Bilateral Nonarteritic Anterior Ischemic Optic Neuropathy Research Articles

1002 Bilateral Nonarteritic Anterior Ischemic Optic Neuropathy (NAION) in a Patient with Obstructive Sleep Apnea (OSA)

Abstract Introduction Nonarteritic Anterior Ischemic Optic Neuropathy (NAION) is an ischemic insult to the anterior portion of the optic nerve with unclear etiology. Several small sized studies and case reports have demonstrated association between OSA and NAION. In this case, we present a patient with bilateral NAION who was later diagnosed with OSA which may signify this important clinical association. Report of case(s) A 57-year-old man with history of hypertension, presented to the ophthalmology clinic for sudden painless decreased visual acuity of the right eye for one-month duration. He had no history of head trauma or other neurological deficits on his initial presentation. He reported having “bad vision” in his left eye for the entire of his life. Funduscopic evaluation revealed bilateral optic disc edema more in the left eye. Laboratory workup including CBC, CMP and HbA1C were within normal limits. Brain MRI showed only mild nonspecific scattered subcortical and deep periventricular hyperintensities suggestive of chronic small vessel ischemic disease and no acute infarct or masses. MRI of the orbits was normal. A diagnosis of bilateral Nonarteritic Anterior Ischemic Optic Neuropathy (NAION) was highly suggested based on the clinical history and examination findings. A referral to a sleep clinic was made to evaluate for possible sleep apnea. A polysomnogram confirmed obstructive sleep apnea with AHI of 7.2/h, REM AHI of 7.7/h and supine AHI 14.9/h. Nocturnal hypoxemia associated with the respiratory events with time of O2 saturation < 88% for 29 minutes. Patient was referred for a titration study to determine the appropriate PAP pressure to treat his sleep disordered breathing. Conclusion This case adds to the current evolving evidence of the link between OSA with NAION. It signifies the importance of having an index of suspicion, among both sleep specialists and ophthalmologists, to recognize patients who may have one of the conditions and consider screening for the other, which may lead to earlier diagnosis and improved outcomes. Support (if any)

Sildenafil (Viagra) as a Possible Culprit for Vision Loss

Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION) is the most common clinical presentation of acute ischemic damage to the optic nerve. In this case report, we are presenting a patient with bilateral sequential NAION who had a history of blood clothing disorders and found to have NAION in the second eye immediately after use of Sildenafil for erectile dysfunction.

Risk Factors for Fellow Eye Involvement in Nonarteritic Anterior Ischemic Optic Neuropathy.

Nonarteritic anterior ischemic optic neuropathy (NAION) is the most common acute optic neuropathy in individuals older than 50 years. Demographic, ocular, and systemic risk factors for NAION have been identified, and we sought to determine which, if any, of these factors also increase risk of NAION in the fellow eye. We performed a retrospective chart review of patients with "ischemic optic neuropathy" (based on International Classification of Disease [ICD] codes) seen at a single eye center between 2007 and 2017. Patients who met diagnostic criteria for unilateral NAION without fellow eye optic neuropathy at diagnosis were included. Demographic information, ocular comorbidities, and systemic diagnoses were recorded, in addition to whether the fellow eye developed NAION during the follow-up period. Univariate and multivariate Cox proportional hazard regression were used to calculate hazard ratios (HRs) for fellow eye involvement. Three hundred eighteen patients were identified by ICD codes, and 119 were included in the study. Twenty-nine (24%) patients developed NAION in the fellow eye over the mean follow-up period of 3.6 years (range: 1 month-11 years). Significant risk factors for fellow eye NAION included the presence of bilateral optic disc drusen (ODD, HR 2.78, 95% confidence interval [CI] 1.12-6.90, P = 0.02) and noncompliance with continuous positive airway pressure (CPAP) in patients with moderate-to-severe obstructive sleep apnea (HR 4.50, 95% CI 1.79-11.3, P = 0.0015). Bilateral ODD and noncompliance with CPAP when indicated are associated with increased risk of NAION in the fellow eye. Patients with these risk factors should be counseled on the potentially devastating visual consequences of bilateral NAION, and compliance with CPAP should be stressed when appropriate.

