary
Illustrated Manual of Ophthalmology. “ 2nd Edition. 2004 . Pg. 344-347.
7. Kunimoto, Derek M.D.; Kanitkar, Kunal M.D. Makar, Mary M.D. (ed.). The Wills
Eye Manual. 4th edition. 2004. Pg. 283-287.