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Beitragstitel Nutritional optic neuropathy during Vitamin B12 nasal supplementation and rapid visual recovery after intramuscular replacement
Autor:innen
  1. Eirini Kaisari Hôpital ophtalmique Jules-Gonin Präsentierende:r
  2. Ségolène Roemer HOJG (UNIL)
  3. Aki Kawasaki HOJG (UNIL)
Präsentationsform ePoster
Themengebiete
  • Neuroophthalmology / Strabology
Abstract-Text Purpose :
Deficiency of cobalamin (vitamin B12) is a rare cause of nutritional optic neuropathy. The typical clinical manifestation is bilateral, progressive painless visual loss associated with central visual field defects and dyschromatopsia. With replacement of vitamin B12, the optic neuropathy often improves. Conventional therapy is parenteral, but new oral and nasal delivery options have recently been introduced. We report a patient who developed a rapidly progressive bilateral optic neuropathy while taking nasal vitamin B12 supplementation. A switch to intramuscular replacement resulted in a visual improvement within days.

Methods :
A 60-year-old man with longtime consumption of alcohol and cigar smoking complained of a progressive visual defect in the left temporal field causing driving difficulty over 6 months. Examination showed small bilateral cecocentral scotomas with visual acuity of 1.0 right eye (OD) and 0.4 left eye (OS). Blood testing revealed a deficiency of vitamin B12 (total B12 116 pmol/l; reference 138-652 pmol/l) and mild macrocytosis (107 fl; reference 81-99 fl). Cyanocobalamin nasal spray (500 μg/0.1 ml once a week) was started. Three months later, he was referred to the neuro-ophthalmology clinic for rapid visual decline in both eyes. Visual acuity had dropped to 0.5 OD and counting fingers OS. Additionally, there was severe dyschromatopsia, a dense central scotoma and mild temporal optic disc pallor in both eyes. Repeat blood testing revealed a persistently low level of vitamin B12 (holotranscobalamin or active B12 36 pmol reference >50 pmol) despite 3 months of nasal spray treatment. Therefore, intramuscular B12 supplementation was started following Swiss medical recommendations (1000 μg daily for 5 days, 1x/week for 1 month, 1x/month thereafter).

Results :
Seven days after initiating intramuscular B12 replacement, visual acuity was improved to 0.6 OD and 0.2 OS and the patient noted definite subjective improvement of vision. The dyschromatopsia and visual field defects were unchanged.

Conclusions :
This case suggests that nasal spray supplementation of B12 is not sufficient to treat nutritional optic neuropathy due to cobalamin deficiency. The clinical course of this patient is a reminder that B12 deficiency may present as rapid, subacute visual loss. Adequate and parenteral supplementation of vitaminB12 (cobalamin) can result in visual improvement within days.