Nutritional Deficiency Optic Neuropathy

    • Subacute or chronic binocularly symmetrical optic neuropathy caused by nutritional deprivation
    • Common deficiencies: vitamins B1 and B12, folic acid
    • Common settings: chronic alcoholism and malnutrition—starvation, restrictive diets, eating disorders, bariatric surgery
    • Treatment is adequate nutrition, vitamin replacement, cessation of alcohol ingestion, which may stop progression and sometimes provide visual improvement
    • Core clinical features
      • Resembles toxic optic neuropathy (See Toxic Optic Neuropathy )
      • Slowly progressive painless binocular visual loss
      • Symmetrical visual acuity loss
      • Pupil size and constriction are normal (no afferent pupil defect)
      • Optic discs appear normal or show temporal pallor
      • Central or centrocecal scotomas in both eyes
      • Profound acquired color vision loss
    • Possible accompanying clinical features
      • Peripheral neuropathy
    • Imaging features
      • Brain imaging is normal or shows reduced optic nerve caliber bilaterally
    • Toxic optic neuropathy
    • Maculopathy
    • Hereditary optic neuropathy (dominantly-inherited or Leber hereditary optic neuropathy)
    • Optic neuritis
    • Compressive optic neuropathy
    • Chiasmal or bilateral retrogeniculate vision loss
    • Psychogenic visual loss
    • Exclude maculopathy, indolent optic neuritis, compressive optic neuropathy, toxic and hereditary optic neuropathies
    • Establish the cause of nutritional deprivation
    • Perform orbit-based MRI even if the diagnosis of nutritional optic neuropathy seems obvious
    • Consider performing visual evoked potentials in equivocal cases, looking for prolonged latency which would exclude psychogenic visual loss
    • Evaluate for peripheral neuropathy, a common and confirmatory accompaniment
    • Order complete blood count and serum methylmalonic acid in search of vitamin B12 deficiency
    • Recommend an improved diet and an alcohol detoxification program if appropriate
    • Prescribe multiple oral vitamins and folate, single-dose intramuscular thiamine 100mg, followed by oral thiamine 50mg/day indefinitely (prescribe higher thiamine doses for co-existing Wernicke encephalopathy)
    • Prescribe intramuscular vitamin B12 if appropriate
    • Visual loss is often irreversible, but improvement may occur with vitamins, improved diet, and reduced alcohol consumption

    Optic Nerve And Chiasm Disorders

    Drusen Optic Neuropathy Colobomatous Optic Neuropathy Optic Pit Neuropathy Morning Glory Optic Neuropathy Hypoplastic Optic Neuropathy Typical Optic Neuritis Atypical Optic Neuritis Papillitis (Neuroretinitis) Non-arteritic Ischemic Optic Neuropathy Arteritic Ischemic Optic Neuropathy Posterior Ischemic Optic Neuropathy Hypotensive Ischemic Optic Neuropathy Radiation-induced Optic Neuropathy Diabetic Papillopathy Hypertensive Optic Disc Edema Papilledema Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) Compressive Optic Neuropathy: Overview Optic Neuropathy of Graves Disease Optic Nerve Sheath Meningioma Sphenoid Meningioma Craniopharyngioma Pituitary Adenoma Pilocytic Astrocytoma (Optic Glioma) Carotid Aneurysm Suprasellar Germinoma Infiltrative (Neoplastic) Optic Neuropathy Paraneoplastic Optic Neuropathy Traumatic Optic Neuropathy Toxic Optic Neuropathy Nutritional Deficiency Optic Neuropathy Dominantly-Inherited Optic Neuropathy Leber Hereditary Optic Neuropathy Primary Open Angle Glaucoma