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Management of ischemic optic neuropathies.

Hayreh SS - Indian J Ophthalmol (2011 Mar-Apr)

Bottom Line: Patients with NA-AION, when treated with systemic corticosteroid therapy within first 2 weeks of onset, had significantly better visual outcome than untreated ones.NA-PION patients, when treated with high-dose systemic steroid therapy during the very early stages of the disease, showed significant improvement in visual acuity and visual fields, compared to untreated eyes.There is no satisfactory treatment for surgical PION, except to take prophylactic measures to prevent its development.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology and Visual Sciences, College of Medicine, University of Iowa, Iowa City, IA, USA. sohan-hayreh@uiowa.edu

ABSTRACT
Ischemic optic neuropathies (IONs) consist primarily of two types: anterior ischemic optic neuropathy (AION) and posterior ischemic optic neuropathy (PION). AION comprises arteritic AION (A-AION: due to giant cell arteritis) and non-arteritic AION (NA-AION: due to other causes). PION consists of arteritic PION (A-PION: due to giant cell arteritis), non-arteritic PION (NA-PION: due to other causes), and surgical PION (a complication of several systemic surgical procedures). These five types of ION are distinct clinical entities etiologically, pathogenetically, clinically and from the management point of view. In the management of AION, the first crucial step with patients aged 50 and over is to identify immediately whether it is arteritic or not because A-AION is an ophthalmic emergency and requires urgent treatment with high-dose steroid therapy to prevent any further visual loss in one or both eyes. Patients with NA-AION, when treated with systemic corticosteroid therapy within first 2 weeks of onset, had significantly better visual outcome than untreated ones. Systemic risk factors, particularly nocturnal arterial hypotension, play major roles in the development of NA-AION; management of them is essential in its prevention and management. NA-PION patients, when treated with high-dose systemic steroid therapy during the very early stages of the disease, showed significant improvement in visual acuity and visual fields, compared to untreated eyes. A-PION, like A-AION, requires urgent treatment with high-dose steroid therapy to prevent any further visual loss in one or both eyes. There is no satisfactory treatment for surgical PION, except to take prophylactic measures to prevent its development.

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Fundus photographs of right eye with A-AION: (a) Before developing A-AION, (b) 1 week after developing A-AION with chalky white optic disc edema and (c) 4 months later showing optic disc cupping with a cup/disc ratio of 0.8 (note no cup in Fig. 11a before developing A-AION)[16]
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Figure 0011: Fundus photographs of right eye with A-AION: (a) Before developing A-AION, (b) 1 week after developing A-AION with chalky white optic disc edema and (c) 4 months later showing optic disc cupping with a cup/disc ratio of 0.8 (note no cup in Fig. 11a before developing A-AION)[16]

Mentions: In A-AION, compared to NA-AION, optic disc edema usually has a diagnostic appearance, i.e., a chalky white color[1951] (seen in 69%)[51] [Figs. 10, 11b and 12a]. When optic disc edema resolves, the optic disc in the vast majority shows cupping, indistinguishable from that seen in glaucomatous optic neuropathy, except that there is pallor of the rim[1951] [compare optic disc cup in Fig. 11a with that in Fig. 11c]. By contrast, in NA-AION no such cupping of the optic disc is seen.[1951] Other fundus findings include cotton-wool spots, central retinal artery occlusion, cilioretinal artery occlusion (which is erroneously diagnosed as “branch retinal artery occlusion”), choroidal ischemic lesions and rarely ocular ischemia.[51] Fluorescein fundus angiography performed during the first few days after the onset of A-AION shows the absence of choroidal filling supplied by the occluded PCA [Fig. 12b]; however, later on, with the establishment of collateral circulation, this information may be lost. A combination of chalky white optic disc edema, retinal infarct in the region of the occluded cilioretinal artery and presence of PCA occlusion on fluorescein angiography is diagnostic of A-AION [Fig. 12].


Management of ischemic optic neuropathies.

