Nutritional Optic Neuropathies: State of the Art and Emerging Evidences

Maculopapillary Bundle Degeneration in Optic Neuropathies

PURPOSE OF REVIEW

Degeneration of the maculopapillary bundle (MPB) is a prominent feature in a spectrum of optic neuropathies. MPB-selective degeneration is seen in specific conditions, such as nutritional and toxic optic neuropathies, Leber hereditary optic neuropathy (LHON), and dominant optic atrophy (DOA). Despite their distinct etiologies and clinical presentations, which encompass variations in age of incidence and monocular or binocular onset, these disorders share a core molecular mechanism: compromised mitochondrial homeostasis. This disruption is characterized by dysfunctions in mitochondrial metabolism, biogenesis, and protein synthesis. This article provides a comprehensive understanding of the MPB's role in optic neuropathies, emphasizing the importance of mitochondrial mechanisms in the pathogenesis of these conditions.

RECENT FINDINGS

Optical coherence tomography studies have characterized the retinal nerve fiber layer changes accompanying mitochondrial-affiliated optic neuropathies. Selective thinning of the temporal optic nerve head is preceded by thickening in early stages of these disorders which correlates with reductions in macular ganglion cell layer thinning and vascular atrophy. A recently proposed mechanism underpinning the selective atrophy of the MPB involves the positive feedback of reactive oxygen species generation as a common consequence of mitochondrial dysfunction. Additionally, new research has revealed that the MPB can undergo degeneration in the early stages of glaucoma, challenging the historically held belief that this area was not involved in this common optic neuropathy. A variety of anatomical risk factors influence the propensity of glaucomatous MPB degeneration, and cases present distinct patterns of ganglion cell degeneration that are distinct from those observed in mitochondria-associated diseases. This review synthesizes clinical and molecular research on primary MPB disorders, highlighting the commonalities and differences in their pathogenesis.

KEY POINTS (BOX)

1. Temporal degeneration of optic nerve fibers accompanied by cecocentral scotoma is a hallmark of maculopapillary bundle (MPB) degeneration. 2. Mechanisms of MPB degeneration commonly implicate mitochondrial dysfunction. 3. Recent research challenges the traditional belief that the MPB is uninvolved in glaucoma by showing degeneration in the early stages of this common optic neuropathy, yet with features distinct from other MPB-selective neuropathies. 4. Reactive oxygen species generation is a mechanism linking mitochondrial mechanisms of MPB-selective optic neuropathies, but in-vivo and in-vitro studies are needed to validate this hypothesis.

Xeropthalmia and optic neuropathy secondary to ARFID: a case report

BACKGROUND

Patients with avoidant/restrictive food intake disorder (ARFID) commonly present with loss of weight or faltering growth in the setting of poor nutrition. However, patients with ARFID can present with micronutrient deficiencies without weight loss. In patients with ARFID, clinicians should be vigilant for micronutrient deficiencies and their presentations.

CASE PRESENTATION

We report a unique case of ARFID in a twelve-year-old girl, who developed micronutrient deficiencies and presented with acute visual loss with a preceding history of impaired night vision. Ophthalmic examination revealed xerophthalmia and bilateral optic neuropathy. Investigations showed severe Vitamin A and folate deficiencies which accounted for her clinical findings. In addition, she was also found to have low Vitamin B12, copper, and Vitamin D levels. She had a history of selective eating from a young age with a diet consisting largely of carbohydrates, with no regular intake of meat, dairy, fruit and vegetables. This was not driven by weight or body image concerns. The patient's symptoms improved significantly with appropriate vitamin replacement and continued multidisciplinary care.

CONCLUSIONS

This report describes a patient with ARFID presenting with visual complaints. In this case, the selective eating behaviours resulted in xeropthalmia and optic neuropathy. Micronutrient deficiencies are uncommon in developed countries. When these deficiencies are suspected, eating disorders, such as ARFID, should be considered. Similarly, clinicians caring for patients with restrictive eating disorders including ARFID should be familiar with the clinical presentations of various micronutrient deficiencies and consider evaluation and treatment for micronutrient deficiencies when clinically indicated.

The potential impact of a vegetarian diet on glaucoma

Treatment of primary open-angle glaucoma has centered on the lowering of intraocular pressure that damages the optic nerve; however, this strategy is not uniformly successful, especially in normal tension glaucoma, and there is interest in antioxidant, anti-inflammatory, and other neuroprotective strategies. Vegetarian diets are known to be rich in antioxidant and anti-inflammatory components and have a number of established health benefits. Thus, it would be reasonable to assume that vegetarian diets would be beneficial in glaucoma, but this approach has not been well studied. We examine the possible role of vegetarian diets and their components in the incidence and progression of glaucoma.

