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Current Treatment Options in Neurology

, Volume 13, Issue 1, pp 92–100 | Cite as

Nonarteritic Anterior Ischemic Optic Neuropathy

  • Edward J. Atkins
Neurologic Ophthalmology and Otology

Opinion statement

Currently there is no generally accepted, well-proven treatment for nonarteritic anterior ischemic optic neuropathy (NAION). Most proposed treatments are empirical and include antithrombotics, vasodynamic agents, treatments aimed at reducing optic disc edema, and various neuroprotective strategies. Most potential treatments have been inadequately studied, prematurely embraced, or prematurely discarded. Evidence for antithrombotic agents is lacking, and small vessel arterial occlusion has never been demonstrated in NAION. Antiplatelet agents have not been studied in acute NAION, but they are often prescribed for acute treatment because of their proven role in stroke prevention. Because NAION is an ischemic disorder occurring more often after the age of 50 in patients with vascular risk factors, I recommend aggressive risk-factor management and antiplatelet therapy. The evidence that aspirin can help to prevent NAION in the fellow eye is divided. I recommend aspirin for secondary prevention, mostly for its proven role in stroke prevention. NAION occurs in patients with physiologically crowded optic nerves and small cup-to-disc ratios. Disc edema may contribute to a “compartment syndrome,” which compresses the fine capillary blood supply of the optic nerve head, resulting in ischemia and axonal damage. There is some limited and debatable evidence that oral steroids may shorten the duration of disc edema and improve visual outcome in NAION. I discuss this evidence with patients who present acutely with NAION, and although I consider prescribing oral steroids on a case-by-case basis, I will not routinely recommend oral steroids until a properly randomized clinical trial is performed. Some neuroprotective strategies have been studied, but none have proven to be helpful. Although some (eg, brimonidine) are probably not harmful, I do not recommend these treatments. Early referral to low vision services may help to improve functional visual outcome.

Keywords

Sleep Apnea Continuous Positive Airway Pressure Vascular Risk Factor Brimonidine Disc Edema 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Disclosure

No potential conflicts of interest relevant to this article were reported.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance•• Of major importance

