 Okay, so it's eight o'clock, so we'll go ahead and get started So we have two different presenters today We have dr. Elizabeth doll and she's a pediatric Neurologist in residency right now. She's in her third of five years Rotating with us currently She comes to us from Kentucky and she's going to talk to us about bariatric surgery in Relation to the eyes and then when she's done if dr. Olson comes we'll go to dr. Olson Hi, I'm Lizzie doll. I'm a third year neurology resident and I wanted to thank the neurophthalmology team for letting me rotate with them last month Today I'm going to talk about the ocular complications of bariatric surgery and particular focusing on Associated vitamin deficiencies so first I'll talk about a patient who we saw in our Neuroophthalmology clinic Then I'll give a brief overview of some bariatric surgical options that are available and then I'll discuss Potential vitamin deficiencies and their ocular counterparts namely vitamin a but also touching on vitamin e thymine and b12 And then I'll give the recommendations that we gave to our patient So our patient was a 56 year old woman with the history of hypertension hyperlipidemia Arthritis renal cell carcinoma status post nephrectomy and gastric bypass surgery Which had occurred 25 years prior and had required one revision Her chief complaint was vision changes at night for one year Although at the time that she had she was seeing us in clinic. She hadn't had any complaints for one month She was a very detailed historian and perfectly described a central scatoma Bilaterally she gave the example of camping in Montana last summer and She could not see the stars in her central vision despite this the sky being profoundly dark The symptoms had come and go and like I said at the time that she saw us. She wasn't having any eye complaints at all She denied any eye pain or double vision Of note. She had started on plaquanel one month prior to the onset of her symptoms and Because of this she was receiving regular ophthalmology follow-up. She had normal visual fields and OCT to date there was not ERG available in In Idaho So past medical history as I've already discussed She was on a number of different medications, but I'll focus on the most important which include plaquanel multivitamin Sorry Vitamin D omega-3 fatty acids and vitamin B12 her family history was unremarkable She did smoke cigarettes and used alcohol occasionally She was disabled but worked part-time as a substitute teacher and her review of systems was unremarkable On examination She was 230 pounds her visual acuity was 20 25 on the right 2025 on the left without correction Her pupils were normally reactive without APD Her visual fields were full to confrontation Her extracure movements were full. She had normal stereo and color vision Slit lamp examination was normal with the exception of one-plus nuclear sclerosis in the lens bilaterally and Dilated funnest exam was also normal So ancillary testing included flicker ampster grid a multifocal ERG OCT and 10-2 Humphrey visual fields all of which were normal Here her visual fields on the left and on the right which were essentially normal Then her multifocal ERG which was also normal So bariatric surgery works two ways either through restriction and or malabsorption So restriction Decreases the amount of food that you can take in by decreasing the size of the stomach whereas malabsorption bypasses a portion of the small intestine to Decrease the surface area available for absorption The ruin why Start up here is the most commonly performed and Places the patient at high risk for nutritional disorders the ruin why works by decreasing the size of the stomach through restriction and also bypassing Duodenum and proximal to Junum and And so because of the malabsorption associated with these procedures You get impaired bile salt absorption and therefore impaired absorption of fat soluble vitamins so here is a diagram of vitamin a absorption metabolism and delivery to the eye and so we ingest Retinoids from animal products or beta carotene from green or leafy vegetables. It's a terrified and absorbed From the intestines and delivered to the liver In the liver, it's hydrolyzed it binds to Retinol binding protein and then from there it's delivered to the eye So with bile salts or excuse me with bypass surgery Bile salt absorption is impaired and therefore Fat soluble vitamins like vitamin a cannot be maximally absorbed As we know in the rods Retinol exists as 11 cis retinol and then when a photon of light hits it it undergoes a Confirmational change from 11 cis retinol to all trans retinol and It creates a nerve impulse from the retina to the brain So vitamin a deficiency is actually the leading cause of blindness worldwide secondary to diet but in industrialized countries like America vitamin a deficiency more often results from intestinal intestinal malabsorption or in alcoholics The primary ophthalmologic manifestation of vitamin a deficiency is their ophthalmia which includes Zerosis, carotomalacia Nectalopia and retinopathy So research on vitamin a deficiency to following bariatric surgery is limited and includes mostly case reports Essentially because it wouldn't be ethical to perform a prospective case study or Study with this It's a lesson in his group in the Journal of Obesity Conducted a retrospective study in 69 obese patients who had undergone the ruin Y procedure and They looked at vitamin levels at six weeks in one year and at those two times 35 percent and 18 percent were vitamin a deficient respectively interestingly a Low level of vitamin a correlated with a low level of pre-albumin which Suggests that their overall nutrition state was poor This picture is from Ophthalmology it was a case study on a 39 year old woman who had undergone the ruin Y procedure 18 months prior and had stopped taking all of her vitamin supplementations You can see in the top photo that she has Conjunctival, cirrhosis, carotidus and corneal scarring And then the bottom picture she has a heavily Carotonized surface and there's pooling of the fluorescein dye So it's important to not forget the other vitamins that can potentially be affected with bariatric surgery which include vitamin e and That can manifest as retinopathy Thymine of course can lead Thymine deficiency of course can lead to Wernicke's And includes nystagmus, dysconjugate gays and gays palsy Independently can also cause ophthalmoplegia and nystagmus and then vitamin B12 can cause a Number of optic neuropathies, but pathanemonic is Sico-central scatoma in our patient We measured her vitamin a e and b1 levels and her vitamin a level did come back low at 19 With a normal range of 38 to 98 and so we therefore recommended either increased oral supplementation or intramuscular supplementation of vitamin a On top of what she was already taking Her albumin interestingly was normal so that suggests that she was Nutritionally replete From another standpoint We did also recommend that she discontinued plaque when all although she did have normal ERG and She it was unlikely for retinal toxicity to develop within one month of symptom onset We thought that the plaque when L could have some added susceptibility to the symptoms that she was experiencing Of note. She did have a normal renal function so when I talked to her yesterday she had discontinued the plaque when L and she was going to talk to her physician about Getting on some kind of vitamin a supplementation. That's it Any questions? Yes, sir, so she had you know completely normal exam and at the time that she was seeing us She didn't have any eye complaints at all But it was the night blindness and then we measured her vitamin a level Well, yeah, so she's getting enough oral Me for a normal person. She would be getting enough vitamins, but because she was having impaired Bile salt absorption because of her bariatric surgery, then she wasn't able to absorb those Effectively Well, I mean you could really max her out. I mean, I think giving her like super therapeutic But it does exist in that intramuscular form, which probably would be more ideal And we don't really know which type of procedure. She underwent 25 years ago whether it was a ruin why or some other one but Thank you