eMedicine Specialties > Ophthalmology > Optic Nerve

Optic Neuropathy, Anterior Ischemic: Treatment & Medication

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

Updated: Nov 26, 2007

Treatment

Medical Care

Comanagement 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 ESR and/or 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 AION 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, there is little point in continuing, as the long-term complications of steroids are considerable.

Surgical Care

Optic nerve fenestration was advocated for AION until the completion of the Ischemic Optic Neuropathy Decompression Trial (IONDT). This study conclusively showed no effect of the surgery. Advocates for decompression in the patient with progressive AION still exist, 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.

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.

Medication

Oral steroids are of little or no use in NAION and are usually of little benefit in established arteritic AION.

It is critical that systemic steroids are initiated early in the case of giant cell arteritis, especially if one eye is involved. Usually, the treatment prevents the second eye from becoming involved, but, sometimes, vision is lost despite steroids.

Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli. In those cases that overlap with the optic neuritis (inflammatory, demyelinating) group (ie, patients in their fourth to fifth decade), a trial of steroids (intravenous) is useful.


Methylprednisolone (Solu-Medrol, Depo-Medrol)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.

Adult

1 g IV qd for 3 d, followed by 100 mg of prednisone qd for 10 d

Pediatric

Not established

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use

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
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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].

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Further Reading

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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

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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.

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.

 
 
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