  1. 1.
    Arnold AC, et al.: Ischemic optic neuropathy. In Clinical Neuro-Ophthalmology, vol. 1, edn 6th. By Miller NR, Newman NJ, Biousse V. Philadelphia: Lippincott, Williams & Wilkins; 2005:349–384.Google Scholar
  2. 2.••
    Atkins EJ, Bruce BB, Newman NJ, Biousse V: Treatment of nonarteritic anterior ischemic optic neuropathy. Surv Ophthalmol 2010, 55(1):47–63.CrossRefPubMedGoogle Scholar
  3. 3.
    Hayreh SS: Ischemic optic neuropathy. Prog Retin Eye Res 2009, 28(1):34–62.CrossRefPubMedGoogle Scholar
  4. 4.
    Bonamour G: Apropos de pseudo-papillites vasculaire. Bull Soc Ophtalmol Fr 1966, 79:846.Google Scholar
  5. 5.
    Calmettes L, Deodati F, Bechac G: Pseudo-papillite vasculaire. Rev Oto Neuro Ophtalmol 1963, 35:64–65.Google Scholar
  6. 6.
    Foulds WS: Visual disturbances in systemic disorders: optic neuropathy and systemic disease. Trans Ophthalmol Soc UK 1970, 89:125–146.PubMedGoogle Scholar
  7. 7.
    Francois J, Verriest G, Neetens A, et al.: Pseudo-papillites vasculaire. Ann Ocul (Paris) 1962, 195:830–885.Google Scholar
  8. 8.
    Georgiades G, Konstas P, Stangos N: Reflexions issues de l’etude de nombreaux cas de pseudo-papillite vasculaire. Bull Soc Ophtalmol Fr 1966, 79:506–536.Google Scholar
  9. 9.
    Lasco F: Les affections vasculaires du nerf optique et leurs manifestations clinique. Opthalmologica 1961, 142:429–445.CrossRefGoogle Scholar
  10. 10.
    Saraux H, Murat JP: Les pseudo-papillites d’origine vasculaire. Ann Ocul (Paris) 1967, 200(1):1–19.Google Scholar
  11. 11.
    Hayreh SS: Anterior ischemic optic neuropathy. III. Treatment, prophylaxis and differential diagnosis. Br J Ophthalmol 1974, 58(12):981–989.CrossRefPubMedGoogle Scholar
  12. 12.
    Hayreh SS, Joos KM, Podhajsky PA, Long CR: Systemic diseases associated with nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 1994, 118(6):766–780.PubMedGoogle Scholar
  13. 13.
    Hayreh SS, Zimmerman MB, Podhajsky P, et al.: Nocturnal arterial hypotension and its role in optic nerve head and ocular ischemic disorders. Am J Ophthalmol 1994, 117(5):603–624.PubMedGoogle Scholar
  14. 14.
    Hayreh SS: Ipsilateral recurrence of non-arteritic anterior ischemic optic neuropathy. Am J Ophthalmol 2001, 132(5):734–742.CrossRefPubMedGoogle Scholar
  15. 15.
    Hayreh SS: Amiodarone, erectile dysfunction drugs, and non-arteritic ischemic optic neuropathy. J Neuroophthalmol 2006, 26(2):154–155.PubMedGoogle Scholar
  16. 16.
    Hayreh SS, Zimmerman MB: Optic disc edema in nonarteritic anterior ischemic optic neuropathy. Graefes Arch Clin Exp Ophthalmol 2007, 245(8):1107–1121.CrossRefPubMedGoogle Scholar
  17. 17.
    Hayreh SS, Jonas JB, Zimmerman MB: Nonarteritic anterior ischemic optic neuropathy and tobacco smoking. Ophthalmol 2007, 114(4):804–809.CrossRefGoogle Scholar
  18. 18.••
    Hayreh SS, Zimmerman MB: Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy. Graefes Arch Clin Exp Ophthalmol 2008, 246(7):1029–1046.CrossRefPubMedGoogle Scholar
  19. 19.
    Hayreh SS: Intravitreal triamcinolone for nonarteritic anterior ischemic optic neuropathy. J Neuroophthalmol 2008, 28(1):77–78.PubMedGoogle Scholar
  20. 20.
    Ischemic Optic Neuropathy Decompression Trial Research Group: Optic nerve decompression surgery for nonarteritic anterior ischemic optic neuropathy (NAION) is not effective and may be harmful. The Ischemic Optic Neuropathy Decompression Trial Research Group. JAMA 1995, 273(8):625–632.CrossRefGoogle Scholar
  21. 21.
    Bennett JL, Thomas S, Olson JL, et al.: Treatment of nonarteritic anterior ischemic optic neuropathy with intravitreal bevacizumab. J Neuroophthalmol 2007, 27(3):238–240.PubMedGoogle Scholar
  22. 22.••
    Atkins EJ, Bruce BB, Newman NJ, Biousse V: Translation of clinical studies to clinical practice: survey on the treatment of nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 2009 Nov, 148(5):809.CrossRefPubMedGoogle Scholar
  23. 23.
    Arnold AC: Pathogenesis of nonarteritic anterior ischemic optic neuropathy. J Neuroophthalmol 2003, 23(2):157–163.PubMedGoogle Scholar
  24. 24.
    Lessell S: Nonarteritic anterior ischemic optic neuropathy: enigma variations. Arch Ophthalmol 1999, 117(3):386–388.PubMedGoogle Scholar
  25. 25.
    Deramo VA, Sergott RC, Augsburger JJ, et al.: Optic neuropathy as the first manifestation of elevated cholesterol in young patients. Ophthalmol 2003, 110(5):1041–1046.CrossRefGoogle Scholar
  26. 26.
