Ischemic Optic Neuropathy

Abstract

Ischemic optic neuropathies (IONs) are the most frequent acute optic neuropathy in patients older than 50 years. They are classified according to the location of the ischemic damage into anterior ION and posterior ION. Ischemic optic neuropathies may also be categorized based on the presence or absence of temporal arteritis as an underlying etiology. Anterior ION presents with sudden, painless visual loss developing over hours to days. Examination findings usually include decreased visual acuity, a visual field defect, color vision loss, a relative afferent pupillary defect, and a swollen optic nerve head. Posterior ION occurs in arteritic, nonarteritic, and surgical settings. It is characterized by acute vision loss without initial disc edema but with subsequent optic disc atrophy.

Clinical approach to optic neuritis: pitfalls, red flags and differential diagnosis

“…However, as in case 4, a painful eye movement is sometimes reported in patients with mucoceles [Avery et al 1983;Rothstein et al 1984] or arterial aneurysms [Petzold, 2008] ON without signs for other demyelinating CNS disease Chronic relapsing inflammatory optic neuropathy (CRION) [Kidd et al 2003] Often bilateral, severe and painful visual loss, relapse after withdrawal of steroids Neuromyelitis optica (NMO) [Wingerchuk et al 2007] ON and transverse myelitis Acute disseminated encephalomyelitis (ADEM) [Tenembaum et al 2007] Usually monophasic, triggered by infections and vaccination, encephalomyelitis, can be bilateral Connective tissue disorders and vasculitis [Theodoridou and Settas, 2006;Cikes et al 2008] Worsening of symptoms after withdrawal of steroids Sarcoidosis Progressive or relapsing severe visual loss, often very painful Systemic lupus erythematosus (SLE) Rare, often unilateral, sometimes associated with transverse myelitis Sjögren's syndrome Often bilateral, severe visual loss Antiphospholipid antibody syndrome Rare, often unilateral, sometimes associated with transverse myelitis Behçet's disease Papillitis, uveitis, chorioretinitis, and retinal vasculitis Wegener's granulomatosis Papillitis, scleritis, conjunctivitis, uveitis, retinal vasculitis Giant cell arteritis (GCA) [Carroll et al 2006] Sudden visual loss (AION, PION), headache, muscle pain, age >50 years, jaw claudication Other inflammatory optic neuropathies Postinfectious and postvaccination Bilateral, often in childhood, good prognosis Neuroretinitis [Ray and Gragoudas, 2001] Swollen optic disc and macular star, spontaneous recovery TolosaHunt syndrome [La Mantia et al 2006] Painful ophthalmoplegia Infectious optic neuropathies Progressive visual loss with exposure to infectious agent Lyme disease [Karma et al 1995] Rare, more often occurring at later stages of disease Syphilis Also manifestation as uveitis, retinitis Tuberculosis [Bodaghi and LeHoang, 2000] Rare, more often presenting as choroiditis or uveitis Viral optic neuritis Most frequently associated with herpes Zoster infection Compressive optic neuropathies Painless and progressive visual loss Primary tumours (meningiomas, gliomas, and pituitary tumours) [Eddleman and Liu, 2007] Optic atrophy Metastases History of or evidence for primary tumour Thyroid ophthalmopathy [Vardizer et al 2010] Protrusion of one or both eyes, dry eyes, systemic signs for hyperthyroidism Arterial aneurysms Painful progressive visual loss, general headache Sinus mucoceles History of sinusitis, may be painful and with subacute visual loss Ischemic optic neuropathies [Fontal et al 2007] Sudden onset of painless visual loss, age >50 years Anterior ischaemic optic neuropathy (AION) Swollen optic disc Posterior ischaemic optic neuropathy (PION) Optic di...…”

Approach to Optic Neuropathies

“…Nonarteritic anterior ischemic optic neuropathy (NAION) is the most common cause of unilateral optic neuropathy in adults over the age of 50, and is commonly associated with vascular risk factors such as diabetes or hypertension. 22 Other risk factors include a crowded optic nerve head (small cup to disc ratio) and nocturnal hypotension, possibly precipitated by antihypertensive therapy 22 (Fig. 12).…”

“…NAION may follow ocular surgery, because an associated increase in intraocular pressure may compromise optic nerve head perfusion. 22 Many patients with NAION will have a stable deficit, although in some cases visual loss will progress over a month. There can be spontaneous improvement in the first 6 months, although in many patients this reflects improved ability with eccentric fixation.…”

Chronic optic disc swelling overlooked in a diabetic patient with a devastating outcome

“…This may present with painless subacute or chronic stepwise, sequential vision loss, which may not recover, in patients >50 years with diabetes and hypertension 3. Segmental swelling of the optic disc is frequently seen, with prominent dilated capillaries over the disc, and peripapillary haemorrhages.…”