Anterior Ischemic Optic Neuropathy (AION) Follow-up

Updated: May 09, 2017
  • Author: Andrew A Dahl, MD, FACS; Chief Editor: Hampton Roy, Sr, MD  more...
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Follow-up

Further Outpatient Care

Patients with anterior ischemic optic neuropathy (AION) need to be observed for several reasons, as follows:

  • They may develop visual loss in the other eye.
  • Underlying medical conditions (eg, hypertension, diabetes) that need ongoing care may be present.
  • In patients with giant cell arteritis (GCA), a long-term plan of steroids and other medications to control the arteritis is needed.
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Inpatient & Outpatient Medications

Systemic steroids, ranging from 100 mg of prednisone daily to lower doses that are tolerated more easily on a long-term basis, may be indicated. Alternate day steroid therapy is not recommended, especially in the acute treatment of arteritic anterior ischemic optic neuropathy (AION). Titration of dosage with clinical symptoms and ESR seems to be the best regimen.

Treatment may be continued for a year or more, and it may be augmented by other antimetabolites, such as Imuran or methotrexate. Ultimately, a low dose of 2.5-5 mg daily, which is very close to physiologic secretion by the adrenals, is desirable. 

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Transfer

Transfer to a rheumatologist is desirable for care of those patients with arteritic forms of anterior ischemic optic neuropathy (AION).

Long-term adverse effects of steroids are common and problematic; these adverse effects require careful control.

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Deterrence/Prevention

No medications of known value are available in the prevention of anterior ischemic optic neuropathy (AION) in the other eye. Currently, most practitioners advise use of an aspirin daily in patients who can tolerate this medication. Its long-term efficacy is not proven. 

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Complications

Other than visual loss in the second eye, which may occur simultaneously with that in the first eye, few ocular complications accompany anterior ischemic optic neuropathy (AION). Ocular palsies in the arteritic form of the disease and ischemia of the entire globe associated with GCA have been reported. Rarely, scalp necrosis can occur.

Steroids have well-known and significant adverse effects. Such adverse effects are beyond the scope of this article, and an internist or a rheumatologist best manages them.

Occasional complications of temporal artery biopsy include hemorrhage or wound infection. Rare complications of temporal artery biopsy include facial nerve palsy, scalp necrosis, and cerebrovascular accident (if the superficial temporal artery supplies a critical collateral to the internal carotid circulation). 

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Prognosis

Prognosis for visual recovery generally is poor. However, in the IONDT study, more recovery of vision and visual field occurred than was expected. Part of this finding may be explained by adaptation, but the measured visual acuity and parameters of the fields did seem to improve substantially in many cases.

A second attack of nonarteritic ischemic optic neuropathy (NAION) has never been documented in an eye that has already suffered one attack. Thus, vision in a patient with NAION, even if both eyes have been affected, should remain stable. However, a second attack in the same eye has been found on occasion with the arteritic form of ischemic optic neuropathy associated with giant cell arteritis (GCA). 

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Patient Education

Anterior ischemic optic neuropathy (AION) is a very frustrating disease, to both patients and physicians, because little can be performed to treat it. Investigation of large vessel diseases, scanning of the brain, and treatment modalities have proven fruitless. Once visual loss has occurred, little can be performed to restore it.

Awareness of the entity of giant cell arteritis (GCA) is important to both physicians and patients, as the intervention of steroids may prevent loss of vision in the other eye, as well as prevention of considerable comorbidity in other organ systems.

General health measures (eg, control of blood pressure, obesity, and diabetes; not smoking) are important, but bear little result in recovery of vision that is already lost. 

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