Vision Loss as a Presenting Symptom of Vitamin B12 Deficiency

Nutritional optic neuropathy is a rare and often overlooked factor leading to bilateral, symmetrical, and gradual visual impairment. This condition falls within the category of metabolic neuropathies. We documented a case involving bilateral nutritional optic neuropathy attributed to pancytopenia associated with vitamin B12 deficiency. A healthy 65-year-old Indian woman reported a bilateral, progressive, painless decline in vision over the past six months. She had a history of reduced oral intake for the preceding year and denied experiencing any gastrointestinal or constitutional symptoms. Bilateral visual acuity was 1/60. Examination revealed pale optic discs with attenuated vessels in both eyes and a cup-disc ratio of 0.3. The blood analysis showed low indices and a deficiency in serum vitamin B12. Despite undergoing treatment, her vision remained impaired due to the chronic nature of the condition. This case highlights the importance of identifying visual symptoms in an elderly woman experiencing malnutrition caused by inadequate dietary habits, which leads to bilateral nutritional optic neuropathy.

Optic Nerve Neuroprotection in Glaucoma: A Narrative Review

In recent years, researchers have been interested in neuroprotective therapies as a cutting-edge therapeutic strategy to treat neurodegenerative disorders by shielding the brain system from harmful events. Millions of individuals worldwide suffer from glaucoma, an ocular neurodegenerative disease characterized by gradual excavation of the optic nerve head, retinal axonal damage, and consequent visual loss. The pathology's molecular cause is still mostly unknown, and the current treatments are not able to alter the disease's natural progression. Thus, the modern approach to treating glaucoma consists of prescribing medications with neuroprotective properties, in line with the treatment strategy suggested for other neurodegenerative diseases. For this reason, several naturally derived compounds, including nicotinamide and citicoline, have been studied throughout time to try to improve glaucoma management by exploiting their neuroprotective properties. The purpose of this review is to examine the naturally derived compounds that are currently utilized in clinical practice for neuroprotection in glaucomatous patients based on scientific data, emphasizing these compounds' pivotal mechanism of action as well as their proven therapeutic and neuroprotective benefits.

Recent advances in the use of optical coherence tomography in neuro-ophthalmology: A review

Optical coherence tomography (OCT) is an in vivo imaging modality that provides non-invasive, high resolution and fast cross-sectional images of the optic nerve head, retina and choroid. OCT angiography (OCTA) is an emerging tool. It is a non-invasive, dye-free imaging approach of visualising the microvasculature of the retina and choroid by employing motion contrast imaging for blood flow detection and is gradually receiving attention for its potential roles in various neuro-ophthalmic and retinal conditions. We will review the clinical utility of the OCT in the management of various common neuro-ophthalmic and neurological disorders. We also review some of the OCTA research findings in these conditions. Finally, we will discuss the limitations of OCT as well as introduce other emerging technologies.

Nutritional blindness from avoidant-restrictive food intake disorder - recommendations for the early diagnosis and multidisciplinary management of children at risk from restrictive eating

Avoidant-restrictive food intake disorder (ARFID) is an eating disorder characterised by limited consumption or the avoidance of certain foods, leading to the persistent failure to meet the individual's nutritional and/or energy needs. The disordered eating is not explained by the lack of available food or cultural beliefs. ARFID is often associated with a heightened sensitivity to the sensory features of different types of food and may be more prevalent among children with autism spectrum disorder (ASD) for this reason. Sight loss from malnutrition is one of the most devastating and life-changing complications of ARFID, but difficult to diagnose in young children and those with ASD who have more difficulty with communicating their visual problems to carers and clinicians, leading to delayed treatment and greater probability of irreversible vision loss. In this article, we highlight the importance of diet and nutrition to vision and the diagnostic and therapeutic challenges that clinicians and families may face in looking after children with ARFID who are at risk of sight loss. We recommend a scaled multidisciplinary approach to the early identification, investigation, referral and management of children at risk of nutritional blindness from ARFID.

Wernicke Syndrome: Case Report and Literature Review of Contributing Factors-Can Malpractice Dynamics Be Identified?

