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Bilateral non‐arteritic ischemic optic neuropathy due to excessive use of transdermal estrogen by transgender patient
Author(s) -
DE ZAEYTIJD J,
DE POTTER R,
MONSTREY S,
LEROY BP,
HEYLENS G,
WIERICKX K,
T'SJOEN G
Publication year - 2012
Publication title -
acta ophthalmologica
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.534
H-Index - 87
eISSN - 1755-3768
pISSN - 1755-375X
DOI - 10.1111/j.1755-3768.2012.t121.x
Subject(s) - medicine , anterior ischemic optic neuropathy , etiology , pallor , optic neuropathy , surgery , optic nerve , ophthalmology
Purpose Nonarteritic anterior ischemic optic neuropathy (NAION) is a common, visually disabling disease. It is usually due to a hypotensive perfusion insufficiency leading to infarction of the optic nerve. Only very rarely, NAION has a thromboembolic etiology. A transgender patient with a sequential bilateral NAION related to excessive use of transdermal estrogen is described. Methods A 44 year‐old male to female transgender patient developed acute painless visual loss in the right eye (RE) followed by the left eye (LE) 2 months later. She underwent a full ophthalmic exam and an extensive etiological work‐up. Results Visual acuity (VA) dropped to perception of light in the RE and, 2 months later, to 3/10 in the left eye. Fundoscopy showed a swollen disc in both eyes in the acute phase, which evolved into pallor later. CT‐brain revealed old ischemic areas unrelated to VA loss. A diagnosis of bilateral sequential NAION was made. Predisposing risk factors, though both well controlled, were diabetes and arterial hypertension. Thrombophilia screening and cardiac work‐up were negative. When estrogen levels of 60 times the normal value were measured, the patient admitted to overdose with transdermal estrogen to enhance her female characteristics. Such high estrogen levels are very thrombogenic. It is highly likely that it caused the cerebrovascular accidents and also triggered the bilateral sequential NAION. Conclusion NAION only rarely has a thromboembolic etiology. However, careful history taking is warranted to exclude modifiable risk factors in the poorly treatable NAION to prevent affection of the second eye and/or the central nervous system.