Tobacco-alcohol optic neuropathy and nutritional optic neuropathy

Nutritional optic neuropathies and alcohol-tobacco-related or alcohol-nutritional-related optic neuropathies share the same clinical presentation. They occur in the context of severe malnutrition and/or chronic alcoholism and/or smoking. They are rare today.

Pathophysiological Elements

The mechanisms behind these neuropathies are still poorly understood. Classic attributions include vitamin deficiencies (particularly B1, B12, and folates), the direct toxicity of alcohol and tobacco, oxidative stress, and microvascular alterations.

Clinical Presentation

These neuropathies are characterized by a slow, progressive decrease in visual acuity, typically bilateral, and asymmetric in the early stages. Alterations in color vision are possible.

Complementary Examinations

No other examination beyond the ophthalmological exam is necessary for a positive diagnosis. The presence of a bilateral central scotoma is suggestive.

Other examinations (blood serologies, MRI focused on the optic nerves, etc.) are only performed if there is doubt about other causes of optic neuropathies.

Treatment and Management

• Alcohol-Tobacco Withdrawal: → Slow recovery of usual visual acuity. Permanent sequelae are common, particularly in cases of advanced neuropathy.
• Emphasize to the patient that without withdrawal, progression to permanent blindness is likely.
• Vitamin supplementation (B1, B6, B12, folates) and improvement of nutrition.

Bibliography

Bradley WG et al., Neurology in clinical practice, 5th ed., Butterworth-Heinemann, e-dition, 2007

EMC, Traité de Neurologie, 2018

Osborne B, Optic neuropathies, UpToDate, 2018