Anterior Ischemic Optic Neuropathy Follow-up

  • Author: Brian R Younge, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Jan 3, 2012
 

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, a long-term plan of steroids and other medications to control the arteritis is needed.
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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. 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.
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Transfer

  • Transfer to a rheumatologist is desirable for care of those patients with arteritic forms of anterior ischemic optic neuropathy.
  • Long-term adverse effects of steroids are common and problematic; these adverse effects require careful control.
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Deterrence/Prevention

  • No medications of known value are available in the prevention of anterior ischemic optic neuropathy 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 nonarteritic anterior ischemic optic neuropathy remains to be seen.
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Complications

  • 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. 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).
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Prognosis

  • 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 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, 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.
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Patient Education

  • Anterior ischemic optic neuropathy 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.
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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.

Specialty Editor Board

Edsel Ing, MD, FRCSC  Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Toronto East General Hospital, Canada

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

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.

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.

References

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  8. 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].

  9. Atkins EJ, Bruce BB, Newman NJ, Biousse V. Treatment of nonarteritic anterior ischemic optic neuropathy. Surv Ophthalmol. Jan-Feb 2010;55(1):47-63. [Medline].

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  13. 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].

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  19. 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].

  20. Love DC, Rapkin J, Lesser GR, et al. Temporal arteritis in blacks. Ann Intern Med. Sep 1986;105(3):387-9. [Medline].

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  23. 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. Jan 2004;111(1):184-8. [Medline].

 
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Anterior ischemic optic neuropathy. Swollen pale disc that can be seen in stereo by converging the eyes and fusing the central image.
Anterior ischemic optic neuropathy, late stage. Optic atrophy has supervened, and the atrophic pale disc with a more pronounced cup can be seen in stereo.
 
 
 
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