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III.
IV.
Case History
a. Patient Demographics: 61 y.o. Caucasian female
b. Chief Complaint: Annual eye exam with moderate, constant, near blur OU
w/o SRx for nearly twenty years; she wears reading glasses with
improvement in vision.
c. OHx: DES OU, congenital nystagmus, s/p CE w/ PCIOL OU, s/p YPC
OS, presbyopia OU; MHx: Type II NIDDM w/ peripheral neuropathy,
hypercholesterolemia, triglyceridemia, GERD, hiatal hernia, chronic LBP,
depression, anxiety, fibromyalgia, obesity s/p Roux-en-Y gastric bypass
(RYGB) (1997), diverticulosis, OSA using CPAP, degenerative disc
disease, OA multiple sites, s/p TAH-BSO, benign colon polyps, breast
cancer s/p modified right radical mastectomy (1991).
d. Medication: prozac 60 mg daily, lasix 40 mg daily, norvasc 10 mg daily,
accupril 40 mg daily, zocor 20 mg daily, voltaren 75 mg daily, neurontin
600 mg t.i.d., januvia 50 mg daily, glucosamine / chondroitin b.i.d.,
omeprazole 20 mg daily, lorazepam 0.5 mg q.h.s., systane artificial tears 1
gtt daily OU.
e. Other salient information: The patient reported no history of smoking,
alcohol or recreational substance abuse; she was unemployed and
collecting disability. She did not drive. She was oriented to time, person,
& place; her mood was normal.
Pertinent Findings
a. Clinical: Distance visual acuity at presentation OD: 20/200 ph NI, OS:
20/70- ph NI, bilateral, symmetric, conjugate, horizontal jerk nystagmus
with secondary vertical and tortional components, severely contracted
GVF OU, bilateral temporal optic disc pallor.
b. Physical: Unremarkable
c. Laboratory studies: CBC w/ diff, ESR, CRP, ANA, ACE, RPR, FTAABS, vitamin B12, folate, methylmalonic acid, BUN, creatinine
d. Radiology studies: MRI brain & orbits w/ & w/o contrast w/ attention to
the visual pathway using 1.5 mm cuts.
e. Others: carotid duplex, fundus photography, Goldman visual fields
Differential diagnosis
a. Primary / leading: Nutritional optic neuropathy (vitamin B12 deficiency
s/p RYGB surgery)
b. Others: Intracranial tumor / metastasis, AION, NAION, autoimmune optic
neuropathy, neurosarcoid, neurosyphilis, toxic optic neuropathy, carotid
occlusive disease
Diagnosis & Discussion
a. Elaborate on the condition: Optic neuropathy is a rare manifestation of
vitamin B12 deficiency. This deficiency, however, is well-documented in
RYGB patients and may occur in greater than 60% of cases. Daily
vitamin supplementation is advised post-surgically.
b. Expound on unique features: This case resulted in low vitamin B12 and
elevated methylmalonic acid serology and ultimately illustrated the
V.
significance of the patient’s surgical history in elucidating the ocular
diagnosis. Compliance with vitamin supplementation post-surgically in
all RYGB patients is imperative for systemic and ocular health.
Treatment, management
a. Treatment & response to treatment: This patient was co-managed with her
PCP who initiated vitamin B12 injections 1 cc IM monthly. She was
monitored with serial dilated fundus examinations and Goldman visual
fields. Visual acuity remained stable at 20/200 OD and improved to
20/50+2 OS; she experienced 15-20° expansion of her visual field in both
eyes. She noted decreased fatigue and improved concentration.
b. Research: Long-term studies on gastric bypass surgery outcomes are now
becoming more available. Nutritional deficiencies are common in postoperative RYGB patients and aggressive prophylactic supplementation
with iron, vitamin B12, folate, calcium, and vitamin D are warranted.
Regular nutrition monitoring and routine serology to monitor for
deficiencies is also necessary.
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VI.
Conclusion
a. Clinical pearls: Knowledge of a baseline optic atrophy work-up was
particularly important in this case to elucidate this diagnosis of exclusion.
Ocular complications of gastric bypass surgery, particularly malabsorption
issues, was paramount in making the diagnosis and initiating appropriate
therapy.