Bilateral Posterior Ischemic Optic Neuropathy as a Presentation of Severe Uncontrolled Diabetes Mellitus

Abstract

Introduction: Posterior ischemic optic neuropathy (PION) is a rare, potentially devastating condition characterized by acute, painless vision loss in one or both eyes and is associated with poor outcomes. Compared with anterior ischemic optic neuropathy, little data has been published on PION, mainly in the form of case reports and anecdotal observations. This is in large part due to the low incidence of this disease. Case Report: Here, we present a newly diagnosed 45-year-old diabetic female with uncontrolled blood sugars and sudden onset bilateral sequential visual loss with left complete ophthalmoplegia with normal fundus, neuroimaging of brain, orbits, and spinal cord. She was empirically treated with intravenous steroids and insulin but her immunologic, demyelinating, and infectious etiologies workup were also normal. Ultimately, the patient was diagnosed with vision loss secondary to diabetic cranial neuropathy and PION given the rest of her evaluation was unrevealing. At discharge her visual acuity was finger counting in right eye and perception of light in left eye with an improvement in bilateral extra ocular movements. At 3 months follow-up her right eye visual acuity had improved to 6/60 while the left eye remained same with normal bilateral extra ocular movements. Conclusion: Diabetic cranial neuropathy usually involves single or sequential nerve involvement but combined involvement of bilateral optic nerve and left 3, 4, and 6th cranial nerve involvement is unique to the current presentation. PION should be kept in mind in patients presenting with sudden painless bilateral vision loss with normal fundoscopy in the background of systemic disease like diabetes mellitus, though it usually occurs postoperatively.