Bilateral Nonarteritic Ischemic Optic Neuropathy in the ICU

Case Presentation:

A 66‐year‐old smoker, hypertensive, diabetic male was admitted to the ICU with MSSA pneumonia resulting in severe septic shock with ventilator‐dependent respiratory failure and multiple organ failure. Subsequently, he developed acute, painless, bilateral visual loss. Blur ring of vision noted on the 7th ICU day initially improved as he was taken off pressors, extubated, and became hemodynamically stable. However, as his blood pressure dipped to 70/40 mm Hg because of C. difficile colitis and diarrbea, he completely lost his eyesight by the 10th hospital day. Besides absence of lighl perception, entoptic phenomenon, presence of afferent pupillary defect, optic disc pallor and edema OU, and bilaleral rales on chest auscultation, physical exam was normal. ESR was normal. Brain MRI was normal. Full ophthalmologic and neurologic evaluations were otherwise within normal limits. He was diagnosed to have acute nonarteritic ischemic optic neuropathy (NAION) OU. Conservative management was advocated.

Discussion:

NAION typically presents as unilateral, sudden, painless visual loss with relative afferent pupillary defect and optic disc edema Risk factors include advanced age, hypertension, and diabetes mellitus. Bilateral NAION is exceedingly uncommon. Severe vascular ischemia from hypotension secondary to septic shock is the likely culprit causing its bilaterality. and hence, complete blindness in a predisposed ICU patient. Complications such as acute renal failure, adrenal insufficiency, and shock liver are secondary to the same mechanism.

Conclusions:

Recognition of blindness as a potential complication of septic shock is critical for hospitalists and intensivists to better anticipate, monitor, prevent, treat and address problems related to this disease including coordinating appropriate subspecialty consults, and planning for recuperation, rehabilitation, safety, and transition of care.

Author Disclosure:

C. Eustaquio, Cooper University Hospital, resident; B. Markovitz, Cooper University Hospital, ophthalmology consultant.