Anterior Ischemic Optic Neuropathy Follow-up
- Author: Andrew A Dahl, MD, FACS; Chief Editor: Hampton Roy, Sr, MD more...
Further Outpatient Care
Patients with anterior ischemic optic neuropathy (AION) need to be observed for several reasons, as follows:
They may develop visual loss in the other eye.
Underlying medical conditions (eg, hypertension, diabetes) that need ongoing care may be present.
In patients with giant cell arteritis (GCA), a long-term plan of steroids and other medications to control the arteritis is needed.
Inpatient & Outpatient Medications
Systemic steroids, ranging from 100 mg of prednisone daily to lower doses that are tolerated more easily on a long-term basis, may be indicated. Alternate day steroid therapy is not recommended, especially in the acute treatment of arteritic anterior ischemic optic neuropathy (AION). Titration of dosage with clinical symptoms and ESR seems to be the best regimen.
Treatment may be continued for a year or more, and it may be augmented by other antimetabolites, such as Imuran or methotrexate. Ultimately, a low dose of 2.5-5 mg daily, which is very close to physiologic secretion by the adrenals, is desirable.
Transfer to a rheumatologist is desirable for care of those patients with arteritic forms of anterior ischemic optic neuropathy (AION).
Long-term adverse effects of steroids are common and problematic; these adverse effects require careful control.
No medications of known value are available in the prevention of anterior ischemic optic neuropathy (AION) in the other eye. Currently, most practitioners advise use of an aspirin daily in patients who can tolerate this medication. Its long-term efficacy is not proven.
Other than visual loss in the second eye, which may occur simultaneously with that in the first eye, few ocular complications accompany anterior ischemic optic neuropathy (AION). Ocular palsies in the arteritic form of the disease and ischemia of the entire globe associated with GCA have been reported. Rarely, scalp necrosis can occur.
Steroids have well-known and significant adverse effects. Such adverse effects are beyond the scope of this article, and an internist or a rheumatologist best manages them.
Occasional complications of temporal artery biopsy include hemorrhage or wound infection. Rare complications of temporal artery biopsy include facial nerve palsy, scalp necrosis, and cerebrovascular accident (if the superficial temporal artery supplies a critical collateral to the internal carotid circulation).
Prognosis for visual recovery generally is poor. However, in the IONDT study, more recovery of vision and visual field occurred than was expected. Part of this finding may be explained by adaptation, but the measured visual acuity and parameters of the fields did seem to improve substantially in many cases.
A second attack of nonarteritic ischemic optic neuropathy (NAION) has never been documented in an eye that has already suffered one attack. Thus, vision in a patient with NAION, even if both eyes have been affected, should remain stable. However, a second attack in the same eye has been found on occasion with the arteritic form of ischemic optic neuropathy associated with giant cell arteritis (GCA).
Anterior ischemic optic neuropathy (AION) is a very frustrating disease, to both patients and physicians, because little can be performed to treat it. Investigation of large vessel diseases, scanning of the brain, and treatment modalities have proven fruitless. Once visual loss has occurred, little can be performed to restore it.
Awareness of the entity of giant cell arteritis (GCA) is important to both physicians and patients, as the intervention of steroids may prevent loss of vision in the other eye, as well as prevention of considerable comorbidity in other organ systems.
General health measures (eg, control of blood pressure, obesity, and diabetes; not smoking) are important, but bear little result in recovery of vision that is already lost.
Uhtoff W. Zu den entzundlichen sehnerven: Affectionen bei arteriosklerose. Ber Dtsch Ophthalmol Gesampte. 1924. 44:196-198.
Ali Ibn Isa. Memorandum Book of a Tenth-Century Oculist. (Translated by CA Wood). Chicago: Northwestern University; 1936.
Hutchinson J. Diseases of the arteries. Arch Surg (London). 1890. 1:323.
Horton BT, Magath TB, Brown GE. An undescribed form of arteritis of the temporal vessels. Proc Staff Meet Mayo Clinic. 1932. 7:700.
The Postoperative Visual Loss Study Group. Risk Factors Associated with Ischemic Optic Neuropathy after Spinal Fusion Surgery. Anesthesiology. 2012 Jan. 116(1):15-24. [Medline].
Miller NR. Anterior ischemic optic neuropathy. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 1982. Vol 1: 212-226.
Subei AM, Eggenberger ER. Optical coherence tomography: another useful tool in a neuro-ophthalmologist's armamentarium. Curr Opin Ophthalmol. 2009 Nov. 20(6):462-6. [Medline].