Visual outcome following bilateral non-arteritic anterior ischemic optic neuropathy: a systematic review and meta-analysis

BackgroundMany patients who suffer unilateral non-arteritic anterior ischemic optic neuropathy (NAION) will eventually develop the same condition in their other eye, worrying them about losing vision in both eyes. The purpose of this meta-analysis is to determine whether it is possible to predict the visual outcome of the consecutive NAION event based on initial presentation and to compare mean visual loss of firstly versus secondly affected eyes.MethodsA systematic review and meta-analysis of studies published between January 1st 1966 and May 31st 2016 reporting on visual acuity and/or visual field loss of both affected eyes, measured either at presentation or follow-up following bilateral NAION.ResultsTen studies were included in the meta- analysis of visual acuity, including 9 retrospective reports and one randomized clinical trial, and five retrospective studies were included in visual field meta-analysis. A significant correlation exists for visual acuity (R = 0.387, P < 0.001) in both eyes of the same patient following bilateral NAION, and also for visual field loss (R = 0.445, P < 0.001) in the two eyes. The calculated coefficient of determination (R2) of 0.149 for visual acuity, and 0.198 for visual field loss indicates that for any given individual suffering from unilateral NAION only 15% of visual acuity and 20% of visual field loss in the secondly affected eye can be explained by these outcomes in the first eye. In addition, there was no difference in mean visual outcome of the first versus second NAION events (standardized mean differences of visual acuity 0.008, P = 0.890; and visual field loss, −0.019, P = 0.819).ConclusionEven though a weak connection exists between visual outcome in both eyes following bilateral NAION it is still impossible to predict with certainty the visual outcome of a sequential contralateral NAION event based on the severity of visual loss in the first affected eye. Measures often taken after the first event are ineffective in improving the visual outcome of a second event should it occur.

Clinical profile and risk factors of non-arteritic anterior ischemic optic neuropathy

Objective To observe the clinical profile and risk factors of non-arteritic anterior ischemic optic neuropathy (NAION). Methods Prospective study was conducted to consecutively recruit 73 patients with NAION from October 2013 through September 2015. A detailed history of previous systemic diseases, smoking and drinking was collected, and a comprehensive ophthalmic evaluation was performed. The prevalence of associated risk factors in NAION patients were compared to the 146 age- and gender-matched normal subjects, and assessed in logistic regression model. Results Of the 73 patients, 65.75% were males, 34.25% were females. The mean age was (55.18±9.89) years. 21.92% were bilateral and 78.08% were unilateral. Arcuate visual field defect (31.58%) was the most prevalent defect detected in unilateral NAION, and there were 8.93% fellow eyes with abnormal optic disc formation in incipient stage. Concentric visual field contraction (40.63%) was the most common in bilateral NAION. Obesity (OR=8.09, 95% CI: 2.94 - 22.23, P<0.001) and diabetes (OR=4.72, 95% CI: 1.57 - 14.25, P=0.006) were significantly associated with NAION. While smoking was marginally associated with NAION (OR=2.76, 95% CI: 1.02 - 7.53, P=0.047). Conclusions The gender predisposition should be reconsidered in NAION. We should pay attention to the fellow eye in case of the incipient NAION patients. Diabetes and obesity are associated with NAION. Key words: Optic neuropathy, ischemic/etiology; Risk factors

Commentary.

