HVF 24-2 testing revealed a clear visual field OD and a stable central scotoma OS. HVF SITA Fast 24-2 revealed improved central defects with mean deviation OD: -1.57 dB and OS: -2.65 dB. Optometric Education is published three times per year. Compressive optic neuropathy can occur from any intraorbital mass and is most easily diagnosed with MRI. The liver can store approximately 500 times the recommended daily allowance; therefore, vitamin B12 deficiency due to dietary insufficiency alone is quite rare.1. WebDFE = Dietary Folate Equivalent; 1 DFE = 1 mcg naturally-occurring folate = 0.6 mcg folic acid taken with food = 0.5 mcg folic acid taken on an empty stomach. In: UpToDate, Motil, KJ (Ed), UpToDate, Waltham, MA. Ultimately, the best vitamin B12 supplement is the one that works best for your dietary needs and preferences. 2014 Dec;9(4):662-6. The UL for vitamin B6 is 100 mg per day. Schrier SL. Am J Hematol. One Capsule Contains: Thiamin (as Thiamin HCl) 40 mg, Riboflavin (25 mg as Riboflavin and 3.6 mg, Riboflavin 5'-Phosphate Sodium) 28.6 mg, Niacin (as Niacinamide) 80 mg, Vitamin B6 (20 mg as Pyridoxine HCl and 3.4 mg as Pyridoxal 5'-Phosphate) 23.4 mg, Folate (400 mcg as L-5-Methyltetrahydrofolate from L-5 SITA Standard 30-2 Humphrey Visual Field testing from the initial visit in February 2011 shows central scotoma OS.Click to enlarge. Web{{configCtrl2.info.metaDescription}} Sign up today to receive the latest news and updates from UpToDate. Use of information in this journal is voluntary. 2007;262:158-64. Available from: Ehlers JP. The subjective refraction did not improve the best-corrected visual acuities. Int J Clin Pract. Dr. Scharnweber [Amber.Scharnweber2@va.gov] practices in the St. Advertising rates are available upon request. (Table 2) Visual field testing was modified to the shorter 24-2 to improve patient cooperation. Vitamin B12 has several vital roles in the body. Follow-up 3: nine months after initial presentation, Figure 3A. Sourced from high quality ingredients, this gluten free B12 supplement is a dietary supplement that has no synthetic dyes and no artificial flavors. OPTOMETRIC EDUCATION is published by the Association of Schools and Colleges of Optometry (ASCO). Stojsavlijevic N, Levic Z, Drulovic J, Dragutinovic G. A 44-month clinical brain MRI follow-up in a patient with B12 deficiency. You are here: Home Current Issue Vitamin B12 Deficiency Optic Neuropathy: a Teaching Case Report, Amber R. Scharnweber, OD, FAAO, ABCMO, and Richard J. Zimbalist, OD, FAAO. SITA Standard 30-2 Humphrey Visual Field (HVF) revealed central scotomas OD and OS; however, testing was somewhat unreliable due to fixation losses. Jarrow Formulas Methylcobalamin. Why is it important to treat vitamin B12 completely before supplementing with oral folic acid? (Figure 3) Mean deviations were OD: -0.79 and OS: -2.87. This case report is intended to educate eyecare providers on the presentation and management of vitamin B12 deficiency optic neuropathy. Organic Vitamin B12 - 5000 mcg, 3 BioActive B12 Forms: Methyl B12, Adenosyl B12 & Hydroxy B12 - Plus L-Methylfolate Cofactor | Sublingual Form, Cherry Flavor, Vegan, Non-GMO (60 Servings) Solimo Vitamin B12 500 mcg - Normal Energy Production and Metabolism, Immune System Support - 100 Gummies (2 Gummies per Natrols Vitamin B12 supplement is a high dosage, fast-delivery option. The ASCO website and materials are provided solely for individual, educational, and noncommercial purposes. The OCT scans were less than optimal due to poor patient fixation and technique. 1,2 The recommended daily requirement is 6-9 mcg. Most individuals in developed countries consume this amount. Available from: Orssaud C, Roche O, Dufier JL. Vitamin B12 Sublingual 5000mcg | Methyl B12 Active Form- 180 Chewable Tablets | Fast Dissolve, Natural Strawberry Flavor, Support Energy, Metabolism Health, Vegan, Non-GMO & No Gluten with D3 Supplement Bone and Heart Health Non-GMO Formula 5000 IU Vitamin D3 & 90 mcg Vitamin K2 MK-7 Easy to Swallow Vitamin D & OPTOMETRIC EDUCATION disclaims responsibility for opinions expressed by the authors. He was status post a December 2004 resection of an oropharyngeal tumor and neck dissection. Update on vitamin B12 deficiency. Vitamins. It plays a key role in DNA synthesis, maintaining normal brain function, protein metabolism and erythropoiesis. Neurology. Interestingly, studies have shown that up to 5% of individuals can have normal vitamin B12 levels when they are, in fact, deficient.11, Diagnosing B12 deficiency can be difficult based on serum B12 levels alone. Folic acid supplementation has also been shown to cause more rapid progression