Bilateral Optic Disc Edema (Grand Rounds)
Bilateral non-arteritic anterior ischemic optic neuropathy (NAION).
- Dr.Diana Beselga states that she has no financial interest, affiliation, or other relationship with the manufacture of any commercial project discussed or with the manufacture of any competing commercial project.
- History of Present Illness
- 46-year-old caucasian male with no complaints, comes to a routine Ophthalmology consultation.
- Review of Systems: frequent headaches
- Past Medical History: Ulcerative colitis, Migraine
- Allergies: None
- Medications: Mesalazine
- BCVA: 20/20 bilaterally
- Pupils: normal pupillary reflexes, no afferent pupillary defect
- Colour vision: The patient was able to read Ishihara plates with each eye separately and without any errors
- Tonometry: 18 mmHg RE and 19 mmHg LE
- Extraocular Motility: without alterations
- Visual Fields: enlarged blind spot bilaterally
- External Exam: no alterations
- Normal blood pressure and pulse
- Slit Lamp Findings: without conjuntival hyperemia, transparent cornea, no anterior chamber reaction, clear lens bilaterally
- Dilated Fundus Exam Findings: bilateral papilledema with an hemorrhagic component; macula and peripheral retina without changes
- Normal blood count, ESR and CRP. No coagulation abnormalities. Analytical infectious and autoimmune evaluation negative.
- Lumbar puncture showed no increased fluid pressure and no cytochemical changes.
- Normal optic nerve/NFL OCT Brain and orbits magnetic resonance without significant changes
- Carotid Doppler US : without significant stenosis or atherosclerotic disease
- Pseudotumor cerebri
- Mesalazine causing intracranial hypertension
- Non arteritic anterior ischemic optic neuropathy
- Infiltrative disease of the optic nerve
- Bilateral non arteritic anterior ischemic optic neuropathy
Non arteritic anterior ischemic optic neuropathy (NAION)
- NAION is an infarction of the optic nerve head caused by compromised blood flow in one or more of the posterior ciliary arteries.
- Bilateral NAION is a well-documented entity that may be seen in 12-19% patients and it usually occurs sequentially instead of simultaneously.
- Patients with migraine may develop NAAION as early as the second or third decade of life.
- Polyarteritis nodosa
- Systemic lupus
- Buerger disease
- Allergic vasculitis
- Postviral vasculitis
- Radiation necrosis
- Systemic vasculopathies
- Diabetes mellitus
- Takayasu disease
- Carotid occlusive disease
- Polycythemia vera
- Sickle cell disease (trait)
- Acute hypotension (shock)
- Glucose-6-phosphate dehydrogenase deficiency (G-6-PD)
- Postcataract (possibly)
- Low-tension glaucoma
- Ex: phosphodiesterase type 5 (PDE-5) inhibitors, amiodarone
- Swollen optic disc, either diffuse or sectoral. Flame-shaped hemorrhages are present at or near the optic disc margin.
- Most patients have either altitudinal or arcuate visual field defects.
- Relative afferent pupillary defect is invariably present unless coexistent optic neuropathy in the fellow eye balances the impaired pupillary response in the affected eye.
- Typically presents with a sudden, painless loss of visual accuity.
- In most patients there are no premonitory symptoms.
- Approximately 50% of patients have visual acuity better than 20/100, so the presence of normal visual acuity does not rule out NAION
- Arteritic anterior ischemic optic neuropathy
- Optic Neuritis
- Compressive optic neuropathy
- Optic nerve inflammation, such as those related to syphilis or sarcoidosis
- Infiltrative optic neuropathies
- Idiopathic forms of optic disc edema, which include diabetic papillopathy and papillophlebitis.
- The treatment of anterior ischemic optic neuropathy to a large degree depends on its etiology in the individual patient.
- Most of the literature on the treatment of NAION consists of retrospective or prospective case series and anecdotal case reports.
- Various medical therapies for NAION have been investigated including systemic corticosteroids, anticoagulants, antiplatelet agents, diphenylhydantoin, and levodopa. None of these treatments have been found to be effective.
- Although numerous practitioners recommend steroids to treat acute NAION, this practice is not based on any level I evidence.
- Hayreh SS, Zimmerman MB. Nonarteritic anterior ischemic optic neuropathy: natural history of visual outcome. Ophthalmology 2008; 115:298.
- Hayreh SS, Zimmerman MB. Optic disc edema in non-arteritic anterior ischemic optic neuropathy. Graefes Arch Clin Exp Ophthalmol 2007; 245:1107.
- PreechawatP Bruce BB Newman NJ Biousse V. Anterior ischemic optic neuropathy in patients younger than 50 years. Am J Ophthalmol 2007; 144:953.
- Boone MI, Massry GG, Frankel RA, et al. Visual outcome in bilateral nonarteritic anterior ischemic optic neuropathy. Ophthalmology 1996, 103:1223.
- Atkins EJ, Bruce BB, Newman NJ, Biousse V. Treatment of nonarteritic anterior ischemic optic neuropathy. Surv Ophthalmol 2010; 55:47. 1996; 103:1223.
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