You Aren’t What You Don’t Eat

By Peter Galvin, MD

In August, “The New England Journal of Medicine” had an interesting case discussion from Massachusetts General Hospital, which I thought I’d share with you. A 12-year-old boy with autism was admitted to pediatrics because of decreased vision in both eyes. He had been in his usual state of health until six weeks before admission, when he began to have difficulty seeing in both eyes. His vision was poor when he woke up, improved during the day, and worsened again at night. Three weeks before admission he finally told his parents about the problem. They took him to an optometry clinic, where no issues were found. During the next three weeks, his vision continued to worsen. He usually walked on his toes while holding his parents’ hands, but they noticed he began leaning heavily on them instead. Two days before admission they noticed him bumping into doors and walls. On the morning of admission, he awoke screaming because he couldn’t see at all.

He had been born three months prematurely, outside of the hospital setting, and he developed hypoxia (low oxygen levels). He was taken to a hospital and spent two months in the neonatal intensive care unit. He had developmental delays in speech, language, cognition, and fine motor skills. He had both autism and ADHD. He had been an avid player of video and virtual reality games, but his parents removed the gaming system two months before his vision changes had begun. He continued to watch videos on the computer and TV, and his parents said he didn’t sit close to the devices and sometimes looked at the wall instead of the screen. His parents noted that he was a “picky eater,” a common occurrence in those with autism. His diet consisted almost exclusively of hamburgers, french fries, ranch dressing, and glazed doughnuts. He refused to try new foods and would not take vitamin pills or gummies because he disliked their taste.

He was very uncooperative with eye examinations, but he allowed a brief fundoscopic exam which revealed very pale optic disks (central part of the retina where the optic nerve enters the eye). “Darkening” of vision is a common descriptor for disorders of the anterior visual pathway (retina and optic nerve). Although his physical exam was mostly normal, horizontal ridges were noted in his toenails. The paleness of his optic disks was suggestive of optic neuropathy, or optic neuritis. While most causes of this disorder are inflammatory, inflammatory optic neuritis usually has a rapid onset, but the onset of vision changes in this case was gradual. That, plus the patient’s poor diet, were suggestive of a nutritional cause. Vitamin A is found naturally in foods like carrots, leafy green vegetables, and dairy and egg products. This patient ate none of these foods. Vitamin A is vital to vision and retinal health and a deficiency can cause poor vision in low-light situations, which this patient had, plus night blindness. Also, as his central vision was poor, he looked to the side and used peripheral vision in order to see.

A diagnosis was made of nutritional optic neuropathy due to vitamin A, zinc, and copper deficiencies. Unfortunately, this patient had an advanced case, and his vision did not improve with vitamin and mineral supplementation. If you know someone with autism, especially if he/she is a “picky” eater, make sure they take nutritional supplements.

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