of neurological symptoms if vitamin B12 is not bioavailable or the B12 deficiency is not treated first.7, The classic neurological symptoms caused by vitamin B12 deficiency consist of a subacute combined degeneration and diffuse demyelination of the posterior and lateral spinal columns resulting in extremity numbness, weakness and loss of vibratory sense.6,8 The neuropathy is usually symmetrical and patients may present with ataxia, spasticity, hyperactive knee and ankle jerks, and even urinary and fecal incontinence.6,8 Similar pathological changes can occur in the cerebral hemispheres due to a defect in myelin formation that is not completely understood.5,6,8,9 Other systemic manifestations of B12 deficiency include generalized pallor, tachycardia, fatigue, palpitations, megaloblastic anemia, unexplained neurological symptoms (i.e., dementia, sensory ataxia, personality changes, loss of positional sense) and osteoporosis.6, Optic neuropathy secondary to vitamin B12 deficiency occurs in less than 1% of B12 deficient patients.5 It results in progressive, bilateral, painless vision loss that is often associated with reduced color vision and central or cecocentral scotomas. Chan, JW. These Nature Made B12 1000 mcg softgels help support energy metabolism(1). 2015 Optometric Education Extraocular muscles were full without restriction. All materials contained on the Association of Schools and Colleges of Optometry (ASCO) website are protected by United States copyright law and may not be reproduced, distributed, transmitted, displayed, published or broadcast without the prior written permission of ASCO, or in the case of third party materials, the owner of that content. about your interest in, questions about, or use of dietary supplements and what may be best for your overall health. It is important to note, however, that a low concentration of vitamin B12 only indicates a short-term imbalance. HEALTH The best time to take vitamins and supplements for maximum Sawicka-Pierko A, Obuchowsak I, Hady RH, Mariak Z, Dadan J. Nutritional optic neuropathy following bariatric surgery. Lebers hereditary optic neuropathy is maternally inherited and usually found in young men age 15-30. (Table 1) At that time, he was prescribed vitamin B12 1000 mcg po daily and folic acid 1 mg po daily. 9. The stomach ulcer was treated with gastric surgery, date unknown, with resultant pernicious anemia. Langan RC, Zawistoski KJ. The cause of death was unknown. Rockville, MD 20852 Its 5000 mcg of vitamin B12 will rapidly raise your bodys circulating levels of vitamin B12. WebVitamin B12 is one of eight components of the vitamin B complex. Diagnosis and treatment of vitamin B12 and folate deficiency. How would you further evaluate the effect of cataract on a patients best-corrected visual acuity? Nature Made Vitamin B12 1000 mcg Softgels help break down food into energy that your body can use all day long. etc.) Recent blood pressure was normotensive at 121/80 mmHg (left arm, sitting) and his calculated BMI was 30.78. 2004;58:977-78. This paper presents a rare case of partial visual recovery following vitamin B12 deficiency optic neuropathy. His best-corrected visual acuity remained 20/400 OD and 20/400 OS and he was only able to see the test plate of the Ishihara color vision test OD and OS. 6110 Executive Boulevard, Suite 420, How is vitamin B12 deficiency optic neuropathy treated? Pregnant women need 2.6 mcg of vitamin B12 a day and breastfeeding women need 2.8 mcg. Accessed Oct. 6, 2015. Available from: Mindel JS. 1995 Apr;48(4):251-5. The patient was diagnosed with bilateral optic neuropathy due to vitamin B12 deficiency. If you are dissatisfied with our formula you have 30 days to return it for a full refund. VITBOOST B12 is one of the best options for B12 supplement on the market because its ingredients dont need to be converted in the liver, and its liquid form makes it highly absorbable and potent. The role of the optometrist in managing this condition to optimize visual recovery is also highlighted. 2013 Jun;38(6):680-4. WebClams and beef liver are some of the best source of vitamin B12. It is one of eight B vitamins.It is required by animals, which use it as a cofactor in DNA synthesis, in both fatty acid and amino acid metabolism. It is important in the normal functioning of the nervous system via its role in the synthesis of myelin, and in the Amazon Brand - Solimo Vitamin B12 500 mcg - Normal Energy Production and Metabolism, Cover test was orthophoric at distance. 8. 