Severe Vision Loss in a Man With Heavy Tobacco and Alcohol C
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A 44-year-old man presented with a 4-month history of gradual vision loss in both eyes. He had a medical history of hypertension, anxiety, and posttraumatic stress disorder, for which he took amlodipine, lorazepam, citalopram, and quetiapine. He smoked 1.5 packs of cigarettes per day for the past 30 years and had a history of substantial alcohol use, drinking 2 to 3 L of wine per day. Because of excessive alcohol intake, he only ate 1 meal per day.

On examination, his visual acuity was 20/400 OU, there was no relative afferent pupillary defect, and his anterior segment examination results were normal. Dilated fundus examination results revealed bilateral optic nerve hyperemia, blurred margins, and subtle telangiectatic vessels on the surface of the optic nerve bilaterally. Humphrey 24-2 Swedish Interactive Testing Algorithm fast visual field testing showed central scotomas in both eyes. Optical coherence tomography results of the macula were normal in both eyes. Neurological examination results revealed otherwise normal cranial nerves, normal sensation in the extremities, normal reflexes, and normal strength. Bilateral optic neuropathies with central scotomas are a result of dysfunction of the papillomacular bundle, which contains small, unmyelinated nerve fibers that have high energy demands. In this patient, the main differential diagnoses to consider are nutritional deficiencies, hereditary causes, or toxic medications, all of which can result in mitochondrial dysfunction and impaired oxidative phosphorylation.

The patient was counseled on reducing alcohol and tobacco use. He enrolled in a rehabilitation program to successfully eliminate his alcohol consumption, was prescribed a B-complex multivitamin containing folic acid, 1 mg, daily, and started eating 3 nutritious meals per day. Repeated bloodwork results 3 months after presentation revealed normal folate levels. At a 12-month followup, his visual acuity improved to 20/30 OU. Mild temporal pallor remained in both optic nerves, but his examination results were otherwise normal.