Neuro-ophthalmic Manifestations of Wernicke Encephalopathy

Figures & data

Table 1 Diagnostic Triad of Wernicke Encephalopathy

Encephalopathy

Disorientation

Inattentiveness

Apathy

Decreased level of consciousness

Memory Impairment

Ataxia

Wide-based gait

Inability to stand

Ophthalmic abnormalities

Gaze-evoked nystagmus

Impaired abduction

Conjugate gaze palsy

Internuclear ophthalmoplegia

Impaired horizontal vestibulo-ocular reflex

Optic disc edema

Retinal hemorrhage

Note: Adapted from Mayo Clin Proc, 94(6), Sinha S, Kataria A, Kolla BP, Thusius N, Loukianova L. Wernicke encephalopathy – clinical pearls., 1065–1072, Copyright (2019), with permission from Elsevier.⁸

Figure 1 Fundus changes in Wernicke encephalopathy. At initial presentation (A), there is bilateral optic disc edema with peripapillary and scattered retinal hemorrhages. At one week (B) and two weeks (C) following thiamine supplementation, there is significant interval improvement. At three weeks (D) following treatment, there is complete resolution of the optic disc edema and retinal hemorrhages except one residual hemorrhage along the inferotemporal arcade of the left eye. Both optic discs became pale with final best-corrected visual acuity of 20/600 in each eye. Reprinted from J Formos Med Assoc, 112(3), Yeh WY, Lian LM, Chang A, Cheng CK. Thiamine-deficient optic neuropathy associated with Wernicke’s encephalopathy in patients with chronic diarrhea, 165–170, Copyright (2013), with permission from Elsevier.³⁶

Figure 2 The metabolic pathways in which thiamine plays a critical role.

Note: Adapted from Thomson AD, Cook CC, Touquet R, Henry JA. The royal college of physician’s report on alcohol: guidelines for managing Wernicke’s encephalopathy in the accident and emergency department. Alcohol Alcohol. 2002;37(6):513–521 by permission of Oxford University Press.⁵⁶

Figure 3 Brain MRI findings in Wernicke encephalopathy. Axial views. (A) Precontrast T1 scan is unremarkable. (B) Postcontrast T1 scan demonstrates enhancement of the mammillary bodies. (C) T2 FLAIR image reveals hyperintensity of the periaqueductal gray. (D) Diffusion-weighted imaging shows hyperintense signal in the medial thalami. (E) ADC map shows mild diffusion restriction, consistent with cytotoxic edema.

Sinha S, Kataria A, Kolla BP, Thusius N, Loukianova L. Wernicke encephalopathy – clinical pearls. Mayo Clin Proc. 2019;94(6):1065–1072. doi:10.1016/j.mayocp.2019.02.01831171116

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Yeh WY, Lian LM, Chang A, Cheng CK. Thiamine-deficient optic neuropathy associated with Wernicke’s encephalopathy in patients with chronic diarrhea. J Formos Med Assoc. 2013;112(3):165–170. doi:10.1016/j.jfma.2012.10.01023473530

 PubMed Web of Science ®Google Scholar

Thomson AD, Cook CC, Touquet R, Henry JA. The royal college of physician’s report on alcohol: guidelines for managing Wernicke’s encephalopathy in the accident and emergency department. Alcohol Alcohol. 2002;37(6):513–521. doi:10.1093/alcalc/37.6.51312414541

 PubMed Web of Science ®Google Scholar