1997 Sep;49(3):878-81. Evaluation of peripapillary retinal nerve fiber layer thickness in patients with vitamin B12 deficiency using spectral domain optical coherence tomography. Physiology of vitamin B12 and folate deficiency. Lancet.1995 Jul 8;346(8967):85-9. Because ASCO does not endorse or warrant the information in this journal, you are advised to use the information after your own review of it and the informations reliability for your purposes. Size: 50 Count (Pack of 1) Verified Purchase. (Figure 2) His best-corrected visual acuity was 20/40- OD and 20/80- OS. The patient experienced significant visual recovery after implementation of parenteral B12 therapy followed by oral folic acid supplementation. Additionally, vitamin B12 plays a crucial role in limiting the amount of plasma homocysteine, which in high amounts can lead to endothelial cell toxicity.1 Vitamin B12 deficiency also leads to elevated levels of methylmalonyl CoA, which interferes with fatty acid synthesis and contributes to abnormal myelin formation. He continued to receive cyanocobalamin 1000 mcg/mL intramuscularly. The optic nerve may appear normal in the early stages of disease until optic atrophy develops. Pernicious anemia is a condition in which the body does not produce enough red blood cells due to decreased intrinsic factor, a glycoprotein secreted by the stomach. Accessed June 29, 2016. Follow-up 2: five months after initial presentation. Schrier SL. All rights reserved. Larner AJ. It should not be taken within 2 hours To access Optometric Education online, please go to www.opted.org. Toxicity can present as nerve damage or skin lesions. It plays a key role in DNA synthesis, maintaining normal brain function, protein metabolism and erythropoiesis.1 The best sources of vitamin B12 are eggs, milk, cheese, meat, fish, shellfish and poultry.1,2 The recommended daily requirement is 6-9 mcg. The patient refused repeat HVF testing at this visit. Toxic and deficiency optic neuropathies. Business and editorial offices are located at The patient denied alcohol and recreational drug use. These optic neuropathies can be further isolated with appropriate laboratory testing, imaging studies and a detailed patient history. You understand and agree that ASCO is not responsible or liable to any party for any direct, indirect, special or other damages for use of the information contained in this journal or websites linked from this journal. of supplemental vitamin B12 is better than the others. While this list is not exhaustive, the most common differential diagnoses (Table 4) are: Vitamin B12 deficiency has traditionally been treated with intramuscular injections at a dosage of 1 mg weekly for eight weeks followed by 1 mg monthly for life or until the underlying etiology is eliminated.15 Oral and nasal B12 formulations came to the market several years ago and offer a suitable alternative to parenteral dosing; however, they require greater patient compliance. Visual failure caused by vitamin B12 deficiency optic neuropathy. (1) This multitasker is an essential vitamin that plays an important role in energy metabolism by helping the body convert food into cellular energy. Buy Nature Made Maximum Strength Vitamin B12 5000 mcg, Dietary Supplement for Energy Metabolism Support, Solimo Vitamin B12 500 mcg - Normal Energy Production and Metabolism, Immune System Support - 100 Gummies (2 Gummies per Serving) Shop around is my best advice. B-12 that dissolves (melts in your mouth) or chewable tablets are the most common choice for vitamin B-12 supplementation. Some breakfast cereals, nutritional yeasts, and other food products are fortified with vitamin B12. Amazon Brand - Solimo Vitamin B12 500 mcg - Normal Energy Production and Metabolism, Immune System Support - 100 Gummies (2 Gummies per Serving) 5.0 out of 5 stars This is the best way to take B12 sublingal. The patient reported his vision was stable. Deceitfully normal levels can be seen in hepatic disorders, and falsely low levels can be seen in folate deficiency and pregnancy.4,12 It is helpful to measure methylmalonate and homocysteine, which are precursors in the B12 pathway, as 85% of patients with B12 deficiency will have elevated levels of these compounds.4 This is particularly useful when the B12 level is in the low- to borderline-low range.4 Additionally, a complete blood count with an elevated mean corpuscular volume (MCV) over 110 fl is also suggestive of vitamin B12 deficiency and warrants further testing.13. Click to enlarge, Figure 1B. Retinal nerve fiber layer (RNFL) evaluation with OCT revealed a small wedge of temporal thinning OD and was unreliable OS. In approximately 30% of cases, the visual deficiencies precede other neurological and hematological signs often due to the presence of folic acid.7 