Bilateral Optic Disc Edema (Grand Rounds)

From EyeWiki


Bilateral non-arteritic anterior ischemic optic neuropathy (NAION).


Financial Disclosure

  • 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

  • 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

Examination

  • 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

Retinography

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Laboratory Testing

  • 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.

Imaging

Diana Beselga Slide9.JPG Diana Beselga Slide10.JPG


Imaging Testing

  • Normal optic nerve/NFL OCT Brain and orbits magnetic resonance without significant changes
  • Carotid Doppler US : without significant stenosis or atherosclerotic disease

Differential Diagnosis

  • Pseudotumor cerebri
  • Mesalazine causing intracranial hypertension
  • Non arteritic anterior ischemic optic neuropathy
  • Infiltrative disease of the optic nerve

Diagnosis

  • Bilateral non arteritic anterior ischemic optic neuropathy


Etiology

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.


  • Vasculitides
    • Polyarteritis nodosa
    • Systemic lupus
    • Buerger disease
    • Allergic vasculitis
    • Postviral vasculitis
    • Postimmunization
    • Syphilis
    • Radiation necrosis
  • Systemic vasculopathies
    • Hypertension
    • Atherosclerosis
    • Diabetes mellitus
    • Migraine
    • Takayasu disease
    • Carotid occlusive disease
  • Hematologic
    • Polycythemia vera
    • Sickle cell disease (trait)
    • Acute hypotension (shock)
    • Glucose-6-phosphate dehydrogenase deficiency (G-6-PD)
  • Ocular
    • Postcataract (possibly)
    • Low-tension glaucoma
  • Medications
    • Ex: phosphodiesterase type 5 (PDE-5) inhibitors, amiodarone

Signs

  • 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.

Symptoms

  • 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

Differential Diagnosis

  • 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.

Treatment

  • 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.

Follow Up

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References

  • 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.

Discussion

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