eMedicine Specialties > Ophthalmology > Optic Nerve

Toxic/Nutritional Optic Neuropathy: Follow-up

Author: Aftab Zafar, MD, Consulting Staff, Department of Ophthalmology, St Mary's General Hospital
Contributor Information and Disclosures

Updated: Aug 27, 2008

Follow-up

Further Outpatient Care

  • Patients with toxic/nutritional optic neuropathy should be observed initially every 4-6 weeks and then, depending on their recovery, every 6-12 months. At each visit, the patient's visual acuity, color vision, visual fields, pupils, and optic nerves should be assessed.

Inpatient & Outpatient Medications

Deterrence/Prevention

  • Patients in whom ethambutol or isoniazid is indicated need to have a baseline ophthalmologic examination before treatment is instituted and should be monitored by their ophthalmologist periodically as long as they are on the drug to detect any optic nerve toxicity as soon as possible. Patients should also be made aware of the potential ocular adverse effects of these drugs and should be encouraged to seek medical attention as soon as visual symptoms become apparent.
  • Any patient for which amiodarone is being considered for treatment requires a baseline ophthalmic examination before the drug is initiated. Furthermore, once on the drug, patients should be evaluated at least every 6 months. Even if a patient presents with corneal changes associated with the drug, their decreased vision should never be attributed to this until any pathology of the optic nerve has been excluded.
  • Patients should seek assistance from their primary physician on methods to stop or reduce their smoking and/or alcohol intake.

Complications

  • No complications are associated with the aforementioned therapy. The only complication of not seeking or complying with therapy is profound bilateral visual loss but never total blindness.

Prognosis

  • If patients with nutritional optic neuropathy are compliant with the treatment regimen, and unless the loss of vision is already far advanced, the prospect for recovery or at least improvement is excellent, except for the most chronic cases. However, the rate of recovery varies from a few weeks to several months. The prognosis is also better if treatment is initiated in the first few months after the onset of symptoms. Visual acuity tends to recover before color vision. When recovery has been complete, recurrences are unusual. Although extremely rare, cases of spontaneous improvement of vision have been reported without patient cooperation.
  • For toxic optic neuropathies, when the responsible toxin is discontinued, vision usually recovers to normal over several days to weeks. However, this does depend in large part on the nature of the offending agent and on its total exposure before it was removed.

Patient Education

  • Patients must be alerted to report any visual problems to their ophthalmologist immediately if they are taking ethambutol, isoniazid, or amiodarone.

Miscellaneous

Medicolegal Pitfalls

  • For both medical and legal reasons, physicians need to be aware of how toxins or nutritional deficiencies can be factors responsible for sporadic cases of visual loss. One should not assume that cecocentral scotomas are caused by toxic/nutritional optic neuropathy because there are many examples of bilateral cecocentral scotomas from compressive or infiltrative lesions of the optic chiasm. Therefore, even if one is very confident of the diagnosis of toxic/nutritional optic neuropathy, neuroimaging should be obtained.
  • Physicians need to be aware of underlying litigating circumstances when it comes to the diagnosis of toxic optic neuropathy. Such issues include medical malpractice, workers' compensation, and product liability and recall. For these reasons, clinicians should have compelling evidence before establishing that a toxin is the cause of an optic neuropathy, although making the diagnosis could assist in preventing visual loss in other people (eg, coworkers) exposed to the same toxin.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Robert C Sergott, MD, to the development and writing of this article.



More on Toxic/Nutritional Optic Neuropathy

Overview: Toxic/Nutritional Optic Neuropathy
Differential Diagnoses & Workup: Toxic/Nutritional Optic Neuropathy
Treatment & Medication: Toxic/Nutritional Optic Neuropathy
Follow-up: Toxic/Nutritional Optic Neuropathy
References
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Further Reading

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Keywords

toxic/nutritional optic neuropathy, toxic-nutritional optic neuropathy, toxic and nutritional optic neuropathy, toxic optic neuropathy, nutritional optic neuropathy, optic neuropathy, optic neuropathies, metabolic optic neuropathy, nutritional deficits, undernutrition, nutritional amblyopia

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Contributor Information and Disclosures

Author

Aftab Zafar, MD, Consulting Staff, Department of Ophthalmology, St Mary's General Hospital
Aftab Zafar, MD is a member of the following medical societies: Canadian Medical Association, Canadian Ophthalmological Society, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Andrew W Lawton, MD, Medical Director of Neuro-Ophthalmology Service, Section of Ophthalmology, Baptist Eye Center, Baptist Health Medical Center
Andrew W Lawton, MD is a member of the following medical societies: American Academy of Ophthalmology, Arkansas Medical Society, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

CME Editor

Ralph Garzia, OD, Assistant Dean for Clinical Programs, Associate Professor, School of Optometry, University of Missouri at St Louis
Ralph Garzia, OD is a member of the following medical societies: American Academy of Optometry and American Optometric Association
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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