Optic nerve head involvement (in the form of optic atrophy) is rare, but can lead to significant visual decline.10, Serum vitamin B12 is the most frequently ordered laboratory test when a patients history is suggestive of vitamin B12 deficiency. Check price at Amazon. Table 3 lists additional etiologies that can contribute to an acquired vitamin B12 deficiency. In: Duanes Ophthalmology 12, Phillips PH. He continued to receive cyanocobalamin 1000 mcg/mL intramuscularly. Vitamin B-12 Sublingual Liquid by Natures Bounty works hard to help you feel your best every day. Incomplete treatment of vitamin B12 deficiency with oral B12 supplementation coupled with oral folic acid can aggravate neurological impairment secondary to vitamin B12 deficiency if the B12 deficiency is not corrected first. Most reports in the literature describe expectations for visual recovery from vitamin B12 deficiency optic neuropathy as guarded, citing time to diagnosis and treatment as the primary limiting factors.7,9,10,16 Improvement of visual symptoms is greatest with early and aggressive therapy.3 Interestingly, this patient recovered vision despite the presence of optic nerve pallor. Nutritional disorders: malnutrition, malabsorption, and B12 and other vitamin deficiency. In: Walsh & Hoyts Clinical Neuro-Ophthalmology 6. Graphic Designer: Kerri McTigue Cloud VA Health Care System in St. His best-corrected visual acuity improved to 20/80 OD and 20/80-2 OS. 17. WebThe DV for vitamin B12 is 2.4 mcg for adults and though supplementation lowers homocysteine levels . Turkyilmaz K, Oner V, Turkyilmaz AK, Kirbas A, Kirbas S, Sekeryapan B. Laboratory testing should also be performed to rule out B12 deficiency. His color vision had also improved to 2/8 OD and 4/8 OS with Ishihara plates. Schrier SL. WebThe .gov means its official. A targeted history and thorough ophthalmic examination is necessary to narrow down a list of probable diagnoses. These include fish, meat, poultry, eggs, milk, and other dairy Optic neuropathy is a rare complication of vitamin B12 deficiency. The goal was to ensure vitamin B12 was bioavailable in the presence of any malabsorption issues the patient may have had secondary to the previous gastric ulcer surgery. What are the classic systemic signs and symptoms of vitamin B12 deficiency? Vitamin B12 deficiency optic neuropathy is a rare complication of this deficiency that results in progressive, bilateral, painless vision loss that is often associated with reduced color vision and central or cecocentral scotomas. Available from: Food sources of vitamin B12 [Internet]. Subjective refraction was OD: +2.00 DS and OS: +2.00 DS. Indexed in Visionet, Vision Cite, Educational Resources Information Center (ERIC) 1979-2003, and Directory of Open Access Journals (DOAJ). The patient continued to report visual improvement and was able to get his drivers license reinstated. (Figure 4) It was also noted that the patient had developed a posterior subcapsular cataract in his left eye. He continued to receive cyanocobalamin 1000 mcg/mL intramuscularly, and his serum B12 and folate levels had noticeably improved from baseline. 500 mg of vitamin C taken daily for 2 weeks significantly raised erythrocyte (red blood cell) glutathione levels. The opinions and information included in the journal are provided by the authors. Sign Up The patient reported his vision had improved slightly since his last exam. Some provide doses of vitamin B12 that are much higher than recommended amounts, such as 500 mcg or Foods from animals, but not plants, naturally have vitamin B12. Its nice for a quick boost in B12, but is less well-suited for prolonged use. A deficiency in vitamin B12 can lead to megaloblastic erythropoiesis, a form of anemia that is characterized by large red blood cells that fail to divide via mitosis. Nutritional optic neuropathies. Since the advent of bariatric surgery, the importance of ophthalmic surveillance in the presence of vitamin deficiencies has been more frequently discussed in the literature.16 Additionally, Turkyilmaz et. In most circumstances, visual recovery does not occur once axonal loss has ensued and optic nerve pallor has formed. Acquired conditions, such as pernicious anemia, also cause inadequate absorption of B12. Optic nerve disorders: diagnosis and management. It contributes to the formation of methionine, an important part of DNA synthesis in cells that undergo rapid turnover, including those of the hematopoietic system and of the enteric lining that produces intrinsic factor. Solimo Vitamin B12 500 mcg - Normal Energy Production and Metabolism, Immune The plan was to continue intramuscular