Wernicke Encephalopathy (WE) is a neurological acute syndrome related to vitamin B1 deficiency and is relatively common in patients with chronic alcoholism. In the case of Hyperemesis Gravidarum, thiamine body stores become unable to meet the increased demand, resulting in acute deficiency. WE is associated with typical clinical and radiological findings. Treatment pathways rely on thiamine replacement. The case herein reported is centered around a 33-year-old diabetic patient at 12 weeks of gestation, with WE due to hyperemesis gravidarum. The disease manifested itself with weakness, mental confusion, headache, and impaired vision. The diagnosis was established after the detection of typical findings by MRI. Thirty days after therapy was started, most of the patient's neurological disorders were resolved. The patient was discharged 40 days later with instructions to continue daily thiamine supplementation. The pregnancy outcome was good. Unfortunately, mild ataxia persisted in 2-year follow-up as a long-term consequence. When diagnosed and treated, WE has a favorable prognosis. However, roughly 80% of patients experience memory loss, which may continue for a long time, while gait disorders reportedly affect about 35% of patients. Mild ataxia and dysmetria may persist, too. We reviewed the scientific literature on WE in women with HG until February 2023. Hardly any authors report data on long-term sequelae. Our report emphasizes how important it is to take into consideration this complication in clinical practice, referring to published guidelines and recommendations. Neurological maternal sequelae can demonstrably persist despite early diagnosis and appropriate management. For this reason, a long-term follow-up is recommended. Wernicke syndrome management cannot yet rely on well-established conclusive guidelines; hence, a cautionary approach ought to be prioritized in order to ensure medicolegal soundness.

Unveiling the Multifaceted Problems Associated with Dysrhythmia

Dysrhythmia is a term referring to the occurrence of spontaneous and repetitive changes in potentials with parameters deviating from those considered normal. The term refers to heart anomalies but has a broader meaning. Dysrhythmias may concern the heart, neurological system, digestive system, and sensory organs. Ion currents conducted through ion channels are a universal phenomenon. The occurrence of channel abnormalities will therefore result in disorders with clinical manifestations depending on the affected tissue, but phenomena from other tissues and organs may also manifest themselves. A similar problem concerns the implementation of pharmacotherapy, the mechanism of which is related to the impact on various ion currents. Treatment in this case may cause unfavorable effects on other tissues and organs. Drugs acting through the modulation of ion currents are characterized by relatively low tissue specificity. To assess a therapy's efficacy and safety, the risk of occurrences in other tissues with similar mechanisms of action must be considered. In the present review, the focus is shifted prominently onto a comparison of abnormal electrical activity within different tissues and organs. This review includes an overview of the types of dysrhythmias and the basic techniques of clinical examination of electrophysiological disorders. It also presents a concise overview of the available pharmacotherapy in particular diseases. In addition, the authors review the relevant ion channels and their research technique based on patch clumping.

Oxidative stress in the eye and its role in the pathophysiology of ocular diseases

Oxidative stress occurs through an imbalance between the generation of reactive oxygen species (ROS) and the antioxidant defense mechanisms of cells. The eye is particularly exposed to oxidative stress because of its permanent exposure to light and due to several structures having high metabolic activities. The anterior part of the eye is highly exposed to ultraviolet (UV) radiation and possesses a complex antioxidant defense system to protect the retina from UV radiation. The posterior part of the eye exhibits high metabolic rates and oxygen consumption leading subsequently to a high production rate of ROS. Furthermore, inflammation, aging, genetic factors, and environmental pollution, are all elements promoting ROS generation and impairing antioxidant defense mechanisms and thereby representing risk factors leading to oxidative stress. An abnormal redox status was shown to be involved in the pathophysiology of various ocular diseases in the anterior and posterior segment of the eye. In this review, we aim to summarize the mechanisms of oxidative stress in ocular diseases to provide an updated understanding on the pathogenesis of common diseases affecting the ocular surface, the lens, the retina, and the optic nerve. Moreover, we discuss potential therapeutic approaches aimed at reducing oxidative stress in this context.

The prevalence of red-green color vision deficiency and its related factors in an elderly population above 60 years of age

AIM

To determine the prevalence of red-green (RG) color vision deficiency (CVD) in an elderly population and its related factors.

METHODS

This report is a part of the Tehran Geriatric Eye Study: a cross-sectional population-based study that was conducted on the elderly population (≥60y) of Tehran, Iran using multi-stage stratified random cluster sampling. All study participants underwent complete ocular examination, including the measurement of uncorrected and best-corrected visual acuity, objective and subjective refraction, and slit-lamp biomicroscopy. The color vision was tested using Ishihara plates with the near optical correction in place.

