eMedicine Specialties > Ophthalmology > Optic Nerve

Optic Neuropathy, Anterior Ischemic: Follow-up

Author: Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Contributor Information and Disclosures

Updated: Nov 26, 2007

Follow-up

Further Outpatient Care

  • Patients with 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, 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 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

  • Transfer to a rheumatologist is desirable for care of those patients with arteritic forms of AION. Long-term adverse effects of steroids are common and problematic; these adverse effects require careful control.

Deterrence/Prevention

  • No medications of known value are available in the prevention of 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.
  • The use of levodopa in NAION remains to be seen.

Complications

  • Other than visual loss in the second eye, which may occur simultaneously with that in the first eye, few ocular complications accompany AION. Ocular palsies in the arteritic form of the disease and ischemia of the entire globe 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

  • Prognosis for visual recovery generally is poor. However, in the IONDT study, it was found that 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. If there is any good news about the nonarteritic form of ischemic optic neuropathy, it is that a second attack has never been documented in an eye that has already suffered one attack. Thus, the vision that the patient has, even if both eyes have been affected, will 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.

Patient Education

  • 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 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.

Miscellaneous

Medicolegal Pitfalls

  • AION has been found in association with many conditions. NAION also has been reported after several surgical procedures (eg, coronary artery bypass grafts, heart valve procedures and replacements, lumbar surgery) and after diagnostic and interventional arteriography procedures. The linkage between such procedures is most likely atherosclerosis and, perhaps, embolism in predisposed individuals.

Special Concerns

  • AION has been associated with drugs. In particular, amiodarone, which commonly is used to control arrhythmias of a very lethal nature, has been reported with AION, but it has not been definitively linked with a cause-and-effect relationship. Reports continue to accumulate, but a masked study has never been undertaken to determine a statistically significant role of the etiology of this drug with AION.
  • Several more references have been appended from recent articles in the literature for those readers who might be interested.
 


More on Optic Neuropathy, Anterior Ischemic

Overview: Optic Neuropathy, Anterior Ischemic
Differential Diagnoses & Workup: Optic Neuropathy, Anterior Ischemic
Treatment & Medication: Optic Neuropathy, Anterior Ischemic
Follow-up: Optic Neuropathy, Anterior Ischemic
Multimedia: Optic Neuropathy, Anterior Ischemic
References
[ CLOSE WINDOW ]

References

  1. Uhtoff W. Zu den entzundlichen sehnerven: Affectionen bei arteriosklerose. Ber Dtsch Ophthalmol Gesampte. 1924;44:196-198.

  2. Ali Ibn Isa. Memorandum Book of a Tenth-Century Oculist. (Translated by CA Wood). Chicago: Northwestern University; 1936.

  3. Hutchinson J. Diseases of the arteries. Arch Surg (London). 1890;1:323.

  4. Horton BT, Magath TB, Brown GE. An undescribed form of arteritis of the temporal vessels. Proc Staff Meet Mayo Clinic. 1932;7:700.

  5. Miller NR. Anterior ischemic optic neuropathy. In: Walsh and Hoyt's Clinical Neuro-Ophthalmology. Vol 1. 1982:212-226.

  6. Bielory L, Ogunkoya A, Frohman LP. Temporal arteritis in blacks. Am J Med. Jun 1989;86(6 Pt 1):707-8. [Medline].

  7. Collignon-Robe NJ, Feke GT, Rizzo JF 3rd. Optic nerve head circulation in nonarteritic anterior ischemic optic neuropathy and optic neuritis. Ophthalmology. Sep 2004;111(9):1663-72. [Medline].

  8. 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. May-Jun 2004;14(3):245-57. [Medline].

  9. Crawley B, Scherer R, Langenberg P, Dickersin K. Participation in the Ischemic Optic Neuropathy Decompression Trial: sex, race, and age. Ophthalmic Epidemiol. Sep 1997;4(3):157-73. [Medline].

  10. Foroozan R, Varon J. Bilateral anterior ischemic optic neuropathy after liposuction. J Neuroophthalmol. Sep 2004;24(3):211-3. [Medline].

  11. 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. Mar 2004;143(3):184-92. [Medline].

  12. Hattenhauer MG, Leavitt JA, Hodge DO, Grill R, Gray DT. Incidence of nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol. Jan 1997;123(1):103-7. [Medline].

  13. Ischemic Optic Neuropathy Decompression Trial. Characteristics of patients with nonarteritic anterior ischemic optic neuropathy eligible for the Ischemic Optic Neuropathy Decompression Trial. Arch Ophthalmol. Nov 1996;114(11):1366-74. [Medline].

  14. Johns LN, Arnold AC. Incidence of nonarteritic anterior ischemic optic neuritis (population based study). J Neuroophthalmol. 1994;14:38-49.

  15. 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].

  16. Love DC, Rapkin J, Lesser GR, Shmookler BM, Kolsky MP, Jackson B, et al. Temporal arteritis in blacks. Ann Intern Med. Sep 1986;105(3):387-9. [Medline].

  17. Munteanu M, Lehaci C. [Acute anterior ischemic optic neuropathy in association with optic nerve drusen]. Oftalmologia. 2004;48(3):16-9. [Medline].

  18. Purvin V, King R, Kawasaki A, Yee R. Anterior ischemic optic neuropathy in eyes with optic disc drusen. Arch Ophthalmol. Jan 2004;122(1):48-53. [Medline].

  19. Salomon O, Rosenberg N, Steinberg DM, Huna-Baron R, Moisseiev J, Dardik R, et al. Nonarteritic anterior ischemic optic neuropathy is associated with a specific platelet polymorphism located on the glycoprotein Ibalpha gene. Ophthalmology. Jan 2004;111(1):184-8. [Medline].

  20. 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. Feb 22 1995;273(8):625-32. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

anterior ischemic optic neuropathy, AION, nonarteritic anterior ischemic optic neuropathy, NAION, arteritic anterior ischemic optic neuropathy, ischemic optic neuropathy, ION, giant cell arteritis, optic atrophy, optic nerve, optic disc

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Brian R Younge, MD, Professor of Ophthalmology, Mayo Clinic School of Medicine
Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

Medical Editor

Edsel Ing, MD, FRCSC, Assistant Professor, Department of Ophthalmology & Vision Sciences, University of Toronto, Sunnybrook and Women's Health Sciences Center, Toronto East General Hospital
Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Canadian Medical Association, Canadian Ophthalmological Society, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.