supplementation with cyanocobalamin. In: UpToDate, Mentzer, WC (Ed), UpToDate, Waltham, MA. WebVitamin B 12, also known as cobalamin, is a water-soluble vitamin involved in metabolism. Due to the high metabolic demand of the papillomacular bundle in the retina, it is believed that this depletion of ATP damages these sensitive papillomacular bundle fibers resulting in the commonly noted bitemporal optic nerve atrophy and cecocentral scotoma seen in B12 deficiency optic neuropathy.4, The prevalence of vitamin B12 deficiency increases with age, and it is estimated that 10% of people over age 75 have the disease with 10% also having coexistent folate deficiency.5 Deficiencies in both vitamin B12 and folate result in megaloblastic anemia, but only the vitamin B12 deficiency causes neurological impairment.6 Vitamin B12 and folic acid are intertwined biochemically.1 Folic acid can minimize the hematological abnormalities of vitamin B12 deficiency, but not the neurological symptoms. The evaluation should include a thorough ophthalmic examination including careful pupillary examination, automated visual field assessment, color vision testing and OCT analysis. Sources of vitamin B12 most often include foods derived from animals (i.e., beef, chicken, eggs, and milk). (typically 500 mg/day or more). SITA Standard 24-2 Humphrey Visual Field test results OS from the patients final visit in November 2011. Amazon Brand - Solimo Vitamin B12 500 mcg - Normal Energy Production and Metabolism, Immune System Support - 100 Gummies (2 The MRI of the brain and orbits was unremarkable. Naurath HJ, Joosten E,Riezler R,Stabler SP,Allen RH,Lindenbaum J. How could this case have been handled differently? Dietitians of Canada; c2014 [cited 2014 May 6]. The mean deviations were -6.07 dB OD and -4.90 dB OS. What are the differential diagnoses for vitamin B12 deficiency optic neuropathy? Doctor's Best Fully Active B12 1500 Mcg, Supports Energy, Mood, Circulation, Non-GMO, Vegan, Gluten Free, 180 Count. The patient was instructed to continue the cyanocobalamin injections and return in six months for follow-up. Diagnosis is confirmed by genetic testing for the primary mutations: 11778, 3460, 15257 and 14484. The researchers concluded that vitamin C supplementation at that level can benefit the Effects of vitamin B12, folate, and vitamin B6 supplements in elderly people with normal serum vitamin concentrations. Curr Eye Res. The patient was able to see only the test plate on color vision testing with Ishihara plates OD and OS. His family history was unremarkable. Lennihan L, Rowland LP. Best Sellers Rank: #1,196 in Health & Household (See Top 100 in Health & Household) #7 in Vitamin B12 Supplements; Customer Reviews: Amazon Brand - Solimo Vitamin B12 500 mcg - Normal Energy Production and Metabolism, Immune System Support - 100 Gummies (2 Gummies per Serving) What is the visual prognosis and limitations for visual recovery from vitamin B12 deficiency optic neuropathy? Before sharing sensitive information online, make sure youre on a .gov or .mil site by inspecting your browsers address (or location) bar. Prompt diagnosis and recognition of vitamin B12 deficiency optic neuropathy is paramount to visual recovery. Note the improvement in the central scotoma compared with initial testing as seen in both the threshold and pattern deviations.Click to enlarge, Figure 4. In a 2013 study in 100 older adults, supplementing with 500 mcg of vitamin B12 for 8 weeks was found to normalize B12 levels in 90% of participants. Differential diagnosis for B12 deficiency optic neuropathy. This change was recommended because incompletely treated vitamin B12 deficiency with oral replacement by folic acid can aggravate the neurological impairment related to B12 deficiency if the B12 is not corrected first. (301) 231-5944. The case report explores multiple facets of vitamin B12 deficiency including pathogenesis, epidemiology, manifestations, differential diagnosis and treatment modalities. Some provide doses of vitamin B12 that are much higher than recommended amounts, such as 500 mcg or 1,000 mcg, but your body absorbs only a small percentage of it. Etiology and clinical manifestations of vitamin B12 and folate deficiency. An in-depth chart review revealed that the patient had been diagnosed with vitamin B12 deficiency in October 2010 as a result of routine bloodwork. MetzJ,McGrathK,Bennett M,Hyland K,Bottiglieri T. Biochemicalindicesof vitaminB12nutrition in pregnant patients with subnormal serum vitaminB12levels. What is the ocular presentation of vitamin B12 deficiency? Links to websites other than those owned by ASCO are offered as a service to our