Anterior Ischemic Optic Neuropathy (AION) Treatment & Management

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

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.

Most scientific data do not support corticosteroid treatment for nonarteritic anterior ischemic optic neuropathy (NAION), although a 27-year prospective study by Hayreh and Zimmerman suggested that NAION eyes treated during the acute phase with systemic corticosteroids resulted in a significantly higher probability of improved visual acuity (P = 0.001) and visual field (P = 0.005) than in the untreated group. Both visual acuity and visual fields improved up to 6 months after onset of NAION. [8]

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) [9, 10] 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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