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Show ]. Clin. Neuro-ophthalmo/. 1: 213-218, 1981. Tobacco-Alcohol Amblyopia JOHN R. SAMPLES, M.D. BRIAN R. YOUNGE, M.D. Abstract A series of S2 patients with scotomas attributed to tobacco smoking, alcohol consumption, and nutritional deficits-alone and in combination-was reviewed. Whether use of tobacco alone can produce a scotoma has been a controversial point; our series suggests that it can. Central and cecocentral scotomas did occur in association with smoking alone; there seems to be an association between cecocentral scotoma and cigar smoking especially. Central scotomas were seen more often in patients who consumed alcohol. Recovery from either type of scotoma was observed in 3 months when a therapeutic program of abstinence and B vitamins was followed. Although the number of patients we see with these scotomas has decreased clinicians are urged to be aware of this disorder. ' The usefulness of visual fields in differentiating the amblyopias due to poor nutrition, tobacco smoking, and alcohol consumption- and combinations thereof-has been a matter for repeated debate. The disagreement started as early as 1879 h I' w en Hirschberg claimed that he could differen-tiate tobacco amblyopia from alcohol amblyopia by the type of scotoma. De Schweinitz2 believed that this discrimination was not valid. Rucker3 differentiated between cecocentral scotoma due to a purely tobaccogenic disease and central scotoma strictly secondary to alcoholism. Carro1l4 reviewed the cases of 58 patients with nutritional amblyopia who did not smoke cigars or a pipe but who generally consumed excessive amounts of alcohol. He reported that of the 58 patients, 54 had cecocentral scotomas and that, while variations in density did occur, the denser area was situated between the blind spot and the point of fixation in all but three instances; in these three the densest part was pericentral. Carroll concluded that the field defect observed in alcohol amblyopia was the same as that observed in tobacco amblyopia. Potts5 cited numerous other disagreements in the literature concerning the tobacco amblyopias. There is some doubt about the relative roles of From the Department of Ophthalmology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. September 1981 tobacco and alcohol in the development of scotomas, and controversy surrounds which form of tobacco causes the disease. Moreover, Potts cited a lack of agreement on the completeness and the rapidity of cure after the cessation of the use of tobacco. Griffith,6 in an analysis of the recovery of 65 patients, showed that from 3 to 42 months was required in the 27 cases in which complete recovery occurred. Harrington,7 among others, noted that the disease seems to have declined in incidence in the second and third quarters of this century. Potts5 concluded that tobacco-alcohol amblyopia is not a disease caused by toxic substances at all but is rather a deficiency of a nutritional type. It has been our opinion that the observation made by Rucker,3 that the type of scotoma is specific for the type of disease, is essentially correct. We sought to confirm or disprove this notion by reviewing our data regarding tobacco and alcohol amblyopia. Materials and Methods The visual field records available for a span of 25 years were reviewed for cases in which central or cecocentral scotomas were found and in which the diagnosis of tobacco, alcohol, or nutritional amblyopia had been entertained. These cases were subsequent to those reported by Rucker3 in 1960. The charts were reviewed further to ascertain whether one of the clinical diagnoses had been established. The medical diagnoses and nutritional state of the patients were determined, and, in addition, as much information as possible was elicited with regard to the patients' history of smoking and alcohol consumption. A patient was classified as "malnourished" for the purposes of our study if this diagnosis had been made by an internist when the patient was seen here for visual problems. Our criteria for the diagnosis of alcohol or tobacco amblyopia required that a patient showed a central or cecocentral scotoma and had