RESULTS

Of the 3791 invitees, 3310 participated in the study. The data of 2164 individuals were analyzed after applying the exclusion criteria. The prevalence of R-G CVD was 3.73% (95%CI: 2.37%-5.09%) in the whole sample; the prevalence of protanomaly, protanopia, and deuteranopia was 1.51%, 1.76%, and 0.45%, respectively. The prevalence of R-G CVD was significantly higher in males than in females. The prevalence of RG CVD increased with advancing age from 2.91% in the age group 60-64y to 5.8% in the age group ≥80y (P=0.070). According to the multiple logistic regression model, male sex, and glaucoma were significantly related to RG CVD. Older age and hypertension also had a marginally significant relationship with RG CVD.

CONCLUSION

Changes in color vision occur in the elderly due to the aging process and some physiological and pathological factors. Since the change in visual perception may affect the person's performance, this aspect of the visual system's function should also be taken into consideration in the examinations of the elderly.

Optic nerve diseases and regeneration: How far are we from the promised land?

The retinal ganglion cells (RGCs) are the sole output neurons that connect information from the retina to the brain. Optic neuropathies such as glaucoma, trauma, inflammation, ischemia and hereditary optic neuropathy can cause RGC loss and axon damage, and lead to partial or total loss of vision, which is an irreversible process in mammals. The accurate diagnoses of optic neuropathies are crucial for timely treatments to prevent irrevocable RGCs loss. After severe ON damage in optic neuropathies, promoting RGC axon regeneration is vital for restoring vision. Clearance of neuronal debris, decreased intrinsic growth capacity, and the presence of inhibitory factors have been shown to contribute to the failure of post-traumatic CNS regeneration. Here, we review the current understanding of manifestations and treatments of various common optic neuropathies. We also summarise the current known mechanisms of RGC survival and axon regeneration in mammals, including specific intrinsic signalling pathways, key transcription factors, reprogramming genes, inflammation-related regeneration factors, stem cell therapy, and combination therapies. Significant differences in RGC subtypes in survival and regenerative capacity after injury have also been found. Finally, we highlight the developmental states and non-mammalian species that are capable of regenerating RGC axons after injury, and cellular state reprogramming for neural repair.

Oxidative Stress: A Suitable Therapeutic Target for Optic Nerve Diseases?

Optic nerve disorders encompass a wide spectrum of conditions characterized by the loss of retinal ganglion cells (RGCs) and subsequent degeneration of the optic nerve. The etiology of these disorders can vary significantly, but emerging research highlights the crucial role of oxidative stress, an imbalance in the redox status characterized by an excess of reactive oxygen species (ROS), in driving cell death through apoptosis, autophagy, and inflammation. This review provides an overview of ROS-related processes underlying four extensively studied optic nerve diseases: glaucoma, Leber's hereditary optic neuropathy (LHON), anterior ischemic optic neuropathy (AION), and optic neuritis (ON). Furthermore, we present preclinical findings on antioxidants, with the objective of evaluating the potential therapeutic benefits of targeting oxidative stress in the treatment of optic neuropathies.

Association Between Vitamin Deficiencies and Ophthalmological Conditions

Vitamin deficiencies can have adverse effects on health, including on the visual system. The ocular manifestations of a vitamin deficiency are related to the underlying biochemical function of the particular nutrient. While vitamin deficiencies are not common in developed counties, they are still prevalent in parts of the developing world and in specific, vulnerable populations. Vitamin deficiencies can cause or contribute to many ophthalmological conditions and eye diseases may even be the first presenting finding of a vitamin deficiency. As such, it is important for ophthalmologists to be aware of the ocular manifestations of vitamin deficiencies, especially given that the complications can be severe and effectively treated if identified early. This review summarizes the literature on the main vitamins known to have characteristic ocular manifestations: vitamins A, B1, B2, B9, B12, C, D, E and K. The function, epidemiology, manifestations, workup, and management of each vitamin is discussed in detail.

Paediatric MOG-antibody disease presenting with intracranial hypertension and unilateral vision loss without radiological evidence of optic neuritis

Intracranial hypertension (IH) is poorly described in paediatric myelin oligodendrocyte glycoprotein antibody disease (MOGAD). We describe a unique case of seropositive MOGAD in an obese 13-year-old boy who presented with an isolated IH, bilateral optic disc swelling and sudden-onset complete vision loss in one eye without radiological evidence of optic nerve involvement. Treatment with intravenous methylprednisolone combined with an emergency shunt fully restored vision and resolved the optic disc swelling. This report adds to the growing body of evidence suggesting that obese children presenting with isolated IH should be investigated for MOGAD, and the importance of managing IH during MOGAD.