Except for the Ischemic Optic Neuropathy Decompression Trial (IONDT), recent attempts at developing prospective controlled treatment trials in acute nonarteritic anterior ischemic optic neuropathy (NAION) have failed because of the extreme difficulty in recruiting NAION patients within a few hours of visual loss.[1] Recent reviews have emphasized that many proposed therapies for NAION have been inadequately studied. In addition, most published studies have used treatment windows much too long to demonstrate any major benefit of any treatment in acute NAION.[12] As discussed in this controversy, the only potential treatment that may be considered in acute NAION is oral prednisone. The rationale for the use of steroids in NAION is based on a study from the late 1960's, which postulated that treatment of NAION with steroids would reduce capillary permeability, thereby inducing faster resolution of disc edema.[3] This, in turn, presumably reduces compression of capillaries in the optic nerve head and improves blood flow, restoring the function of surviving, but nonfunctioning, ischemic axons. However, there is no evidence that decreasing the duration of disc edema directly improves visual outcome of patients with NAION.[2] The study published by Hayreh and Zimmerman in 2008[4] on the treatment of a large cohort of NAION patients with oral prednisone has generated a vivid debate regarding the treatment of acute NAION. In the Hayreh and Zimmerman study,[4] 312 patients voluntarily opted for oral prednisone and 301 patients elected not to be treated. The authors suggested that early treatment of NAION with prednisone 80 mg improved visual acuity and visual field more than in the untreated group.[4] However, because the patients were not randomized, the untreated group had more vascular risk factors, including diabetes, suggesting possible bias from unmeasured health factors related to self-selection for treatment, making it difficult to interpret the results of this study. A subsequent small nonrandomized controlled case series comparing 27 control NAION patients with 10 acute NAION patients treated with 80 mg of daily prenisolone for 2 weeks, showed opposite results.[5] No significant change was found in visual acuity, visual fields, and retinal nerve fiber layer thickness measured with optical coherence tomography at 6 months. More importantly, the study was halted early due to the higher rate of complications in the group treated with oral steroids. Given the paucity of data regarding the exact pathophysiology of NAION and its treatment, the maxim “first, do no harm” describes the first tenet in the management of this devastating optic neuropathy. I believe that we should not systematically recommend oral steroids to patients with acute NAION; oral prednisone should only be considered in selected patients without vascular risk factors, who have persistent disc edema, or unusual progressive worsening of vision over more than 2-3 weeks, or those with bilateral NAION or sequential NAION with poor outcome in the first eye.

Bilateral Nonarteritic Anterior Ischemic Optic Neuropathy

In patients with bilateral sequential nonarteritic anterior ischemic optic neuropathy (NA-AION), previous studies have reported conflicting results on whether or not the visual outcome is similar in the 2 eyes. The authors investigated this issue in 174 consecutive patients with bilateral NA-AION. At the first visit, all patients had a detailed ophthalmic and medical history and comprehensive ophthalmic evaluation. Visual evaluation was performed by recording Snellen visual acuity and visual fields with kinetic perimetry. The same ophthalmic evaluation was performed at each follow-up visit. The data on the difference in visual acuity, which was converted to logarithm of the minimum angle of resolution (logMAR) form, and visual field defects between the first eye and the second eye of each patient at the initial visit and at the final follow-up were analyzed. A similar subgroup analysis was performed on patients treated with systemic corticosteroids. At presentation, both initial visual acuity and visual field defects were significantly better in the second eye than in the first eye (P < 0.0001). As a predictor of initial visual acuity in the second eye, the initial logMAR of the first eye only explained 7.0% (R2) of the total variation in the initial logMAR of the second eye. Intraclass correlation (ICC) between the paired eyes was 0.19 (95% confidence interval [CI], 0.04-0.33), indicating poor agreement. The absolute difference in initial visual field grade between the 2 eyes was 0.5 or greater in 78%. The weighted kappa statistic for agreement between visual field defects of the 2 eyes was 0.27 (95% CI, 0.19-0.36), indicating poor agreement. At the final follow-up, a difference in logMAR of at least 0.3 between the paired eyes was found in 38% of the steroid-treated group and 45% of the untreated group. For visual field grade, there was a difference of at least 0.5 in 70% of those who were treated with steroid and in 76% of those not treated. The ICC for logMAR and weighted kappa for visual field grade for the paired eyes was below 0.60 for both the groups. The findings indicated poor agreement between the 2 eyes. The results show that in patients with bilateral sequential NA-AION, there are large differences between the visual acuity and visual field findings of paired eyes at initial and final visit, whether or not treated with steroids. It is not possible to predict the visual acuity and visual field grade in the second eye based solely on the first eye.