given a history of daily use of tobacco or alcohol or both for several years but no history of retrobulbar optic neuritis, hereditary optic neuropathy, drug-induced visual loss, or any other neurologic disorder. No patient had applanation tensions of greater than 22. We found it useful to separate the patients into two groups: those with cecocentral scotomas and 213 Tobacco-Alcohol Amblyopia TABL[ I. h Ten Male Patients with Scotomas" Allributed to Use of Tobacco Alone Visu,,1 ct<:uity Improvement t\~,. Response ('.Iti.'nl Tl)h.h l tl ll...l~t· Beftln' Tn'.llnu'nl Aft{'r Tr('cltment Time' Iv ..... ) Field Subjective l 1./1. OS OD. as 62 5 ci~.1rs/d 20/50 20/40 20/50 20/40 Yes Yes 4 mos. 2 46 IS cil(~rs/d 20/400 20/400 Did not return for follow-up J 5Q 4- 10 ci~Jrs/d 20/200 20/20 Yes Yes 6 mos. 4 72 "2+" <'i~Jrs/d 20/400 20/400 20/25 20/25 Yes Yes 4 mos. 5 67 6-11 cigJrs/d 20/Cr 20/CF 20/60 20/70 Yes Yes 4 mos. 6 6Q Several cigars 20/CF 20/CF 20/60 20/70 Yes Yes 23 mos. daily 7 61 Cigars, amount 20/70 20/100 20/40 20/40 Yes Yes 60 mos. not stated 1\ 78 6-8 ci~ars/d 20/CF 20/200 20/40 20/25 Yes Yes 6 mos. Q 74 12 cigars/d 20/300 20/300 Did not return for follow-up 10 55 Pipe 8 hid 20/200 20/200 20/100 20/30 Yes Yes 14 yrs. " All were cecocentral except the central scotoma in patient 1. I, No p.ltients used alcohol or were nutritionally deficient. . . d' I f Id ' Response time is the time at which improvement or lack of improvement was documented for both vIsual acuIty an vlsua Ie . Data on follow-up for patient 8 came through correspondence rather than our own visual field studIes. • Had a history of alcohol use • 900 '0 of this group smoked No history of alcohol use 100% Of this group smoked Figure 2. Smoking and alcohol histori66 in 25 patients who had cecocentral scotomas. tional amblyopia. Figure 1 demonstrates a cecocentral scotoma on a visual field chart which is typical of the kind that was found. Of these patients, 15 (60%) had a history of alcohol use and 10 (40%) did not; virtually all patients smoked cigars, cigarettes, or a pipe (Table 1; Fig. 2). Indeed, 17 patients (68%) smoked at least several cigars each day. Although 15 of the 25 patients (60%) with cecocentral defects had medical examinations done by an internist from our clinic dUring the course of their workup, a thorough review of the charts revealed that only four patients were ever mentioned as having poor nutrition. Follow-up data were available for 16 patients, including a documentation of visual acuity and visual field after the initial diagnosis (Fig. 3). The interval from initial diagnosis to follow-up examination varied from 3 months to 14 years. Thirteen of 14 patients who had been advised to follow a regimen of abstinence had visual improvement to a degree that acuity in at least one eye was improved by three lines on the eye chart. Two patients improved within 3 months, three in 4 months, and two in 6 months. As already mentioned, in one patient, a pipe those with central scotomas. Any patient with the diagnosis of retrobulbar optic neuritis, hereditary optic neuropathy, including Leber's disease, or any drug-induced visual loss, such as that from chloroquine and ethambutol, was excluded from this study. Cases in which the ingesti0n of chemical or toxic substances such as methanol was suspected or incriminated were excluded. Cases of glaucoma were excluded too, except one case in which there could be no doubt that tobacco-alcohol amblyopia was also present because the scotoma completely resolved after the substance abuse was discontinued. ,.... 8/14/75 w.e. 20 14 w.e. 20 14 100 56c+2 5042c+2 1 1000 9 1000 Figure 1. Visual field chart demonstrating a typical cecocentral scotoma in a 57-year-old patient who had normal fundi and a long history of daily, almost continuous, pipe smoking and chronic bronchitis. Results Cecocentral Scotomas TWPllty-fivp patients had bilateral cecocentral '.