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Anterior Ischemic Optic Neuropathy Treatment & Management

  • Author: Andrew A Dahl, MD, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Jan 05, 2016
 

Medical Care

Comanagement of anterior ischemic optic neuropathy (AION) with an internist, especially a rheumatologist, is helpful in patients with giant cell arteritis (GCA). 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 GCA, 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 cyclosporine, 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.

Scientific data do not support corticosteroid treatment for nonarteritic anterior ischemic optic neuropathy (NAION). When 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

The Ischemic Optic Neuropathy Decompression Trial (IONDT)[8, 9] showed that optic nerve decompression has no effect in the treatment of ischemic optic neuropathy.

Temporal artery biopsy is warranted for diagnosis when arteritis is a possibility.

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Consultations

Consultation with a rheumatologist is advisable if any indication of giant cell arteritis (GCA) is present.

Consultation with other specialists on a case-by-case basis may be required. GCA 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

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department 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, Association for Research in Vision and Ophthalmology, American Glaucoma Society

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Brian R Younge, MD Professor of Ophthalmology (Retired), Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

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, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

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. 2012 Jan. 116(1):15-24. [Medline].

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

  7. 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].

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

  9. 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].

  10. 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].

  11. 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].

  12. 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].

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

  14. 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].

  15. 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].

  16. 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].

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

  18. 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].

  19. 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].

  20. 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].

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

  22. 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].

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

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

  25. 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].

  26. 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].

 
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Anterior ischemic optic neuropathy of the right eye. Swollen pale disc that can be seen in stereo by converging the eyes and fusing the central image.
Sectorial optic atrophy of the right eye as a late finding resulting from anterior ischemic optic neuropathy. Atrophy has supervened, and the atrophic pale disc with a more pronounced cup can be seen in stereo.
 
 
 
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