Sequential, non-arteritic anterior ischemic optic neuropathy in patients taking sildenafil: a report of ten cases

Aim/purposeTo present a summary of 10 cases of non-arteritic anterior ischemic optic neuropathy (NAION) in patients who received phosphodiesterase type 5 (PDE-5) inhibitors. MethodsA case series of 10 patients who, after regular intake of Sildenafil, presented with a first episode of NAION in one eye. NAION was diagnosed based on the following criteria: acute, painless, unilateral loss of vision, fundus features consistent with NAION and exclusion of other possible causes. ResultsDespite the initial adverse event (first episode of NAION), all of these patients continued to use the medication and developed a second episode of NAION in the contralateral eye. Only one of the 10 patients presented with bilateral simultaneous NAION. ConclusionThis largest case series published to date, reinforces the general consensus that PDE-5 inhibitors are contraindicated in patients with a history of unilateral NAION.

Bilateral non‐arteritic ischemic optic neuropathy due to excessive use of transdermal estrogen by transgender patient

AbstractPurpose Nonarteritic anterior ischemic optic neuropathy (NAION) is a common, visually disabling disease. It is usually due to a hypotensive perfusion insufficiency leading to infarction of the optic nerve. Only very rarely, NAION has a thromboembolic etiology. A transgender patient with a sequential bilateral NAION related to excessive use of transdermal estrogen is described.Methods A 44 year‐old male to female transgender patient developed acute painless visual loss in the right eye (RE) followed by the left eye (LE) 2 months later. She underwent a full ophthalmic exam and an extensive etiological work‐up.Results Visual acuity (VA) dropped to perception of light in the RE and, 2 months later, to 3/10 in the left eye. Fundoscopy showed a swollen disc in both eyes in the acute phase, which evolved into pallor later. CT‐brain revealed old ischemic areas unrelated to VA loss. A diagnosis of bilateral sequential NAION was made. Predisposing risk factors, though both well controlled, were diabetes and arterial hypertension. Thrombophilia screening and cardiac work‐up were negative. When estrogen levels of 60 times the normal value were measured, the patient admitted to overdose with transdermal estrogen to enhance her female characteristics. Such high estrogen levels are very thrombogenic. It is highly likely that it caused the cerebrovascular accidents and also triggered the bilateral sequential NAION.Conclusion NAION only rarely has a thromboembolic etiology. However, careful history taking is warranted to exclude modifiable risk factors in the poorly treatable NAION to prevent affection of the second eye and/or the central nervous system.

Bilateral Sequential Nonarteritic Anterior Ischemic Optic Neuropathy

To better define the concordance of visual loss in patients with nonarteritic anterior ischemic optic neuropathy (NAION). The medical records of 86 patients with bilateral sequential NAION were reviewed retrospectively, and visual function was assessed using visual acuity, Goldmann visual fields, color vision, and relative afferent papillary defect. A quantitative total visual field score and score per quadrant were analyzed for each eye using the numerical Goldmann visual field scoring method. Outcome measures were visual acuity, visual field, color vision, and relative afferent papillary defect. A statistically significant correlation was found between fellow eyes for multiple parameters, including logMAR visual acuity (P=.01), global visual field (P<.001), superior visual field (P<.001), and inferior visual field (P<.001). The mean deviation of total (P<.001) and pattern (P<.001) deviation analyses was significantly less between fellow eyes than between first and second eyes of different patients. Visual function between fellow eyes showed a fair to moderate correlation that was statistically significant. The pattern of vision loss was also more similar in fellow eyes than between eyes of different patients. These results may help allow better prediction of visual outcome for the second eye in patients with NAION.

Optic nerve head change in non-arteritic anterior ischemic optic neuropathy and its influence on visual outcome.