•. ,I,. "I' It I rif'",lt"j to tnbJCCO, alcohol, or nutri- 214 Journal of Clinical Neuro-ophthalmology 20/30 20/50 20/70 20/100 20/400 CF 20/30 20/50 20/70 20/100 20/400 CF Figure 3. Visu.tl recovery in 16 p.ttients with cecocentr.tl 5cotom.ts followin~ di.t~nosis .tnd tre.ttment. The oblique line represents the vuious levels of visu.tl .tcuity before tre.ttment; e.tch circle represents one eye .tfter tre.ttment .tnd indic.ttes the l.tst determin. ttion of vision. A line extends from the visu.tl .tcuity before tre.ttment to the circle. demonstr.tting improvement if it rose up .tnd worsening if it dropped down. CF = counting fingers. Figure 4. Visu.tl field ch.trt demonstrating a typical centr.tl scotoma in a 65-year-old p.ttient who had a history of consuming four bottles of whiskey a week and a history of delirium tremens. A diagnosis of macular degener.ttion h.td been m.tde by another ophthalmologist. Results of fundus ex.tmin.ttion were entirely normal. Poor nutrition alone Had poor nutrition Smoking alone No nutritional deficiency noted Figure 5. Nutrition.tl deficiency in p.ttients with centr.tl scotom. ts. chart which was typical for these patients. Twentysix of the 27 patients had bilateral involvement. Fifteen patients (56%) used tobacco, and 19 (70%) ingested alcohol to some degree. Sixteen patients (59%) underwent physical examination by an internist as part of the eye evaluation. Unlike the cecocentral group, in which only four patients were noted to have poor nutrition, comments regarding poor nutrition made by internists or ophthalmologists appeared in the records of 18 (67%) of the patients with central sco- Combmed smoking and alcohol Figure 6. Smoking .tnd alcohol histories in 18 patients who h.td centr.tl scotom.ts and a history of nutritional deficiencv. 1 1000 PH W.C. 20 20 14 200 70 89 _3_ 1000 Myd In eyes 3/29/67 W.C. 20 14 30 89 1 1000 smoker, the diagnosis of chronic open-angle glaucoma was made at the same time as the diagnosis of tobacco-alcohol amblyopia. His visual field showed marked improvement after 3 months of abstinence from tobacco. Moreover, over 3 months, his visual acuity improved from 20/40 to 20/30 in the right eye and from 20/400 to 20/40 in the left eye. Two patients showed visual worsening both by visual field and by visual acuity. The physician's notes make it clear that both patients were not complying with the therapeutic regimen of B vitamins and abstinence which had been outlined for them. Central Scotomas Twenty-seven patients had central scotomas. Figure 4 demonstrates a scotoma on a visual field Sep~f'mr'er 1981 215 Tobacco-Alcohol Amblyopia 20/30 20/50 20170 20/100 20/400 CF 20/50 20170 20/100 20/400 2 CF Figure 7. Visual recovery in II patients with central scotomas following diagnosis .and treatment consisting of abstinence and B vitamins. The oblique line represents the vanous levels of visual acuity before treatment; each circle represents one eye after treatment and indicates the last determination of vision. A line extends from the visual acuity before treatment to the circle. demonstrating improvement if it rose up and worsening if it dropped down. CF = counting fingers. tomas (Fig. 5). Ten of the 18 patients had a history of tobacco use, alone or in combination with alcohol use. Five of the nine patients presumed to have good nutrition smoked. One case in which central scotomas were well documented was that of a cigar smoker who did not have a history of alcohol use, nor did he appear clinically to be malnourished. The rest used tobacco in combination with alcohol (Fig. 6). Three patients had poor nutrition without any substance abuse. One patient who had a history of whiskey drinking and cigarette use was noted to have been a prisoner of war in Vietnam and had acquired his central scotomas while a prisoner. Follow-up data were available in 11 patients (Fig. 7). Of these, seven had visual fields only at follow-up examination, and the remaining four had visual acuities only. Seven patients showed improvement by at least two lines of visual acuity in both eyes after undergoing a therapeutic regimen of abstinence and vitamins. Four did not show any response or the visual acuity worsened. One of the four patients not showing any improvement was the patient who had central scotomas in association with cigar smoking alone. His visual field did not show improvement at 4 months after diagnosis. For the seven patients whose condition improved, the mean time to response was 3.4 months, and the time until a response was noted ranged from 2 to 5 months. All of these patients were observed relatively closely. It was clear that two of the patients not improving did not cooperate. A third pati('nl who did not improve was able to give up whiskey but was not able to stop smoking ;;",1 rp! t·~·.:. 