Anterior Ischemic Optic Neuropathy Workup

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

Laboratory Studies

  • The erythrocyte sedimentation rate (ESR) is commonly obtained in patients with anterior ischemic optic neuropathy (AION). In patients with arteritic anterior ischemic optic neuropathy, 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.
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Imaging Studies

  • Ultrasound of the temporal arteries and ocular Doppler ultrasound have been described, but their use in mainstream diagnosis of arteritic anterior ischemic optic neuropathy versus nonarteritic anterior ischemic optic neuropathy remains to be seen.
  • Ocular plethysmography (OPG) may be advocated. OPG is thought to be abnormal in patients with arteritic anterior ischemic optic neuropathy.
  • MRI is useful in younger individuals who may have demyelinating disease. It is not useful in older age groups, in either the arteritic or nonarteritic form of anterior ischemic optic neuropathy.
  • CT scanning is not useful in either the arteritic or nonarteritic form of anterior ischemic optic neuropathy.
  • Fluorescein angiography has been suggested as a possible method of distinguishing arteritic anterior ischemic optic neuropathy from nonarteritic anterior ischemic optic neuropathy. With arteritic anterior ischemic optic neuropathy, a markedly prolonged choroidal filling time is usually present.
  • Angiography of the cerebral circulation has been useful in giant cell arteritis, showing segmental stenosis or even occlusion of the extracranial vessels. However, this invasive study has fallen into less frequent use.
  • Optical coherence tomography (OCT) has been used in patients with anterior ischemic optic neuropathy with success.[7]
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Procedures

  • Temporal artery biopsy is used to diagnose giant cell arteritis. It is especially useful in patients with any of the symptoms of giant cell arteritis 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 giant cell arteritis in older patients with anterior ischemic optic neuropathy.
  • Whenever possible, a biopsy specimen of at least 2-3 cm should be obtained to minimize the possibility of skip lesions. Bilateral temporal artery biopsy should be considered if giant cell arteritis is still suspected despite an initial negative result of the 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 within 4 weeks of initiation of steroid treatment, although positive biopsy results can be obtained months after steroids have begun.
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Histologic Findings

  • 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 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.
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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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