We are describing an unusual case of retinal hemorrhage leading to visual changes which manifested as Wernicke Encephalopathy (WE) 

WE is described as fatal illness of sudden onset, usually characterized by a triad of somnolence, gait ataxia and ophthalmoplegia due to thiamine deficiency. The ocular abnormalities occur in about 29% of patients which include nystagmus, lateral rectus palsy, and conjugate gaze palsies. Fundus signs, such as retinal hemorrhage, optic disc swelling and peripapillary telangiectasia, are rarely mentioned in the literature.

A 35-year-old woman with significant history of morbid obesity s/p sleeve gastrectomy started having acute onset of blurry vision which progressively worsened over next couple of months to gait ataxia. Shortly thereafter she presented with acute encephalopathy characterized by recurrent starring episodes. MRI brain showed no acute abnormality. Symptoms progressed to somnolent stage in couple of days and transferred to our institution for further evaluation. Pertinent examination showed bilateral disc edema with peripapillary retinal hemorrhages on optic disc visualization. EEG showed slowing of right temporo-occipital region but no epileptiform discharges. Lab work showed elevated liver enzymes. Copper, ceruloplasmin, ANA, TSH levels came back unremarkable. Patient developed acute respiratory failure and was intubated. Repeat MRI brain showed FLAIR hyperintensity involving periaqueductal gray matter, medial thalami and mammillary bodies. Parenteral thiamine was initiated due to concern for WE. Vitamin B1 level came back less than 2 (reference range 4-15). Due to irreversible damage, patient was transitioned to comfort care as per family’s request.