users and ASCO was not involved in their production and is not responsible for their content. Facilitate case discussion to achieve learning objectives, Clinical skills can be tested via practicum of visual field, OCT and fundus photography, Knowledge base can be assessed by comparison of normal and abnormal visual fields, OCTs, fundus photos and MRI, Knowledge base can be assessed by student presentations of differential diagnoses or written theoretical case examples. Similarly, infiltrative optic neuropathies are best diagnosed with neuroimaging and cerebrospinal fluid and/or vitreous analysis. SITA Standard 30-2 Humphrey Visual Field testing from the initial visit in February 2011 shows central scotoma OD. The amount of vitamin B12 in supplements varies widely. Vitamin B12 (also known as cobalamin) is an essential vitamin for neurological function. Unfortunately, he passed away in February 2012. Pupils were equally round and reactive to light, without an afferent pupillary defect. 2011 Jun 15;83(12):1425-30. Federal government websites always use a .gov or .mil domain. Accessed May 31, 2016. The patient in this teaching case report developed painless, progressive vision loss with temporal optic disc pallor and central scotomas after oral replacement of B12 and folic acid. Vitamin B12 Sublingual 5000mcg | Methyl B12 Active Form- 180 Chewable Tablets | Fast Dissolve, Natural Strawberry Flavor, Support Energy, Metabolism Health, Vegan, Non-GMO & No Gluten with D3 Supplement Bone and Heart Health Non-GMO Formula 5000 IU Vitamin D3 & 90 mcg Vitamin K2 MK-7 Easy to Swallow Vitamin D & Natrol Vitamin B12. Repeat RNFL OCT testing revealed stable temporal thinning OD and was unreliable OS. Web{{configCtrl2.info.metaDescription}} Sign up today to receive the latest news and updates from UpToDate. Magnetic resonance imaging (MRI) of the brain and orbits was ordered to rule out other neurological etiologies. The funduscopic views of the left eye were decreased consistent with the cataract formation, thus the cataract was likely also limiting the patients best-corrected visual acuity. Even in high doses, your body can only absorb a fraction of B12 supplements. Cirrus HD-OCT RNFL imaging from Nov. 10, 2011 (10 months after the change in therapy by hematology).Click to enlarge. Confrontation visual fields were full to finger count OD and OS without extinction. Follow-up 1: one month after initial presentation. New York, NY: Springer Science+Business Media, LLC; 2007. His current medications included allopurinol 100 mg daily, cyanocobalamin 1000 mcg/mL intramuscularly monthly, folic acid 1 mg daily, and aspirin 81 mg daily. J Neurol Sci. The patients primary care provider consulted hematology, and treatment was amended in January 2011 to intramuscular cyanocobalamin 1000 mcg/mL once weekly for four weeks and monthly thereafter to be followed by folic acid 1 mg daily po. In: Merritts Neurology 12. As mentioned above, incompletely treated vitamin B12 deficiency with oral replacement of folic acid can actually aggravate the neurological impairment related to B12 deficiency if the B12 deficiency is not corrected first. The patients medical history was positive for obesity, nicotine dependence, gouty arthropathy, mild carotid artery stenosis,throat cancer and stomach ulcer. A 63-year-old Caucasian male presented to the eye clinic for a second opinion regarding cataract surgery in February 2011 following a gradual decline in his vision over the previous two months. Toxic optic neuropathy can result from numerous substances. No part of this journal may be reproduced or transmitted in any form or by any means for any commercial purpose without permission in writing from ASCO. His color vision had improved to 5/8 OD and remained stable at 4/8 OS with Ishihara plates. Of particular relevance to this case report, vitamin B12 acts as a cofactor in the formation of succinyl CoA, an integral part of the Krebs cycle that ultimately produces adenosine triphosphate (ATP).3 This impaired oxidative metabolism causes a depletion of ATP. (Figure 1) Optical coherence tomography (OCT, Stratus) macular testing was normal, but the scans were off-center with poor signal strength. It highlights the clinical importance of careful history, ophthalmic examination and use of ancillary testing. Intrinsic factor is commonly reduced in atrophic gastritis, autoimmune diseases, and secondary to gastric surgery. This teaching case highlights the diagnosis, pathogenesis and treatment of vitamin B12 deficiency optic neuropathy. Associate Editor: Keshia Sims Elder, OD, MS, FAAO. His current prescription measured OD: +1.75 DS and OS: +2.00 -0.50049. Cloud, Minn. Dr. Zimbalist practices at the Harry S. Truman Memorial Veterans Hospital inColumbia, Mo. Am Fam Physician. The Wills Eye Manual: office and emergency room diagnosis and treatment of eye disease: 5. #1 Best Seller in Vitamin B (P5P)] 5 mg 294%, Folate [Quatrefolic (5-Methyl Folate)] 400 mcg 100%, Vitamin B12 24 mcg 1000%, Biotin 300 mcg 1000%, Pantothenic Acid 25 mg 500%, PABA 10 mg, Choline 10 mg, Inositol 10 mg, CoQ10 2 mg, Organic Fruit & Vegetable Blend 210 mg [Organic- Apple, Grape, Kiwi, Strawberry, Tart The maculae were flat with even pigment, and a positive foveal light reflex was noted in both eyes. Buy Vitamin B12 - 5000 MCG Supplement with Methylcobalamin Our Vitamin B-12 is backed by our best in the industry 100% MONEY BACK GUARANTEE for 30 days. al found that temporal quadrant retinal nerve fiber layer thickness correlates with plasma vitamin B12 levels.17 Eyecare providers should look beyond the eye and order appropriate lab work in light of pertinent ocular findings and be cognizant that incompletely treated vitamin B12 deficiency with oral supplementation with folic acid can aggravate neurological symptoms. RNFL OCT testing (Cirrus HD-OCT 4000) revealed temporal and inferior thinning OD and OS. He received new glasses from a private provider in December 2010 but continued to experience decreased visual acuity. Radiation optic neuropathy typically develops one to five years after radiation therapy for the eye, orbit, sinus, nasopharynx or brain and can be detected on MRI. Short-term imbalances will normalize quickly by the ingestion of a well-balanced meal with an emphasis on meat and dairy products. Wideochir Inne Tech Maloinwazyjne. Sign Up Nature Made site also has subscription For best absorption take doses that range from 500-600 mg two to four times daily depending on your needs. Progressive, painless, bilateral loss of vision and temporal optic atrophy with central or cecocentral scotomas are signs and symptoms seen in a handful of miscellaneous optic neuropathies. 1 The best sources of vitamin B12 are eggs, milk, cheese, meat, fish, shellfish and poultry. Buy Solgar Vitamin B12 100 mcg, 100 Tablets - Energy Metabolism, Heart Health, Healthy Nervous System - Non-GMO, Solgar Vitamin B12 500 mcg, 100 Vegetable Capsules - Energy Metabolism, Nervous System Support, Heart Health - Non-GMO, Vegan, Gluten Free, Dairy Free, Kosher, Halal - 100 Servings Best Sellers . At the conclusion of this case discussion, participants should be able to: Vitamin B12 is one of eight components of the vitamin B complex. Buy Solgar Methylcobalamin (Vitamin B12) 5000 mcg, 60 Nuggets - Supports Energy Metabolism - Body-Ready, Active Form of B12 - Vitamin B - Non GMO, Vegan, Gluten, Dairy Free, Kosher - 60 Servings on At least 500 mcg per day of Vitamin B12 (cobalamin or methylcobalamin). SITA Standard 24-2 Humphrey Visual Field testing OD from the patients final visit in November 2011 shows a clear visual field.Click to enlarge, Figure 3B. A limited license to use Optometric Education for your personal, educational or other noncommercial use is provided to ASCO members and the general public. MRI of the brain and orbits is required to rule out compressive, ischemic, inflammatory, demyelinating and/or infiltrative etiologies. Anterior segment evaluation was unremarkable except for 1+ nuclear sclerotic lenticular opacities in both eyes. The rest of the posterior segment was unremarkable OU. Key Words: vitamin B12 deficiency, optic neuropathy, pernicious anemia, folate deficiency, optic atrophy, cobalamin. Reviewed in the United States on November 17, 2022. Taking a high-dose B-complex supplement can also turn the urine bright yellow. Accessed June 1, 2016. Intraocular pressures as measured by Goldmann tonometry were 16 mmHg OD and 16 mmHg OS. Ocular history was only remarkable for recently diagnosed cataracts. Optic neuropathy refers to any condition in which the optic nerve is damaged. He was also referred to a private ophthalmologist for cataract surgery, but the procedure was not performed as it was believed that the lenticular changes were not the primary etiology of his visual loss. The SUNY Hackathon Series:Redesigning 21st Century Eye Care, Journal Bestows 2017 Writing Excellence Award, Vitamin B12 Deficiency Optic Neuropathy: a Teaching Case Report. The patient was oriented to time, place and person, and his mood and affect were appropriate. The journal of the Association of Schools and Colleges of Optometry. What are the demographics of vitamin B12 deficiency and vitamin B12 deficiency optic neuropathy? Taking more than 1,000 mcg of folic acid a day can mask a type