Hayreh SS - Indian J Ophthalmol (2011 Mar-Apr)

Fundus photographs of right eye with A-AION: (a) Before developing A-AION, (b) 1 week after developing A-AION with chalky white optic disc edema and (c) 4 months later showing optic disc cupping with a cup/disc ratio of 0.8 (note no cup in Fig. 11a before developing A-AION)[16]
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3116541&req=5

Figure 0011: Fundus photographs of right eye with A-AION: (a) Before developing A-AION, (b) 1 week after developing A-AION with chalky white optic disc edema and (c) 4 months later showing optic disc cupping with a cup/disc ratio of 0.8 (note no cup in Fig. 11a before developing A-AION)[16]
Mentions: In A-AION, compared to NA-AION, optic disc edema usually has a diagnostic appearance, i.e., a chalky white color[1951] (seen in 69%)[51] [Figs. 10, 11b and 12a]. When optic disc edema resolves, the optic disc in the vast majority shows cupping, indistinguishable from that seen in glaucomatous optic neuropathy, except that there is pallor of the rim[1951] [compare optic disc cup in Fig. 11a with that in Fig. 11c]. By contrast, in NA-AION no such cupping of the optic disc is seen.[1951] Other fundus findings include cotton-wool spots, central retinal artery occlusion, cilioretinal artery occlusion (which is erroneously diagnosed as “branch retinal artery occlusion”), choroidal ischemic lesions and rarely ocular ischemia.[51] Fluorescein fundus angiography performed during the first few days after the onset of A-AION shows the absence of choroidal filling supplied by the occluded PCA [Fig. 12b]; however, later on, with the establishment of collateral circulation, this information may be lost. A combination of chalky white optic disc edema, retinal infarct in the region of the occluded cilioretinal artery and presence of PCA occlusion on fluorescein angiography is diagnostic of A-AION [Fig. 12].

Bottom Line: Patients with NA-AION, when treated with systemic corticosteroid therapy within first 2 weeks of onset, had significantly better visual outcome than untreated ones.NA-PION patients, when treated with high-dose systemic steroid therapy during the very early stages of the disease, showed significant improvement in visual acuity and visual fields, compared to untreated eyes.There is no satisfactory treatment for surgical PION, except to take prophylactic measures to prevent its development.

View Article: PubMed Central - PubMed

Affiliation: Department of Ophthalmology and Visual Sciences, College of Medicine, University of Iowa, Iowa City, IA, USA. sohan-hayreh@uiowa.edu

ABSTRACT
Ischemic optic neuropathies (IONs) consist primarily of two types: anterior ischemic optic neuropathy (AION) and posterior ischemic optic neuropathy (PION). AION comprises arteritic AION (A-AION: due to giant cell arteritis) and non-arteritic AION (NA-AION: due to other causes). PION consists of arteritic PION (A-PION: due to giant cell arteritis), non-arteritic PION (NA-PION: due to other causes), and surgical PION (a complication of several systemic surgical procedures). These five types of ION are distinct clinical entities etiologically, pathogenetically, clinically and from the management point of view. In the management of AION, the first crucial step with patients aged 50 and over is to identify immediately whether it is arteritic or not because A-AION is an ophthalmic emergency and requires urgent treatment with high-dose steroid therapy to prevent any further visual loss in one or both eyes. Patients with NA-AION, when treated with systemic corticosteroid therapy within first 2 weeks of onset, had significantly better visual outcome than untreated ones. Systemic risk factors, particularly nocturnal arterial hypotension, play major roles in the development of NA-AION; management of them is essential in its prevention and management. NA-PION patients, when treated with high-dose systemic steroid therapy during the very early stages of the disease, showed significant improvement in visual acuity and visual fields, compared to untreated eyes. A-PION, like A-AION, requires urgent treatment with high-dose steroid therapy to prevent any further visual loss in one or both eyes. There is no satisfactory treatment for surgical PION, except to take prophylactic measures to prevent its development.

Show MeSH
Related in: MedlinePlus