Ischaemic Optic Neuropathy

1. ISCHAEMIC OPTIC NEUROPATHY
HAYREH, S. S. (2009). ISCHEMIC OPTIC NEUROPATHY. PROGRESS IN RETINAL AND EYE
RESEARCH, 28(1), 34-62.
Ade Wijaya, MD – December 2017

2. INTRODUCTION
 One of the major causes of blindness or seriously
impaired vision among the middle-aged or elderly
population
 The term ION first used at 1974
 Anterior vs posterior
 Most common: NA-AION

3. ANATOMY (VASCULARIZATION)
• Posterior ciliary
artery (PCA)
• Non-arteritic vs
arteritic
AION
• Multiple sources
non-PCA
PION

4. ANATOMY

5. FACTORS INFLUENCING THE BLOOD FLOW IN
THE OPTIC NERVE HEAD
 Blood flow
 Autoregulation
 Arterial blood pressure
 Intraocular pressure

6. NON-ARTERITIC
ISCHAEMIC OPTIC NEUROPATHY
(NA-ION)

7. PATHOGENESIS
 Due to transient non-perfusion or hypoperfusion of
the ONH circulation.  most common
 Due to embolic lesions of the arteries/arterioles
feeding the ONH.

8. PATHOGENESIS
Optic nerve
ischaemia /
hypoxia
Axoplasmic flow
stasis in the
optic nerve
fibers
Axonal swelling
Asymtopmatic
optic disc
edema
compression of
the intervening
capillaries
when there is no cup or
only a small cup, the
swollen axons are
crowded in a restricted
space in
the optic disc

9. RISK FACTORS
 Predisposing
- systemic
- ocular
 Precipitating  nocturnal arterial hypotension
 Drugs: phosphodiesterase inhibitors, amidarone
 Familial

10. SYSTEMIC PREDISPOSING RISK FACTORS
 Arterial hypertension
 Nocturnal arterial
hypotension,
 Diabetes mellitus
 Ischemic heart disease
 Hyperlipidemia
 Atherosclerosis
 Arteriosclerosis
 Sleep apnea
 Embolism
 Migraine
 Defective
cardiovascular
autoregulation
 Type A personality
 Carotid dissection

11. OCULAR PREDISPOSING RISK FACTORS
 Absent or small cup in the optic disc
 Raised IOP
 Optic disc edema
 Location of the watershed zone of the PCAs in
relation to the optic disc
 Vascular disorders
 Optic disc drusen
 Cataract extraction

12. HISTOPATHOLOGY

13. EPIDEMIOLOGY
 Incidence: 2.30 – 10,20 per 100,000 population >
50 years old in the US
 White > black or hispanic
 Middle-aged / elderly
 Men > women

14. SIGNS & SYMPTOMS
 Sudden painless deterioration of vision
 Usually discovered on waking in the morning
 Visual field defects
 Photophobia
 Normal visual acuity doesn’t rule out NA-ION
 Might have improvement up to 6 months
 RAPD
 Acute: disc edema ; Chronic: disc pallor
 Simultaneous bilateral onset of NA-AION is
extremely rare, except in patients who develop
sudden, severe arterial hypotension, e.g. during
hemodi-alysis or surgical shock.

15. MANAGEMENT
 Optic nerve sheath decompression.
 Aspirin
 Systemic corticosteroid therapy
 Intravitreal triamcynolone
 Intravitreal bevacizumab
 Reduction risk factors

16. ARTERITIC
ISCHAEMIC OPTIC NEUROPATHY
(A-ION)

17. PATHOGENESIS
 Causes: mostly GCA, other types of vasculitis, e.g.,
polyarteritis nodosa, systemic lupus erythematosus,
and herpes zoster.
 T-cells dependent disease affecting PCA
 Genetic predisposition  caucasians
 Late middle-aged and elderly

18. SIGNS & SYMPTOMS
 Amaurosis fugax
 Visual loss
 Visual field defects
 GCA symptoms
 Extraocular motility disorders
 RPD
 Optic disc changes. ODE, compared to NA-AION,
usually has a diagnostic appearance in A-AION, i.e.
chalky white color
 High ESR and CRP

19. OPTIC DISC APPEARANCES
 Chalky white color
 Retinal cotton wool spots
 CRAO
 Cilioretinal artery occlusion
 Choroidal ischaemic lesions
 Ocular ischaemia

20. MANAGEMENT
 Management of A-AION is actually management of
GCA
 Prime medical emergency
 STEROID!

22. POSTERIOR
ISCHAEMIC OPTIC NEUROPATHY
(PION)

23. INTRODUCTION
 First described by Hayreh at 1981
 Much less common than AION
 A diagnosis of exclusion
 Classification: non-arteritic, arteritic, surgical
 Middle-age / elderly
 Women > men
 Clinical manifestation similar to AION with normal
funduscopic appearance
 In surgical PION  symptoms bilateral

24. DIAGNOSIS
 Sudden onset of visual deterioration with or without
deterioration of central visual acuity
 Optic nerve related visual field defects
 RAPD
 Normal fundus
 No other ocular, orbital or neurological abnormality
to explain the visual loss;
 Development of optic disc pallor, usually within 6–8
weeks
 Surgical PION: dramatic visual loss noticed as soon
as the patient is alert enough after a major surgical
procedure

25. MANAGEMENT & PROGNOSIS
 Similar to AION
 Prognosis:
- NA PION  good with steroid
- A PION  steroid could prevent further visual
deterioration
- Surgical PION  poor prognosis

26. SUMMARY
 Spectrum of several type of condition with its own
etiology, pathogenesis, and management
 Could cause blindness or severe visual impairment
 Therapy during early stage of the diseases might
be beneficial

27. THANK YOU