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Ischemic optic neuropathy

 
, medical expert
Last reviewed: 05.07.2025
 
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Ischemic optic neuropathy is an infarction of the optic nerve head. The only symptom is painless loss of vision. The diagnosis is clinical. Treatment is ineffective.

There are two types of optic nerve infarction: non-arteritic and arteritic. The non-arteritic form is more common and typically affects people aged 50 to 70; vision loss tends to be less severe than in the arteritic form, which typically occurs in patients over 70.

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What causes ischemic optic neuropathy?

Most cases of ischemic optic neuropathy are unilateral. Bilateral sequential disease occurs in 20% of cases, but bilateral simultaneous involvement is rare. Atherosclerotic narrowing of the posterior ciliary vessels, especially after an episode of hypotension, may contribute to nonarteritic optic infarction. Any inflammatory arteritis, especially temporal arteritis (see p. 374), may cause the arteritic form. The importance of recognizing the arteritic form is not so that anything can be done to improve the affected eye, but rather to initiate preventive treatment of the other eye.

Acute ischemia causes swelling of the nerve, which further worsens the ischemia. Small disc excavation is a risk factor for the development of nonarteritic ischemic optic neuropathy. There is usually no obvious medical condition that causes the nonarteritic variety, although some patients have diabetes and hypertension, which are thought to be risk factors. Vision loss on awakening leads investigators to suspect postural hypotension as a potential cause of the nonarteritic variant.

Symptoms of ischemic optic neuropathy

Vision loss in both types is usually sudden and painless. Some patients notice vision loss upon awakening. Symptoms of temporal arteritis may include general malaise, muscle pain, headache over the temple, and difficulty moving the jaw, but these symptoms may not occur until vision loss occurs. Visual acuity is reduced, and there is an afferent pupillary reflex. The optic disc is swollen, with surrounding hemorrhages.

Diagnosis of ischemic optic neuropathy

Visual field examination often reveals a defect in the inferior or central visual field. The ESR is usually markedly elevated in the arteritic variant and normal in the nonarteritic form. C-reactive protein is also a useful test. If temporal arteritis is suspected, a temporal artery biopsy should be performed. In selected cases of progressive visual loss, CT or MRI should be performed to exclude widespread lesions. The most important aspect of the evaluation is to exclude the arteritic variant, since the other eye is at risk unless treatment is started quickly.

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Treatment of ischemic optic neuropathy

There is no effective treatment, and vision is not restored in most cases; however, in the nonarteritic form, some degree of vision is spontaneously restored in 30% of patients. The arteritic form is treated with oral glucocorticoids (prednisolone 80 mg/day) to prevent disease in the other eye. Treatment should be delayed pending biopsy results. Treatment of the nonarteritic form with aspirin or glucocorticoids is of no benefit. Low vision aids may be helpful.

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