Anterior Ischemic Optic Neuropathy Workup
- Author: Andrew A Dahl, MD, FACS; Chief Editor: Hampton Roy, Sr, MD more...
The erythrocyte sedimentation rate (ESR) is commonly obtained in patients with anterior ischemic optic neuropathy (AION). In patients with arteritic AION, the ESR is usually elevated, although 10% of patients may have a normal ESR. In nonarteritic anterior ischemic optic neuropathy (NAION), the ESR is more likely to be normal, assuming no comorbid condition is present. The Westergren ESR is thought to be more reliable than the Wintrobe ESR.
A hematology group is useful. Mild anemia may be present.
Other blood tests, such as the C-reactive protein (CRP), have been found useful in diagnosing giant cell arteritis (GCA). In a few patients with GCA, the CRP level has been shown to be elevated despite the finding of a normal ESR.
Ultrasonography of the temporal arteries and ocular Doppler ultrasonography have been described, but the utility of ultrasonographic evaluation in the differentiation between arteritic anterior ischemic optic neuropathy (AION) and nonarteritic anterior ischemic optic neuropathy (NAION) has not been proven.
Ocular plethysmography (OPG) findings have been described as being abnormal in patients with arteritic AION.
MRI is useful in younger individuals in identifying unilateral visual loss of optic nerve with possible demyelinating disease. It is not useful in older age groups, in either the arteritic or nonarteritic form of AION.
CT scanning is not useful in either the arteritic or nonarteritic form of AION.
Fluorescein angiography has been suggested as a possible method of distinguishing arteritic AION from NAION. With arteritic AION, a markedly prolonged choroidal filling time is usually present.
Angiography of the cerebral circulation has been useful in giant cell arteritis (GCA), showing segmental stenosis or even occlusion of the extracranial vessels. However, angiography is rarely used because of its invasive nature. CT angiography has been described as sometimes revealing segmental stenosis in GCA.
Optical coherence tomography (OCT) has been used in patients with AION with success.
Temporal artery biopsy is used to diagnose giant cell arteritis (GCA). It is especially useful in patients with any of the symptoms of GCA or in patients with visual loss and a high ESR. A normal result of the temporal artery biopsy is often used to exclude the diagnosis of GCA in older patients with anterior ischemic optic neuropathy (AION).
Whenever possible, a biopsy specimen of at least 2-3 cm should be obtained to minimize the possibility of skip lesions. Bilateral temporal artery biopsies increase the yield of positive results. A second temporal artery biopsy should be considered if GCA is still suspected despite an initial negative result of the first temporal artery biopsy. Delaying the second side a few weeks may improve the yield of a positive biopsy result on that second side.
Biopsy should generally be performed either before or soon after the initiation of steroid therapy, although positive biopsy results can sometimes be obtained months after steroids have begun.
The idiopathic form of ischemic optic neuropathy has no characteristic pathology other than obliterative occlusion of the cilioretinal arteries and ischemic necrosis of the optic nerve head in variable degree.
Giant cell arteritis (GCA) has a characteristic inflammatory infiltrate that has a granulomatous appearance, sometimes with giant cells. Complete occlusion of the ophthalmic artery within the orbit may result in ischemic changes of the globe in its entirety. The use of frozen section for temporal artery biopsy is very useful in determining arteritis, and it may establish the diagnosis with a single temporal artery biopsy. Rarely, if the initial temporal artery biopsy result is negative, the contralateral biopsy result may be positive due to minimal involvement or skip areas. Inflammatory infiltrate in the adventitia often is considered to be sufficient evidence for diagnosis, even with the elastica intact.
Uhtoff W. Zu den entzundlichen sehnerven: Affectionen bei arteriosklerose. Ber Dtsch Ophthalmol Gesampte. 1924. 44:196-198.
Ali Ibn Isa. Memorandum Book of a Tenth-Century Oculist. (Translated by CA Wood). Chicago: Northwestern University; 1936.
Hutchinson J. Diseases of the arteries. Arch Surg (London). 1890. 1:323.
Horton BT, Magath TB, Brown GE. An undescribed form of arteritis of the temporal vessels. Proc Staff Meet Mayo Clinic. 1932. 7:700.
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].
Miller NR. Anterior ischemic optic neuropathy. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 1982. Vol 1: 212-226.
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].
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].
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].
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].
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].
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].
Bielory L, Ogunkoya A, Frohman LP. Temporal arteritis in blacks. Am J Med. 1989 Jun. 86(6 Pt 1):707-8. [Medline].
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].
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].
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].
Foroozan R, Varon J. Bilateral anterior ischemic optic neuropathy after liposuction. J Neuroophthalmol. 2004 Sep. 24(3):211-3. [Medline].
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].
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].
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].
Johns LN, Arnold AC. Incidence of nonarteritic anterior ischemic optic neuritis (population based study). J Neuroophthalmol. 1994. 14:38-49.
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].
Love DC, Rapkin J, Lesser GR, et al. Temporal arteritis in blacks. Ann Intern Med. 1986 Sep. 105(3):387-9. [Medline].
Munteanu M, Lehaci C. [Acute anterior ischemic optic neuropathy in association with optic nerve drusen]. Oftalmologia. 2004. 48(3):16-9. [Medline].
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].
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].