Toxic and Nutritional Amblyopia
(Nutritional Optic Neuropathy)
Toxic amblyopia is usually bilateral and symmetric. Undernutrition and vitamin deficiencies (eg, vitamins B1 or B12 or folate) may be the cause, particularly in postbariatic surgery patients (1) and alcoholics. True tobacco-induced amblyopia is rare. Lead, methanol, chloramphenicol, digoxin, ethambutol, and many other chemicals can damage the optic nerve. Deficiencies of protein and antioxidants are likely risk factors. Toxic amblyopia may occur with other nutritional disorders, such as Strachan syndrome (polyneuropathy and orogenital dermatitis).
In patients with toxic amblyopia, vision blurring and dimness typically develop over days to weeks. An initially small central or pericentral scotoma slowly enlarges, typically involving both the fixation and the blind spot (centrocecal scotoma), and progressively interferes with vision. Total blindness may occur in methanol ingestion, but other nutritional causes typically do not cause profound vision loss. Retinal abnormalities do not usually occur, but temporal disk pallor may develop late.
A history of undernutrition, bariatric surgery, or toxic or chemical exposure combined with typical bilateral scotomata on visual field testing justifies treatment. Laboratory testing for lead, methanol, suspected nutritional deficiencies, and other suspected toxins is done.
The cause of the patient's amblyopia is treated. Exposure to toxic substances should stop immediately. Alcohol and other potentially causative chemicals or drugs should be avoided. Chelation therapy is indicated in lead poisoning. Dialysis, fomepizole, ethanol, or a combination is used for methanol poisoning. Treatment with oral or parenteral B vitamins and/or folate before vision loss becomes severe may reverse the condition when undernutrition is the presumed cause.
Low-vision aids (eg, magnifiers, large-print devices, talking watches) may be helpful.
The role of antioxidants has not been fully characterized. Their use could be justified on a theoretic basis; however, there is no proof of efficacy, and the at-risk population that should receive such supplements has not been defined.
Toxic amblyopia is reduced visual acuity caused most often by drugs or toxins or nutritional deficiencies, particularly in alcoholics or in those who have undergone bariatric surgery.
Vision loss is usually gradual and partial.
Diagnosis is mainly clinical (eg, bilateral scotomata, suggestive history).
Treat the cause (eg, stopping exposure to a drug or toxin, improving nutrition).
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