216 Quantification of Tobacco and Alcohol Consumption In the records of only nine patients with cecocentral scotomas was the number of cigars smoked daily explicitly stated. The mean was 8.67 cigars per patient, with a range of 2-15 cigars per day. In four patients with cecocentral scotomas associated with cigarette smoking, the mean consumption was 1.88 packs per day. It was not possible to provide similar quantification for pipe smokers, because the amount of pipe smoking was expressed in various terms. For instance, one patient smoked 8 hours a day, continuously, and consumed three packages of "Foxy Grandpa" brand pipe tobacco every week; another stated that he consumed about 5 Ibs. of pipe tobacco per week. It also proved to be difficult to quantify the amount of alcohol ingested by the patients with scotomas. This was, in part, because of the retrospective nature of the study. Often, no reliable estimation of the amount of alcohol consumed had been made. However, at least eight patients with cecocentral scotomas had made explicit statements regarding their consumption of whiskey. The mean amount consumed was 4.6 oz. per day, with a range of 1-8 oz. per day. A similar attempt at quantification was made for the group with central scotomas. The one patient who smoked only cigars smoked five cigars a day for 40 years. Seven patients who smoked cigarettes consumed an average of 1.3 packs per day. The records of eight patients contained explicit statements regarding whiskey drinking. The aver- Journal of Clinical Neuro-ophthalmology age daily consumption was 5.38 oz., slightly higher than that for the group with cecocentral scotomas. The amount of whiskey ingested ranged from 2 to 16 oz. of 80-proof liquor a day. [n five patients, beer was reportedly consumed at an average rate of 62.4 oz. a day, the range being 12-144 oz. a day. Three patients who used both whiskey and cigars smoked 8-10 cigars a day, 6-7 cigars a day, and 78 cigars a day. All had done so for years. Of three patients who had central scotomas in association with cigarette smoking and poor nutrition, two had smoked in excess of two packs of cigarettes a day for many years, and the third patient smoked only half a pack per day. However, her physicians believed that her central scotomas were primarily due to nutritional neglect. Discussion Patients with tobacco-alcohol amblyopia constitute a population that is difficult to study because such patients frequently do not return for follow-up examinations. It may be, for instance, that only the patients who respond to the prescribed treatment of abstinence and vitamin supplements return and that the patients who do not respond fail to return. Alternatively, it may be reasonable to assume that a fair sampling of the patients return for follow-up examinations. lessell8 pointed out that there is general agreement that tobacco and ethyl alcohol do not act synergistically and that amblyopia occurs in alcoholic patients owing to the effects of malnutrition rather than to the direct, toxic effects of alcohol. A major controversy remains, however, concerning the ability of tobacco to cause injUry to the visual system. Potts5 denied the existence of an amblyopia due to tobacco alone. On the other hand, Harrington9 stated that he has seen more than a dozen cases of true tobacco amblyopia during the past 42 years. We found that among our patients with cecocentral scotomas, 10 patients had no history of alcohol use; this group consisted of eight cigar smokers, one pipe smoker, and one patient thought to have a purely nutritional amblyopia. Similarly, among our patients with central scotomas, eight did not have a history of alcohol use. Histories of alcohol consumption are notoriously unreliable, whether they are volunteered by the patient or elicited by the physician. Thus, we think it probable