Delayed and reversible ethambutol optic neuropathy

Purpose

To document an unusual example of ethambutol optic neuropathy developing three years from treatment start date in the absence of renal dysfunction.

Observations

The patient, an 82-year-old, 61-kg male undergoing treatment for Mycobacterium Avium Complex, presented with visual acuity that was significantly worse than baseline three years after beginning a treatment regimen which included ethambutol at <15 mg/kg/day. He was also found to have central and paracentral scotomas in both eyes. Ethambutol treatment was immediately halted, and the patient's visual acuity and visual fields improved in the months following.

Conclusions and Importance

It is important to have a high index of suspicion for ethambutol toxicity in any patient on this drug who presents with vision changes consistent with optic neuropathy. The development of ethambutol optic neuropathy can be delayed, and vision loss may be reversible and can continue to improve over months after cessation of therapy.

Toxic and nutritional factors trigger leber hereditary optic neuropathy due to a mitochondrial tRNA mutation

Leber hereditary optic neuropathy is a mitochondrial disease mainly due to pathologic mutations in mitochondrial genes related to the respiratory complex I of the oxidative phosphorylation system. Genetic, physiological, and environmental factors modulate the penetrance of these mutations. We report two patients suffering from this disease and harboring a m.15950G > A mutation in the mitochondrial DNA‐encoded gene for the threonine transfer RNA. We also provide evidences supporting the pathogenicity of this mutation.

Toxic and Nutritional Optic Neuropathies—An Updated Mini-Review

Optic neuropathies constitute a group of conditions with various etiologies and might be caused by different factors; we can distinguish the genetic and acquired causes of optic neuropathies. Even though the symptoms are not highly specific, this condition is primarily characterized by unilateral or bilateral vision loss with worsening color detection. The loss may be acute or gradual depending on the causation. In this article, we included a specification of toxic optic neuropathy (TON) mainly triggered by alcohol abuse and also the usage of other substances, including drugs or methanol, as well as intoxication by metals, organic solvents, or carbon dioxide. Nutritional deficiencies, vitamin absorption disorder, and anemia, which usually appear during excessive alcohol intake, and their effect on the etiology of the optic neuropathy have been likewise discussed.

Visual loss and optic neuropathy in a patient with Klinefelter's syndrome, open-angle glaucoma, vitamin B12 (cobalamin) and folate deficiency

A 54-year-old man with Klinefelter's syndrome presented to the neuro-ophthalmology clinic with progressive painless visual blurring in the right eye over 2 years. He was receiving intramuscular testosterone therapy for hypogonadism and hypromellose for dry eye. Acuity was reduced bilaterally, and the right optic nerve head appeared pale and asymmetrically cupped. Optical coherence tomography revealed loss of retinal nerve fibre layer thickness in the right eye and visual field testing showed a developing right-ring scotoma. Blood tests showed vitamin B12 and folate deficiencies and polycythaemia. The patient was managed with intramuscular hydroxocobalamin, oral folate administration and re-initiation of his glaucoma medication. In Klinefelter's syndrome, signs of comorbid deficiency can be masked by the polycythaemic effect of testosterone therapy. For patients on long-term testosterone therapy, such as those with Klinefelter's syndrome, we recommend baseline ophthalmic examination and assessment, including intraocular pressure measurement, pachymetry, gonioscopy and screening 24-2 visual field testing.

Perspective: Striking a Balance between Planetary and Human Health: Is There a Path Forward?

The global adoption of predominantly plant-based sustainable healthy diets will help reduce the risk of obesity- and malnutrition-related non-communicable diseases while protecting the future health of our planet. This review examines the benefits and limitations of different types of plant-based diets in terms of health and nutrition, affordability and accessibility, cultural (ethical and religious) acceptability, and the environment (i.e., the four pillars underlying sustainable healthy diets). Results suggest that, without professional supervision, traditional plant-based diets (vegan, vegetarian and pescatarian diets) can increase the risk of nutritional deficiencies among infants, children/adolescents, adult females, pregnant/lactating women and the elderly. In contrast, flexitarian diets and territorial diversified diets (TDDs, e.g., Mediterranean and New Nordic diets) that include large quantities of plant-sourced foods, low levels of red meat and moderate amounts of poultry, fish, eggs and dairy can meet the energy and nutrition needs of different populations without the need for dietary education or supplementation. Compared to vegan, vegetarian and pescatarian diets, more diverse flexitarian diets and TDDs are associated with reduced volumes of food waste and may be more acceptable and easier to maintain for people who previously followed western diets. Although flexitarian diets and TDDs have a greater impact on the environment than vegan, vegetarian and pescatarian diets, the negative effects are considerably reduced compared to western diets, especially if diets include locally-sourced seasonal foods. Further studies are required to define more precisely optimal sustainable healthy diets for different populations and to ensure that diets are affordable and accessible to people in all countries.

