Wernicke’s Encephalopathy with Upbeat Nystagmus and Nutritional Optic Neuropathy

Abstract

A 15-year-old girl presented with complaints of blurred vision, nystagmus, and diplopia for 1 week. She had been diagnosed with anorexia nervosa 3 years ago based on parameters of weight and her reluctance to food intake. In the most recent 6 months, she collapsed multiple times from poor nutrition, was in a constantly depressed mood, and had also developed amenorrhea. In the past 1 week, she complained of blurring, diplopia, and nystagmus. Ecchymosis was found over her right cheek region. Gingival bleeding was noted as well. Her best-corrected vision was 6/60 (−6.25–0.75 × 11) in the right eye and 6/60 (−6.25–0.75 × 176) in the left eye. A Hirschberg test was orthophoric. Extraocular movement was full and free (Fig. 35.1). Upbeat nystagmus could be found on primary gaze, which increased on upgaze and decreased on lateral gazes and turned into downbeat on downgaze (Video 35.1). Anterior segments were normal. Preretinal and flame-shaped retinal hemorrhage was found over the superotemporal and inferotemporal arcades in both eyes (Fig. 35.2). Mildly increased thickness of the peripapillary retinal nerve fiber layer (RNFL) was found in the left eye. A fluorescein angiography demonstrated blocked fluorescein over retinal hemorrhages and dye staining on bilateral optic discs (Fig. 35.2). Relative central scotoma was found in both eyes (Fig. 35.3). The patient was admitted under the impression of Wernicke’s encephalopathy with upbeat nystagmus and nutritional optic neuropathy.