    Fry CL, Carter JE, Kanter MC, et al.: Anterior ischemic optic neuropathy is not associated with carotid artery atherosclerosis. Stroke 1993, 24(4):539–542.PubMedGoogle Scholar
  27. 27.
    Mojon DS, Hedges TR, Ehrenberg B, et al.: Association between sleep apnea syndrome and nonarteritic anterior ischemic optic neuropathy. Arch Ophthalmol 2002, 120(5):601–605.PubMedGoogle Scholar
  28. 28.
    Behbehani R, Mathews MK, Sergott RC, et al.: Nonarteritic anterior ischemic optic neuropathy in patients with sleep apnea while being treated with continuous positive airway pressure. Am J Ophthalmol 2005, 139(3):518–521.CrossRefPubMedGoogle Scholar
  29. 29.
    Lee AG, Newman NJ: Erectile dysfunction drugs and nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 2005, 140(4):707–708.CrossRefPubMedGoogle Scholar
  30. 30.
    Landau K, Winterkorn JM, Mailloux LU, et al.: 24 hour blood pressure monitoring in patients with anterior ischemic optic neuropathy. Arch Ophthalmol 1996, 114(5):570–575.PubMedGoogle Scholar
  31. 31.
    Kajiwara K, Tsubota K, Hara Y: High dose urokinase thrombolysis and stellate ganglion block for anterior ischemic neuropathy. Fola Ophthalmol Jpn 1990, 41(1):59–64.Google Scholar
  32. 32.
    Botelho PJ, Johnson LN, Arnold AC: The effect of aspirin on the visual outcome of nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 1996, 121(4):450–451.PubMedGoogle Scholar
  33. 33.
    Kupersmith MJ, Frohman L, Sanderson M, et al.: Aspirin reduces the incidence of second eye NAION: a retrospective study. J Neuroophthalmol 1997, 17(4):250–253.PubMedGoogle Scholar
  34. 34.
    Salomon O, Huna-Baron R, Steinberg DM, et al.: Role of aspirin in reducing the frequency of second eye involvement in patients with non-arteritic anterior ischaemic optic neuropathy. Eye 1999, 13(Pt 3a):357–359.PubMedGoogle Scholar
  35. 35.
    Beck RW, Hayreh SS, Podhajsky PA, et al.: Aspirin therapy in nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 1997, 123(2):212–217.PubMedGoogle Scholar
  36. 36.••
    Lee AG, Biousse V: Should steroids be offered to patients with nonarteritic anterior ischemic optic neuropathy? J Neuroophthalmol 2010, 30(2):193–198.PubMedGoogle Scholar
  37. 37.••
    Biousse V, Bruce BB, Newman NJ: Author’s response. Surv Ophthalmol 2010, 55(4):400–401.CrossRefGoogle Scholar
  38. 38.••
    Hayreh SS: Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy. Surv Ophthalmol 2010, 55(4):399–400.CrossRefPubMedGoogle Scholar
  39. 39.
    Kaderli B, Avci R, Yucel A, et al.: Intravitreal triamcinolone improves recovery of visual acuity in nonarteritic anterior ischemic optic neuropathy. J Neuroophthalmol 2007, 27(3):164–168.PubMedGoogle Scholar
  40. 40.
    Yaman A, Selver OB, Saatci AO, Soylev MF: Intravitreal triamcinolone acetonide injection for acute non-arteritic anterior ischaemic optic neuropathy. Clin Exp Optom 2008, 91(6):561–564.CrossRefPubMedGoogle Scholar
  41. 41.
    Sohn BJ, Chun BY, Kwon JY: The effect of an intravitreal triamcinilone acetonide injection for acute nonarteritic anterior ischemic optic neuropathy. Korean J Ophthalmol 2009, 23:59–61.CrossRefPubMedGoogle Scholar
  42. 42.
    Ischemic Optic Neuropathy Decompression Trial Research Group: Characteristics of patients with non-arteritic anterior ischemic optic neuropathy eligible for the Ischemic Optic Neuropathy Decompression Trial. Arch Ophthalmol 1996, 114(11):1366–1374.Google Scholar
  43. 43.
    Scherer RW, Feldon SE, Levin L, et al.: Visual fields at followup in the Ischemic Optic Neuropathy Decompression Trial: evaluation in change of pattern defect and severity over time. Ophthalmol 2008, 115(10):1809–1817.CrossRefGoogle Scholar
  44. 44.
    Stelmack JA, Tang XC, Reda DJ, et al.: Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol 2008, 126(5):608–617.CrossRefPubMedGoogle Scholar
  45. 45.
    Jung CS, Bruce B, Newman NJ, et al.: Visual function in anterior ischemic optic neuropathy: Effect of vision restoration therapy—a pilot study. J Neurol Sci 2008, 268(1–2):145–149.CrossRefPubMedGoogle Scholar
  46. 46.
    Newman NJ, Scherer R, Langenberg P, et al.: Ischemic Optic Neuropathy Decompression Trial Research Group: The fellow eye in NAION: report from the Ischemic Optic Neuropathy Decompression Trial follow-up study. Am J Ophthalmol 2002, 134(3):317–328.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Royal University HospitalSaskatoonCanada

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