Anterior ischemic optic neuropathy (AION) Most common over 50 years Painless monocular over hours to days Visual acuity Visual field APD

AION Arteritic AION is associated with giant cell arteries (GCA) Nonarteritic AION

AAION Is less frequent 5-10% Older patients (mean 70yr) Inflammatory and thrombotic occlusion post. Cilliary artery Systemic symptoms

Systemic Findings of GCA Are usually present  Headache, temporal and scalp tenderness  Jaw claudication  Malaise, anorexia, weight loss, fever, joint & muscle pain  Ear pain

AAION Sever visual loss Pale edema Cotton wool spot F.A. delayed choroidal filling Normal cup.

Treating AAION Immediate therapy is critical Temporal artery biopsy may delayed treat IV prednisolone 1 g/day for 3-5 days Then oral prednisolone 100 mg/day tapered 3-12 month or more

Major Goals of Therapy Prevent contralateral visual loss Fellow eye involved 95% days or weeks Affected eye improve somewhat Avoid systemic vascular complication Risk of recurrence is 7% so tapering must be slow and careful

Nonarteritic Anterior ISchemic Optic Neuropathy (NAION) More common 90-95% of AION In younger age groups (mean age 60yr) Related to optic disc microcirculation On awakening, noctural systemic Hypotension Systemic symptoms are absent

NAION V.A. > 20/200 in over 60% of cases Palor is less common Optic disk in other eye is small and small or absent cup. 5 yr risk of other eye is 14.7% (psued- foster kennedy syd)

Risk Factors of NAION Crowding of disk (disk at risk) Systemic hypertension Diabetes (young) Smoking, hyperlipidemia Hyperhomocysteinemia, platelet polymorphism, sleep apnea Phosphodiestrase inhibitors (sildenafil or viagra) ?? Hypotensive effect

Differential Diagnosis of NAION Optic neuritis Infiltrative optic neuropathies Anterior orbital lesion Diabetic papillopathy

<40>50Age 92%+Unusualpain APD+ Pupil CentralAltitudinalVF Edema 33% hyperemic Edema 100% pale Optic disk UnusualCommonRetinal hemorrhage No delayedDelayed disk filling F.A. enhancementNo optic nereve enhancement MRI NAIONOptic neurtis

Treatment of NAION Untreated case remain stable but recovery of 3 lines 31% after 2 years Recurrence unusual 6.4% No proven therapy surgery no benefit No proven prophylaxis Asprin reducing incidence of fellow eye is unclear

60 yrMean 70 yrAge F=MF>MSex NoneHeadache …Symptoms >20/200 60%<20/200 60%VA Small cup Hyperemic edema Normal cup pale edema Fundus Mean 20-40mm/hrMean 70mm/hrESR NormalElevatedC.R.P. 31% improved 12-19% fellow eye Rarely improved 54-95% fellow eye Natural history None provenSystemic steroidstreatment summary