PurposeTo evaluate changes in cup/disc (C/D) diameter ratios and parapapillary atrophy in patients with non-arteritic anterior ischemic optic neuropathy (NA-AION), using morphometric methods.MethodsThe clinical non-interventional study included 157 patients with unilateral or bilateral NA-AION. Optic disc photographs taken from both eyes at the end of follow-up were morphometrically examined.ResultsFollow-up was 86.3±70.3 months. Horizontal and vertical disc diameters (P = 0.30;P = 0.61, respectively), horizontal and vertical C/D ratios (P = 0.47;P = 0.19,resp.), and size of alpha zone and beta zone of parapapillary atrophy (P = 0.27;P = 0.32,resp.) did not differ significantly between affected eyes and contralateral normal eyes in patients with unilateral NA-AION. Similarly, horizontal and vertical disc diameters, horizontal and vertical C/D ratios, and size of alpha zone and beta zone did not vary significantly (all P>0.05) between the unaffected eyes of patients with unilateral NA-AION and the eyes of patients with bilateral NA-AION. Optic disc diameters, C/D ratios, size of alpha zone or beta zone of parapapillary atrophy were not significantly associated with final visual outcome in the eyes affected with NA-AION (all P>0.20) nor with the difference in final visual acuity between affected eyes and unaffected eyes in patients with unilateral NA-AION (all P>0.25).ConclusionsNA-AION did not affect C/D ratios nor alpha zone and beta zone of parapapillary atrophy. Optic disc size was not related to the final visual acuity outcome in NA-AION.

Bilateral Simultaneous Nonarteritic Anterior Ischemic Optic Neuropathy after Ingestion of Sildenafil for Erectile Dysfunction

Purpose. To describe a patient who developed bilateral, simultaneous nonarteritic anterior ischemic optic neuropathy (NAION) after ingestion of Sildenafil citrate (Viagra) for erectile dysfunction. Methods. Observational case report. Results. A 60-year-old diabetic man noted sudden decrease of vision in both eyes 16 hours after his third consecutive 50 mg daily Sildenafil ingestion. A diagnosis of bilateral NAION was made and he was treated for three days with methylprednisolone 1 g/d intravenously, followed by oral prednisone 75 mg/d. Final visual acuity was 20/50 right eye (OD) and 20/20 left eye (OS). He had preexisting diabetes. Conclusion. This is the first reported case of simultaneous bilateral NAION occurred in a diabetic patient early after Sildenafil intake. Patients with predisposing conditions such as diabetes have to be warned against the use of PDE inhibitors.

A case of nonarteritic anterior ischemic optic neuropathy of a male with family history of the disease after receiving sildenafil

A 51-year-old male was referred to the University Eye Clinic of Ioannina with nonarteritic anterior ischemic optic neuropathy (NAION) 12 hours after receiving sildenafil citrate (Viagra®). Examination for possible risk factors revealed mild hypercholesterolemia. Family history showed that his father had suffered from bilateral NAION. Although a cause-and-effect relationship is difficult to prove, there are reports indicating an association between the use of erectile dysfunction agents and the development of NAION. Physicians might need to investigate the presence of family history of NAION among systemic or vascular predisposing risk factors before prescribing erectile dysfunction drugs.

Pegylated Interferon Alpha-Associated Optic Neuropathy

A 52-year-old man with chronic hepatitis C presented with painless, bilateral, simultaneous nonarteritic anterior ischemic optic neuropathy (NAION) and peripheral neuropathy. Symptoms began 19 weeks after starting peginterferon alpha-2a. The peripheral neuropathy and vision of the right eye improved, but the vision of the left eye worsened after stopping interferon. We identified 23 additional cases of NAION during interferon alpha therapy. At least 12 of these patients suffered bilateral NAION. Patients lost vision 1-40 weeks after initiating therapy. Of 21 eyes that had documented initial and follow-up acuities, 8 improved, 1 worsened, and the rest remained stable. One patient had a painful peripheral neuropathy. Treatment with interferon alpha may result in NAION. Discontinuation of therapy deserves consideration after weighing individual risks and benefits.

