Nutritional Optic Neuropathy: Bariatric Surgery Gone Wrong

A 52-year-old woman presented with a two-week history of progressive and painless bilateral central blurring of vision, associated with malaise and loss of appetite. Bariatric surgery was done 18 months prior, which was complicated by malnutrition. Ophthalmic examination showed reduced visual acuity and color vision (red-green color vision deficiency) bilaterally with no relative afferent pupillary defect. Examinations of the anterior segment and fundus were unremarkable. A Humphreys visual field test revealed bilateral central scotoma. Optical coherence tomography of the retinal nerve fiber layer and macula was normal. Laboratory investigations showed low serum copper levels (50.29 ug/dL, normal: 80-155 ug/dL). Serum iron, vitamin B12, and folate were normal. Magnetic resonance imaging of the brain and orbit showed no abnormalities. A diagnosis of nutritional optic neuropathy was made. The patient was given total parenteral nutrition (including copper) and oral multivitamin supplements. Over time, her bilateral vision improved to 6/6 N5, and her color vision normalized. Unfortunately, the bilateral central scotoma persisted up to 18 months.