Altered nutrition behavior during COVID-19 pandemic lockdown in young adults

PURPOSE

The COVID-19 pandemic and the implemented lockdown strongly impact on everyone's daily life. Stressful situations are known to alter eating habits and increase the risk for obesity. In our study, we aimed to investigate the effect of the lockdown measures on nutrition behavior among young adults.

METHODS

In this cross-sectional study, we enrolled 1964 voluntary participants from Bavarian universities. All participants were asked to complete an online questionnaire, semi-quantitatively evaluating the amount and type of food before and during pandemic lockdown. Study subjects were inquired to give information about acquisition and food procurement. The primary outcome was the change in food amount, secondary outcomes included alterations of food composition and procurement.

RESULTS

Our study cohort (mean age 23.3 ± 4.0 years, 28.5% male) had a mean body mass index of 22.1 ± 4.5 kg/m2. The overall food amount increased in 31.2% of participants (n = 610) during lockdown and decreased in 16.8% (n = 328). A multinominal regression model revealed that an increased food intake was less likely in male participants (OR, 0.7 [CI 0.6-0.9]) and more likely with increasing BMI (OR, 1.4 [CI 1.3-2.0]), increased sports activity (OR, 1.3 [CI 1.2-1.8]), augmented mental stress (OR 1.4 [1.1-1.7]), and an alteration of alcohol consumption (reduced alcohol amount, OR, 1.4 [CI 1.1-1.7], increased alcohol, OR, 1.9 [CI 1.4-2.5]). Increase in food intake was mainly triggered by consumption of bread (increased in 46.8%, n = 284) and confectionary (increased in 64.4%, n = 389).

CONCLUSION

The COVID-19 pandemic lockdown significantly affected eating habits in young adults. Further investigation to evaluate long-term effects on weight change and comorbidities are warranted.

Case Report: Intensive Inpatient Neurorehabilitation Achieves Sustained Real-World Benefits in Severe Alcohol-Related Wernicke-Korsakoff Syndrome: A Case Study With 7-Years Follow-Up

About 85% of survivors of acute Wernicke's Encephalopathy (WE), a frequent and serious consequence of thiamine deficiency and alcohol misuse, sustain chronic neurocognitive deficits also known as chronic Wernicke-Korsakoff syndrome (WKS). If alcoholism is combined with smoking, tobacco alcohol optic neuropathy (TAON) may occur which leads to visual impairment. In contrast to WKS, TAON may be treated successfully by early vitamin substitution and detoxification. Little research has been conducted on WKS longterm outcomes. Existing literature suggests poor prognosis. Symptoms remaining beyond the acute treatment with thiamine are thought to be irreversible. Whether neurorehabilitation may be an effective route to help recovery of those persistent symptoms is an open question. At our neurorehabilitation center, which specializes in the treatment of severe chronic deficits after brain injury, the opportunity arose to treat a 35 year old male with WKS, and to conduct follow-up assessments 3- and 7-years post discharge, respectively. Initially MK was admitted to emergency care with suspected postconcussive syndrome, alcohol-related thiamine deficiency, and TAON. Thiamin, cobalamin, and folate substituion improved TAON but major cognitive deficits remained. When admitted to our center 4 months later, he was fully reliant on care staff for all activities of daily living (ADL). Through intensive neurocognive training and psychological treatment he improved gradually and, after 26 months, was well enough to be discharged into the community and pursue work in a sheltered setting. Neuropsychological tests, as well as patient reports obtained at the follow-ups showed that the benefits apparent at discharge had been sustained, and for some scores, improved further. This was particularly evident in the Rey-Osterrieth Complex Figure Test which improved from percentage ranges <1 for immediate recognition and recall at discharge to rank 16 for immediate recognition and rank 5 for recall at the 7-year follow-up. This case study illustrates the immense benefits neurorehabilitation can have for WKS induced by alcohol misuse. It further demonstrates how skills and strategies, learned in the inpatient setting, translate into living well and independently, and how the latter promotes further improvement long after discharge.