Wernicke encephalopathy presenting with severe optic neuropathy and oculomotor dysfunction

A female in her 40s presented with binocular diplopia and blurry vision for three days following two months of daily vomiting, diarrhoea and poor oral intake. Initial examination was notable for bilateral abduction palsies and bilateral dysmetria on finger-to-nose testing. One day later, oculomotor dysfunction progressed with new restriction in upwards and downwards gaze. Dilated fundoscopic examination revealed severe bilateral optic disc oedema with surrounding haemorrhage. MRI Brain and Orbits were notable for T2Fluid-Attenuated Inversion Recovery (FLAIR) hyperintensities in the periaqueductal grey matter and the left optic nerve. Thiamine and folic acid deficiencies were confirmed with low serum levels of the vitamins, respectively. Following thiamine and folate supplementation, the patient exhibited improvements in her mentation, oculomotor function, vision and gait. This case illustrates a multifactorial nutritional optic neuropathy as a rare complication of thiamine and possible folate deficiency, and the importance of considering nutritional deficiencies in similar presentations.