A woman presented with blurred vision in both eyes a few days after dyeing her hair with a box dye from the drugstore. Eventually, she was diagnosed with RAHDAA, a rare condition attributed to an ingredient in the hair dye: aromatic amines.

Chirpaz N, Bricout M, Elbany S, et al. Retinopathy associated with hair dye. JAMA Ophthalmol. Published online September 12, 2024. [Published correction appears in JAMA Ophthalmol. 2024 Sep 19.]

Mudell E. Ingredient in hair dye led to a woman's vision loss. US News & World Report. September 12, 2024.

 

“RAHDAA may be rare or underdiagnosed,” wrote the authors of a case report in JAMA Ophthalmology.

Chirpaz N, Bricout M, Elbany S, et al. Retinopathy associated with hair dye. JAMA Ophthalmol. Published online September 12, 2024. [Published correction appears in JAMA Ophthalmol. 2024 Sep 19.]

“However, identifying this pathology may allow prompt consideration to remove exposure to such hair dye in an attempt to limit persistent RPE [retinal pigment epithelium] damage.”

 

 

 

The leading cause of preventable blindness

 

According to the American Diabetes Association, “Retinopathy is the leading cause of preventable blindness.”

American Diabetes Association. What is retinopathy? Accessed September 25, 2024.

 

Retinopathy is caused by damage to the blood vessels of the retina, the light-sensitive tissue at the back of the eye. While diabetes is the most common cause of retinopathy, hypertensive retinopathy—caused by acute or chronic episodes of hypertension—is also very prevalent. Retinopathy is also linked to low birth weight, age-related macular degeneration, and environmental and genetic factors.

American Diabetes Association. What is retinopathy? Accessed September 25, 2024.

Stone WL, Patel BC, Basit H, et al. Retinopathy. StatPearls (Internet). Treasure Island (FL): StatPearls Publishing. Updated August 8, 2023.

 

Individuals with retinopathy may experience blurred or fluctuating vision or see black specks, strings, or dark empty areas. Early diagnosis is critical to prevent long-term damage. Treatments may include injecting medications into the vitreous, or the use of focal or scatter laser therapy. Vitrectomy is a surgical procedure done to remove blood from the vitreous and scar tissue that is pulling on the retina.

American Diabetes Association. What is retinopathy? Accessed September 25, 2024.

 

 

Diagnosing the damage

 

The authors of the case report explained that RAHDAA presents similarly to MEK inhibitor-associated retinopathy, involving the mitogen-activated protein kinase enzymes MEK1 and MEK2. MEK inhibitors—agents used to treat some types of cancer—may disrupt the neurochemical pathway involved in RPE cell survival and self-regulation. 

 

Clinicians should consider RAHDAA after ruling out other potential retinopathies, including central serous chorioretinopathy, according to the JAMA authors. They noted that systemic absorption of aromatic amines can occur through scalp lesions, thus possibly explaining why RAHDAA is presumably rare.

Toxic retinopathy related to the use of hair dye had been reported back in 2022, in a case report published in Retinal Cases & Brief Reports that followed three women (aged 32–66) with RAHDAA.

Faure C, Salamé N, Cahuzac A, et al. Hair dye-induced retinopathy mimicking MEK-inhibitor retinopathy. Retin Cases Brief Rep. 2022;16(3):329–332.

Their symptoms included moderate to severe vision loss in both eyes. Slit-lamp examinations were normal, but fundus examinations showed multiple serous retinal detachments mainly in the posterior pole.

 

The examination results, together with those from optical coherence tomography (OCT), were suggestive of MEK-inhibitor retinopathy. The women’s vision improved as the retinal detachments resolved, and the time course was in proportion to the intensity of the aromatic amine exposure.

 

A warning to patients

 

 

Her visual acuity was 20/40 and 20/20 in the right and left eyes, respectively. Fundus examination and OCT revealed bilateral multiple serous retinal detachments mainly in the posterior pole, and OCT showed diffuse thickening of the neurosensory retina. The choroidal vessels were normally dilated, ruling out central serous chorioretinopathy.

The patient underwent several examinations, blood tests, and scans to exclude sarcoidosis, oculocerebral lymphoma, and acute exudative polymorphous vitelliform maculopathy. The results were normal.

“RAHDAA was diagnosed based on the temporal association between symptoms and hair dye exposure, consistent with the description including OCT appearance,” the JAMA Ophthalmology authors wrote.

At 4 months follow-up, the patient’s visual acuity had improved to 20/20. The retinal detachments had resolved, but OCT showed increased autofluorescent deposits below the retina. At 4-year follow-up, the patient reported switching to aromatic amine-free hair dye with no recurrence of blurred vision. Her 20/20 vision persisted. However, the subretinal deposits remained, and the neurosensory retina thickening resolved only slowly. The persistent thickening, wrote the authors, suggests that “aromatic amines could be responsible for long-lasting RPE dysfunction.”