Anterior Ischemic Optic Neuropathy
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- Posterior Ischemic Optic Neuropathy
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As with many optic neuropathies, treatment options are limited and vision restoration is challenging. This is due to both the fragile nature of the optic nerve and the underlying pathophysiology being not well understood. Furthermore, many potential therapies have not been adequately studied. Animal models are currently being used in the evaluation of neuroprotective approaches which may prove to be invaluable in the future.
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A recent study indicated that the drug was able to significantly increase the probability of achieving a sustained discontinuation of using corticosteroids as well as decreasing the risks of relapses with the disease. Corticosteroid therapy while effective, can be very toxic leading to almost 60% of individuals getting major side effects such as diabetes or cataracts. At this time, methotrexate looks to serve best as a way to reduce exposure to corticosteroids and their adverse effects. The best therapeutic option may be conjunction therapy, in order to decrease exposure and possible relapse for those patients with AAION.
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As a result, there is a movement amongst clinicians to signify temporal artery biopsy as the gold standard diagnostic test for GCA. Here, we present a case of non-arteritic anterior ischemic optic neuropathy. Additionally, we discuss the etiology of AAION and NAION as well as routine work-up and treatment strategies for both conditions.
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Non-arteritic AION is more common than AAION and usually occurs in slightly younger persons. While only a few cases of NAION result in near total loss of vision, most cases of AAION result in nearly complete vision loss. Research indicates that nocturnal systemic hypotension likely plays a major role in NAION development, especially in people with dramatic nocturnal dips.
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Optic neuritis may closely resemble NAION in regards to vision loss, visual field defects, optic disc appearance, and symptom onset; however key differences include age, pain with eye movement, and type of disc edema. Optic neuritis patients are generally younger, report pain with eye movement, and have diffuse disc edema without hemorrhages. Optic neuritis patients may also have retrobulbar optic nerve swelling in which case the optic nerve head appears normal. NAION disc edema is more likely to be altitudinal or segmental in nature and have disc pallor, vessel attenuation, and hemorrhages.
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The article is a summary of material published in peer-reviewed ophthalmic journals. For more detailed information, please refer to the papers in the bibliography and the various articles cited in those papers. Additionally, we notified his PCP of the exam findings and recommended yearly comprehensive eye examinations. We encouraged the PCP to consider referring the patient to a cardiologist to rule out any cardiac turbulence that could have produced the small emboli that caused the ischemia. With a bit of uncertainty, the patient reported that he had been diagnosed with AION in his right eye three years ago and then in his left eye approximately one year later. Further, the patient indicated that he was diagnosed with hypertension five months earlier and was being medicated with 25mg hydrochlorothiazide every morning.
It is much more common among women than men (71% versus 29%, respectively). There is evidence that GCA is far more common among Caucasians than other races. Amaurosis fugax is an important visual symptom of A-AION, present in about one third, and it is an ominous sign of impending visual loss in GCA. Keep in mind that a patient is classified as having GCA if at least three out of the five criteria are met. However, it must be noted that this diagnostic criteria is highly controversial, because there is a significant risk for vision loss––especially with regards to occult GCA .
Posterior Ischemic Optic Neuropathy
More posterior ischemia results in a similar condition, without visible swelling, and is termed posterior ischemic optic neuropathy. Erythrocyte sedimentation rate , C-reactive protein level , and complete blood count should be performed on any patient over the age of 50 with ION who are being considered for GCA because contralateral vision loss is rapid and common. The results of the combination of these diagnostic tests is highly predictive for GCA (sensitivity of 97%). When these tests confirm GCA, the treatment generally entails high doses of intravenous steroids. From the ophthalmic artery to the choroid, branches of the posterior ciliary artery run along and penetrate the optic nerve. The pial plexus supplies the posterior portion of the optic nerve through small branches off the ophthalmic and posterior ciliary arteries. However, the centermost area of the posterior optic nerve is more susceptible to ischemia than the anterior optic nerve due to a limited number of capillaries penetrating and eventually extending to the innermost tissue in this area.
Physical exam may also reveal diplopia, ptosis, nystagmus or pain or nodularity upon palpitation of the temporal artery. Non-arteritic anterior ischemic optic neuropathy is due to impaired circulation of blood to the front of the optic nerve. It is called “non-arteritic” because there is reduced blood flow without true inflammation of the blood vessels .
Depending on other clinical factors, some blood work may be done to exclude other diseases that affect the optic nerve. For example, it is important to exclude the possibility of Temporal Arteritis, which requires urgent treatment to prevent loss of vision in the other eye.
Anterior Ischemic Optic Neuropathy is a potentially visually devastating disease that occurs in the middle aged and the elderly. This condition is often referred to as a stroke of the optic nerve, and it usually begins suddenly with little warning in one eye, but frequently progresses to the other eye over time. Vision loss often includes both the loss of visual field and visual acuity which can vary from being nearly normal to severely impaired. The unexpected sudden visual acuity and visual field loss makes AION a particularly overwhelming disease for many patients. When optic disc edema resolves, the optic disc in the vast majority shows cupping, indistinguishable from that seen in glaucomatous optic neuropathy, except that there is pallor of the rim [compare optic disc cup in Fig.
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- In most cases of ischemic optic neuropathy, the doctor will see swelling of the optic nerve in the back of the eye.
- As with many optic neuropathies, treatment options are limited and vision restoration is challenging.
- Within the orbit, compartment syndrome may lead to cyclical swelling and ischemia with possible subsequent infarction.
- It is worthwhile to mention that patients using amiodarone generally already have vasculopathic risk factors predisposing them to NAION development.
- The temporal artery duplex ultrasound has demonstrated a sensitivity and specificity of 87% and 96% respectively with regard to clinical diagnosis.
- We may, but are not obligated to, update any outdated, incomplete, or inaccurate information.
Author: Steve Goldstein
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