Stepwise Decline in Visual Field After Serial Sildenafil Use

Stepwise Decline in Visual Field After Serial Sildenafil Use

Nonarteritic anterior ischemic optic neuropathy in patients with sleep apnea while being treated with continuous positive airway pressure

To report three cases of nonarteritic anterior ischemic optic neuropathy (NAION) that occurred in patients with sleep apnea syndrome (SAS) while being treated with continuous positive airway pressure (CPAP). A prospective, noncomparative case series. Prospective review of 108 patients with NAION diagnosed between 2002 and 2003 to identify any patients who developed NAION while being treated for SAS with CPAP. One patient had bilateral sequential NAION and two patients had unilateral NAION despite treatment with CPAP for SAS. All the patients were being treated with CPAP for a period ranging from 4 months to 6 years before the onset of NAION. In this series, CPAP did not prevent the development of NAION in SAS patients. Larger observational studies are needed to study the benefit of CPAP in preventing NAION in patients with SAS.

Confocal Scanning Laser Ophthalmoscopy of Eyes with Nonarteritic Anterior Ischemic Optic Neuropathy

Purpose: To evaluate optic nerve head topography in patients with nonarteritic anterior ischemic optic neuropathy (NAION) using confocal scanning laser ophthalmoscopy. Methods: Both eyes of patients with NAION were imaged using a Heidelberg retina tomograph (HRT II; version 1.5) several months after initial presentation, when the optic disc edema had settled. Data from the stereometric analysis of optic nerve heads of eyes with NAION were compared to those of fellow eyes without NAION and eyes of an age- and sex-matched control group. Stereometric parameter values of the fellow eyes were compared with those of the control group. Results: Average age of the 23 Caucasian patients was 57.96 ± 10.41 years (range: 28–71 years). Seven patients (30%) were female and 16 (70%) were male. Four patients (17%) had bilateral NAION. Cup area, cup volume, cup/disc area, linear cup/disc area, mean cup depth, maximum cup depth, mean retinal nerve fiber layer (RNFL) thickness, and RNFL cross-sectional area values were smaller in the NAION eyes than in the control eyes (p < 0.05). A comparison of the NAION eyes with their fellow eyes revealed lower mean cup depth, maximum cup depth, mean RNFL thickness, and RNFL cross-sectional area in the diseased eyes (p < 0.05). Moreover, cup area, cup volume, cup/disc area, linear cup/disc area, mean cup depth, maximum cup depth values were smaller in the fellow eyes than the control eyes (p < 0.05). Conclusion: Using an objective imaging method, confocal scanning laser ophthalmoscopy, eyes with NAION were shown to have a smaller cup volume and cup/disc area, but not a smaller optic disc area than control eyes.

Visual Outcome in Bilateral Nonarteritic Anterior Ischemic Optic Neuropathy

Nonarteritic anterior ischemic optic neuropathy (NAION) is a common cause of visual loss in the older population. Bilateral NAION is a well-documented entity; however, no study to date has compared the visual outcome between affected eyes. The authors retrospectively reviewed the charts of 99 patients with diagnoses of NAION over 3 1/2 years. In the 23 patients with bilateral involvement, 16 were included in the study for analysis of final visual outcome between affected eyes. Snellen acuity, Ishihara color plates, and Humphrey automated perimetry were evaluated as the parameters of visual function. Descriptive analysis of the outcome between affected eyes for each parameter is presented as a frequency distribution of pre-defined groups. Statistical significance is established using nonparametric tests. Bilateral NAION was found in 23% (23/99) of the patients studied. The authors identified a high percent agreement between eyes with regard to visual acuity (81% within 3 Snellen lines), color vision (69% within 3 plates), and Humphrey visual field (75% within 5 decibels of mean deviation). Additionally, there was a statistically significant correlation between affected eyes for all three visual parameters: visual acuity (P = 0.043), color vision (P = 0.001), and Humphrey visual field (P = 0.039). The authors found a high percent agreement and statistically significant correlation in final outcome between affected eyes of patients with bilateral NAION for visual acuity, color vision, and visual field loss. With a larger series, it may be possible to predict the visual outcome of the second affected eye based on the parameters of the first eye.