Clinical presentation of ischemic optic neuropathies

ABSTRACT

Introduction

Ischemic optic neuropathies (IONs) are the leading cause of sudden, permanent optic nerve-related visual loss.

Areas covered

There are three types of anterior and posterior (retrobulbar) IONs: nonarteritic, perioperative, and arteritic. In this review, we discuss the clinical manifestations, management, and prognoses – visual and systemic – of each type. A literature search was conducted via MEDLINE (PubMed) 1 January 1973 to 1 April 2023.

Expert opinion

There is no consistently beneficial treatment for the nonarteritic IONs. Patients who have experienced either spontaneous nonarteritic anterior ION (NAION) or an acute optic neuropathy following uncomplicated cataract surgery should be warned that they may have an increased risk of a similar event in their fellow eye if they undergo cataract surgery in that eye. Early recognition of perioperative ION after non-ocular surgery is crucial so that anemia and hypotension can be corrected as soon as possible, hopefully resulting in visual improvement. Finally, arteritic ION requires early recognition and timely treatment with systemic corticosteroids to prevent subsequent visual loss in the fellow eye as well as the many other complications of giant cell arteritis. The interleukin-6 inhibitor tocilizumab can be used to reduce both the dose of steroids and the duration steroids are needed.

KEYWORDS:

• Ischemic optic neuropathy
• giant cell arteritis
• nonarteritic anterior ischemic optic neuropathy
• perioperative ischemic optic neuropathy
• post-cataract surgery ischemic optic neuropathy

Article highlights

• Nonarteritic ischemic optic neuropathies are the most common cause of sudden optic nerve-related visual loss in older adults.

• There is no consistently beneficial treatment for anterior or posterior nonarteritic ischemic optic neuropathy.

• An optic neuropathy consistent with nonarteritic anterior ischemic optic neuropathy can occur after apparently uncomplicated cataract surgery; patients in whom this occurs as well as patients who experience spontaneous nonarteritic ischemic optic neuropathy may have an increased risk of a similar event in the fellow eye if they undergo cataract surgery and should be warned of this possibility.

• Patients who are to undergo non-ocular surgery in which there is a potential for significant blood loss, hypotension, or both (such as prone-position spine surgery and cardiac surgery with cardiopulmonary bypass) should be warned of the possibility of permanent loss of vision in one or both eyes due to ischemic optic neuropathy.

• Patients in whom ischemic optic neuropathy occurs after non-ocular surgery should have any anemia and hypotension corrected as soon as possible.

• It is crucial to distinguish arteritic from nonarteritic ischemic optic neuropathy so that timely corticosteroid therapy can be begun for patients with arteritic ischemic optic neuropathy.

• Early treatment of unilateral arteritic ischemic optic neuropathy with corticosteroids may prevent a similar event in the fellow eye as well as other complications from the underlying systemic arteritis, most often giant cell arteritis.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.