Anterior Ischemic Optic Neuropathy Treatment & Management

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

Medical Care

Comanagement of anterior ischemic optic neuropathy (AION) with an internist, especially a rheumatologist, is helpful in patients with giant cell arteritis. Control of blood pressure and diabetes, often comorbid conditions, is helpful in the general sense, but it is of little use in the recovery of visual loss.

  • In giant cell arteritis, the steroid regimen is as follows:
    • The initial dose is 40-60 mg/d of prednisone, depending on the size of the patient and the severity of the disease. If starting at 40 mg/d, hold for 2-4 weeks; then, reduce as below. If starting at 60 mg/d, reduce by 10 mg every 2 weeks to 40 mg, followed by 5-mg reductions every 1-2 weeks to 20 mg/d, and then 2.5 mg every 1-2 weeks. Below 10 mg/d, reduce 1 mg per month. The reduction schedule depends of the course on the patient.
    • Obtain erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) at monthly intervals to monitor the course of the patient. Brief interviews at monthly intervals are helpful. If recurrences develop, the reduction schedule needs to be delayed, and, sometimes, small increments need to be given again for flare-ups. Avoid large increments for flare-ups if possible.
  • Some authors have advocated larger doses, even intravenous doses of 1 gram daily for several days, followed by the standard treatment as above. Support for this is currently lacking, but, in an ongoing study at the Mayo Clinic, a double-masked study is underway to determine if intravenous doses accelerate the recovery and shorten the need for months of long-term steroids.
  • At a later stage in the steroid management, it is sometimes useful to add antimetabolites, such as methotrexate or cyclosporin, to reduce the dosage of steroids, particularly if adverse effects are becoming a problem. Careful monitoring of liver function and blood counts is essential and is best left to the rheumatologist.
  • Steroid treatment for the nonarteritic type of anterior ischemic optic neuropathy (NAION) has its advocates, but data do not support its use. In those cases where the diagnosis is in question, a short-term trial is warranted. Once temporal arteritis has been ruled out, continuing is unnecessary because the long-term complications of steroids are considerable.
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Surgical Care

  • Optic nerve fenestration was advocated for anterior ischemic optic neuropathy until the completion of the Ischemic Optic Neuropathy Decompression Trial (IONDT).[8] This study conclusively showed no effect of the surgery.[9] Advocates for decompression in the patient with progressive anterior ischemic optic neuropathy are still noted, but, to date, no evidence is available to establish the effectiveness of this treatment.
  • Temporal artery biopsy is warranted for diagnosis in those cases in which arteritis may be the etiology.
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Consultations

  • Consultation with a rheumatologist is advisable if any indication of giant cell arteritis is present.
  • Consultation with other specialists on a case-by-case basis may be required. Giant cell arteritis is a systemic disease and can affect multiple organ systems.
  • Numerous complications of steroid use require medical monitoring with the help of a primary care physician or an internist.
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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

  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. The Postoperative Visual Loss Study Group. Risk Factors Associated with Ischemic Optic Neuropathy after Spinal Fusion Surgery. Anesthesiology. Jan 2012;116(1):15-24. [Medline].

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

  7. Subei AM, Eggenberger ER. Optical coherence tomography: another useful tool in a neuro-ophthalmologist's armamentarium. Curr Opin Ophthalmol. Nov 2009;20(6):462-6. [Medline].

  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].

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

  11. 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].

  12. 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].

  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].

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

  15. 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].

  16. 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].

  17. 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].

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

  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].

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

  22. 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].

  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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