that some patients incorporated into this study underestimated their alcohol consumption or denied it altogether. Nonetheless, on the basis of our data, it seems certain that a cecocentral scotoma can arise from use of tobacco alone, and it is probable that a central scotoma can also arise from the use of tobacco alone. A connection seems to exist between cigar smoking and cecocentral scotomas since 68% of September 1981 Samples, Younge our patients with cecocentral scotomas smoked cigars. Seventy percent of patients with central scotomas and 60% of patients with cecocentral scotomas were noted to use alcohol. Alcohol use therefore seems to be equally prevalent among patients regardless of type of scotoma. Mention of poor nutrition was found in the medical charts of 18 of 27 patients with central scotomas but in only four of 25 patients with cecocentral scotomas. Such findings suggest that, as part of a general physical examination, the physician is more likely to see malnutrition in patients with central scotomas than in those with cecocentral scotomas. Our data also seem to support the notion that the patient with a cecocentral scotoma has a good prognosis if the scotoma is detected early. With proper compliance in a therapeutic program of abstinence and B vitamins, some improvement may be expected within 4 months. Moreover, the prognosis is not necessarily poor in the patient with a central scotoma. Some recovery may be seen in 3 months, with proper patient compliance. Physicians seeing patients with scotomas should bear in mind the social problems associated with tobacco and alcohol abuse. These patients are easily lost to follow-up, and unfortunately, the untreated scotoma in the noncomplying patient will probably become permanent. We should point out that our observation that for some unknown reason the incidence of scotomas due to tobacco and alcohol seems to be decreasing is consistent with observations made by other authors.?' 9 In recent years we have seen very few cases at the Mayo Clinic, and most large institutions have smaller series than ours. Conclusions Study of a series of 52 patients with scotomas attributed to tobacco smoking, alcohol consumption, and nutritional deficits-alone and in combination- suggest that cecocentral and central scotomas may occur from smoking alone. There seems to be a particular association between cigar smoking and the cecocentral scotoma. Central scotomas were observed more often in patients who consumed alcohol. Although the number of patients with scotomas due to tobacco and alcohol abuse tends to be decreasing, clinicians are urged to consider this important and potentially reversible disorder in patients who have a history of smoking or of long-term use of large amounts of alcohol. References 1. Hirschberg, T.: Tobacco and alcohol amblyopia. Br. Med. j. 2: 810-811, 1879. 2. De Schweinitz, G. E.: The Toxic Amblyopias: Their Classification, History, Symptoms, Pathology, and 217 Tob.Keo-Alcohol AmblyopiJ Tre.ltment. LeJ Brothers & Co., Phil<1delphiJ, 1896, p.85. 3. Rucker, C. W.: TobJeco JmblyopiJ. Pwe Stdff Meet. M,1Yll Clin. 35: 345-348, 1%0. 4. C.Uroll , F. D.: NutritionJI JmblyopiJ. Arch. Ophth. l/nlll/. 76: 400-41 I, 1900. 5. Potts, A. M.: Tob.lcco .lmblyopi<1. Surv. OphthJ/mol. 17: 313-331, 1973. o. Griffith, A.H.: Toxic JmblyopiJ. Trdns. Ophthalmol. Soc. u.K. 7: 81-90, 1887. 7. HJrrington, D.O.: AmblyopiJ due to tobJcco, Jlcohoi Jnd nutritionJI deficiency: Differential diagnosis with speci<11 reference to the character of the visual field defect. Trans. Pac. Coast Otoophthalmol. Soc. Annu. Meet. 42: 217-228,1961. 218 8. Lessell, S.: Comment. In Controversy in Ophthalmology, R. J. Brockhurst, S. A. Boruchoff, B.T. Hutchinson, and S. Lessell, Eds. W. B. Saunders, Philadelphia, 1977, pp. 873-874. 9. Harrington, D. 0.: What is the etiology of alcohol and tobacco amblyopia? In Controversy in Ophthalmology, R. J. Brockhurst, S. A. Boruchoff, B. T. Hutchinson, and S. Lessell, Eds. W. B. Saunders, Philadelphia, 1977, pp. 866-872. Write for reprints to: John R. Samples, M.D., c/o Section of Publications, Mayo Clinic, Rochester, Minnesota 55905. Journal of Clinical Neuro-ophthalmology |