The Ischemic Optic Neuropathy Decompression Trial Research Group. Optic nerve decompression surgery for nonarteritic anterior ischemic optic neuropathy (NAION) is not effective and may be harmful. The Ischemic Optic Neuropathy Decompression Trial Research Group. JAMA. 1995 Feb 22. 273(8):625-32. [Medline].
Atkins EJ, Bruce BB, Newman NJ, Biousse V. Treatment of nonarteritic anterior ischemic optic neuropathy. Surv Ophthalmol. 2010 Jan-Feb. 55(1):47-63. [Medline].
Reddy D, Rani PK, Jalali S, Rao HL. A Study of Prevalence and Risk Factors of Diabetic Retinopathy in Patients with Non-Arteritic Anterior Ischemic Optic Neuropathy (NA-AION). Semin Ophthalmol. 2013 Oct 30. [Medline].
Kulkarni RR, Pradeep AV, Bairy BK. Disulfiram-induced combined irreversible anterior ischemic optic neuropathy and reversible peripheral neuropathy: a prospective case report and review of the literature. J Neuropsychiatry Clin Neurosci. 2013 Oct 1. 25(4):339-42. [Medline].
Radoi C, Garcia T, Brugniart C, Ducasse A, Arndt C. Intravitreal triamcinolone injections in non-arteritic anterior ischemic optic neuropathy. Graefes Arch Clin Exp Ophthalmol. 2013 Nov 1. [Medline].
Bielory L, Ogunkoya A, Frohman LP. Temporal arteritis in blacks. Am J Med. 1989 Jun. 86(6 Pt 1):707-8. [Medline].
Collignon-Robe NJ, Feke GT, Rizzo JF 3rd. Optic nerve head circulation in nonarteritic anterior ischemic optic neuropathy and optic neuritis. Ophthalmology. 2004 Sep. 111(9):1663-72. [Medline].
Costello F, Zimmerman MB, Podhajsky PA. Role of thrombocytosis in diagnosis of giant cell arteritis and differentiation of arteritic from non-arteritic anterior ischemic optic neuropathy. Eur J Ophthalmol. 2004 May-Jun. 14(3):245-57. [Medline].
Crawley B, Scherer R, Langenberg P, Dickersin K. Participation in the Ischemic Optic Neuropathy Decompression Trial: sex, race, and age. Ophthalmic Epidemiol. 1997 Sep. 4(3):157-73. [Medline].
Foroozan R, Varon J. Bilateral anterior ischemic optic neuropathy after liposuction. J Neuroophthalmol. 2004 Sep. 24(3):211-3. [Medline].
Glueck CJ, Wang P, Bell H, Rangaraj V, Goldenberg N. Nonarteritic anterior ischemic optic neuropathy: associations with homozygosity for the C677T methylenetetrahydrofolate reductase mutation. J Lab Clin Med. 2004 Mar. 143(3):184-92. [Medline].
Hattenhauer MG, Leavitt JA, Hodge DO, Grill R, Gray DT. Incidence of nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol. 1997 Jan. 123(1):103-7. [Medline].
Ischemic Optic Neuropathy Decompression Trial. Characteristics of patients with nonarteritic anterior ischemic optic neuropathy eligible for the Ischemic Optic Neuropathy Decompression Trial. Arch Ophthalmol. 1996 Nov. 114(11):1366-74. [Medline].
Johns LN, Arnold AC. Incidence of nonarteritic anterior ischemic optic neuritis (population based study). J Neuroophthalmol. 1994. 14:38-49.
Kuprjanowicz L, Goslawski W, Karczewicz D, Szych Z. [Evaluation of retinal nerve fiber thickness with scanning laser polarimetry in patients with anterior ischemic optic neuropathy]. Klin Oczna. 2004. 106(3 Suppl):440-2. [Medline].
Love DC, Rapkin J, Lesser GR, et al. Temporal arteritis in blacks. Ann Intern Med. 1986 Sep. 105(3):387-9. [Medline].
Munteanu M, Lehaci C. [Acute anterior ischemic optic neuropathy in association with optic nerve drusen]. Oftalmologia. 2004. 48(3):16-9. [Medline].
Purvin V, King R, Kawasaki A, Yee R. Anterior ischemic optic neuropathy in eyes with optic disc drusen. Arch Ophthalmol. 2004 Jan. 122(1):48-53. [Medline].
Salomon O, Rosenberg N, Steinberg DM, et al. Nonarteritic anterior ischemic optic neuropathy is associated with a specific platelet polymorphism located on the glycoprotein Ibalpha gene. Ophthalmology. 2004 Jan. 111(1):184-8. [Medline].