Case Report: Nutritional and Toxic Optic Neuropathy: A Diagnostic Dilemma

A Case of Syphilis with a Rare Finding: Subretinal Hypopyon

PURPOSE

To report clinical features and follow-up of a case with subretinal hypopyon due to syphilis infection.

CASE PRESENTATION

We present a case of syphilis admitted with optic neuritis and treated with intravenous pulse steroids without antibiotics. The patient was referred to the uvea clinic in the follow-up because of decreased vision and the onset of multiple retinitis foci. We determined subretinal hypopyon in the left eye and a positive TPHA test. A significant regression was observed in retinitis and hypopyon with antibiotic therapy.

CONCLUSION

Before starting a steroid treatment, infective etiologies should be considered in patients with optic neuritis. Treating with a high dosage of steroids without antibiotics in syphilis would worsen the clinical features and prognosis.

Micronutrient Deficiencies Presenting with Optic Disc Swelling Associated with or without Intracranial Hypertension: A Systematic Review

Idiopathic intracranial hypertension (IIH) is a neurological disorder characterised by optic disc swelling secondary to raised intracranial pressure (ICP) of unknown cause. Obesity is the most established and prevalent risk factor in developed countries. As obesogenic diets are high in calories and nutrient-poor, there may be associated nutritional deficiencies that contribute to the clinical presentation of IIH. Yet none, aside from iron deficiency, are currently included in the inclusion or exclusion criteria for the diagnosis of IIH. Our primary aim was to determine which micronutrient deficiencies, aside from iron deficiency, could present with optic disc swelling associated with or without intracranial hypertension that could potentially meet current IIH diagnostic criteria. To this end, we conducted a systematic search of articles published between 1 January 1980 and 18 December 2020 reporting cases of optic disc swelling associated with micronutrient deficiencies. In total, 65 cases met the eligibility criteria from initial searches: all were case reports and case series with a high risk of bias. Our findings suggest that patients with IIH or unexplained optic disc swelling ought to be screened, investigated, and treated for associated micronutrient deficiencies in vitamin A, B1 and B12; and weight loss interventions in IIH patients ought to promote better nutrition in addition to overall calorie restriction.

Visual electrophysiology in the assessment of toxicity and deficiency states affecting the visual system

Visual disturbance or visual failure due to toxicity of an ingested substance or a severe nutritional deficiency can present significant challenges for diagnosis and management, for instance, where an adverse reaction to a prescribed medicine is suspected. Objective assessment of visual function is important, particularly where structural changes in the retina or optic nerve have not yet occurred, as there may be a window of opportunity to mitigate or reverse visual loss. This paper reviews a number of clinical presentations where visual electrophysiological assessment has an important role in early diagnosis or management alongside clinical assessment and ocular imaging modalities. We highlight the importance of vitamin A deficiency as an easily detected marker for severe combined micronutrient deficiency.