of anemia caused by vitamin B12 deficiency. Evaluation of a patient with progressive vision loss in the presence of bilateral optic atrophy with central or cecocentral scotomas should include a detailed history including family and dietary backgrounds. The patients entering aided visual acuities were 20/400 OD and 20/400 OS at distance. He had an allergy to hydrochlorothiazide, which caused hyponatremia. Optometric Education: Volume 42 Number 3 (Summer 2017), Anterior Uveitis, More than a Red Eye:a Teaching Case Report, Bowens Disease of the Eyelid: a Teaching Case Report, Ocular and Visual Manifestations of Parkinsons Disease: a Teaching Case Report, Understanding Geographic Atrophy in Advanced Non-Exudative Age-Related Macular Degeneration: a Teaching Case Report, The Many Faces of Polypoidal Choroidal Vasculopathy: a Teaching Case Report, Optometric Education Volume 47 Number 1 (Fall 2021), Optometric Education Volume 46 Number 3 (Summer 2021), Optometric Education Volume 46 Number 2 (Winter-Spring 2021), Optometric Education Volume 46 Number 1 (Fall 2020), Optometric Education Volume 45 Number 3 (Summer 2020), Optometric Education Volume 45 Number 2 (Winter-Spring 2020), Optometric Education Volume 45 Number 1 (Fall 2019), Optometric Education Volume 44 Number 3 (Summer 2019), Optometric Education Volume 44 Number 2 (Winter-Spring 2019), Optometric Education Volume 44 Number 1 (Fall 2018), Optometric Education Volume 43 Number 3 (Summer 2018), Optometric Education Volume 43 Number 2 (Winter-Spring 2018), Optometric Education Number 43 Volume 1 (Fall 2017), Optometric Education Volume 42 Number 3 (Summer 2017), Optometric Education: Volume 42 Number 2 (Winter-Spring 2017), Optometric Education: Volume 42 Number 1 (Fall 2016), Optometric Education: Volume 41 Number 3 (Summer 2016), Optometric Education: Volume 41 Number 2 (Winter-Spring 2016), Optometric Education: Volume 41 Number 1 (Fall 2015), Optometric Education: Volume 40 Number 3 (Summer 2015), Optometric Education: Vol 40, No 2 (2015), Optometric Education: Vol 40, No 1 (2014), Optometric Education: Vol 39, No 3 (2014), Optometric Education: Vol 39, No 2 (2014), Optometric Education: Volume 39, No 1 (2013), Optometric Education: Vol 38, No 3 (2013), Optometric Education: Vol 38, No 2 (2013), Optometric Education: Vol 38, No 1 (2012), Optometric Education: Vol 37, No 3 (2012), Optometric Education: Vol 37, No 2 (2012), Optometric Education: Vol 37, No 1 (2011), Optometric Education: Vol 36, No 3 (2011), Optometric Education: Vol 36, No 2 (2011), Optometric Education: Vol 36, No 1 (2010), Optometric Education: Vol 35, No 3 (2010), Optometric Education: Vol 35, No 2 (2010), Optometric Education: Vol 35, No 1 (2009), Updated Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals, https://www.uptodate.com/contents/physiology-of-vitamin-b12-and-folate-deficiency, https://www.dietitians.ca/Your-Health/Nutrition-A-Z/Vitamins/Food-Sources-of-Vitamin-B12.aspx, https://www.uptodate.com/contents/etiology-and-clinical-manifestations-of-vitamin-b12-and-folate-deficiency, https://www.uptodate.com/contents/diagnosis-and-treatment-of-vitamin-b12-and-folate-deficiency, Understand the systemic causes of vitamin B12 deficiency, Understand the systemic and ocular manifestations of vitamin B12 deficiency, Recognize the additional testing necessary to identify the cause of optic neuropathy and the importance of reviewing the medical record and history, Understand the treatment of vitamin B12 deficiency, Understand the importance of collaborating with other health professionals in managing vitamin B12 deficiency optic neuropathy, Understand the need to investigate further if the clinical picture does not match the best-corrected visual acuity, Describe the ocular presentation of toxic/nutritional optic neuropathy, Describe additional testing that can be performed to confirm the diagnosis of optic neuropathy, Understand the pathogenesis of vitamin B12 deficiency optic neuropathy, Describe treatment and team management for vitamin B12 optic neuropathy, Identify differential diagnoses that can present with similar findings to B12 deficiency optic neuropathy. The following case report discusses the diagnosis and management of vitamin B12 deficiency optic neuropathy and is appropriate as a teaching guide for third- and fourth-year optometry students as well as optometry residents. In: UpToDate, Mentzer, WC (Ed), UpToDate, Waltham, MA. Figure 1A. Dilated fundus examination showed distinct, flat optic nerves with cup to disc ratios of 0.5 OD, 0.5 OS and mild temporal optic nerve head pallor in both eyes. 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