Risk of Nonarteritic Anterior Ischemic Optic Neuropathy After Cataract Surgery.

PURPOSE: To determine whether the development of nonarteritic anterior ischemic optic neuropathy (NAION) is increased after receiving cataract surgery in a large general population. DESIGN: Nationwide, population-based, retrospective cohort study. METHODS: Setting: A 12-year nationwide, population-based, retrospective cohort study including 1,025,340 beneficiaries in the 2002-2013 Korean National Health Insurance Service database. PATIENTS: We identified 40,356 patients who had undergone cataract surgery and matched non-cataract surgery controls (1:2) using estimated propensity scores in reference to age, sex, demographics, comorbidities, and co-medications. OBSERVATIONS: Kaplan-Meier curves and Cox proportional hazard models were generated to determine the risk of developing NAION in the cataract surgery group compared to the non-cataract surgery group. MAIN OUTCOME MEASURES: Effect (hazard ratio [HR]) of cataract surgery on NAION development. RESULTS: The 10-year incidence probability of NAION was 0.70% (95% confidence interval [CI], 0.55%-0.86%) in the cataract surgery group and 0.27% (95% CI, 0.25%-0.29%) in the non-cataract surgery group (P < .0001, log-rank test). The cataract surgery group had an increased risk of developing NAION compared to the non-cataract surgery group (HR = 1.80; 95% CIs, 1.46-2.21) even after adjusting for demographics, comorbidities, Charlson comorbidity index, and co-medications. CONCLUSION: Our results suggest that patients undergoing cataract surgery have an increased risk of NAION.

Repeated intravitreal injections of antivascular endothelial growth factor in patients with neovascular age-related macular degeneration may increase the risk of ischemic optic neuropathy.

BACKGROUND: Previous case reports have demonstrated the occurrence of ischemic optic neuropathy (ION) following intravitreal injections of antivascular endothelial growth factor (anti-VEGF). However, no previous studies have investigated the impact of injection numbers on the risk of ION. The aim of our study was to investigate whether repeated intravitreal injections of anti-VEGF would increase the risk of subsequent ION in patients with neovascular age-related macular degeneration (AMD). METHODS: A population-based, retrospective cohort study using the Taiwan National Health Insurance Research Database was conducted from 2007 to 2013. Neovascular AMD patients receiving intravitreal injections of anti-VEGF during the study period were enrolled in the study cohort. Enrollees were divided into three groups according to the categorized levels of injection number (first level: < 10 times, second level: 10-15 times, and third level: > 15 times). Kaplan-Meier curves were generated to compare the cumulative hazard of subsequent ION among the three groups. Cox regression analyses were used to estimate crude and adjusted hazard ratios (HRs) for ION development with respect to the different levels of injection numbers. The confounders included for adjustment were age, sex, and comorbidities (diabetes, hypertension, hyperlipidemia, ischemic heart disease, and glaucoma). RESULTS: In total, the study cohort included 77,210 patients. Of these, 26,520, 38,010, and 12,680 were in the first-, second-, and third-level groups, respectively. The Kaplan-Meier method revealed that the cumulative hazards of ION were significantly higher in those who had a higher injection number. After adjusting for confounders, the adjusted HRs for ION in the second- and third-level groups were 1.91 (95% confidence interval [CI], 1.32-2.76) and 2.20 (95% CI, 1.42-3.43), respectively, compared with those in the first-level group. CONCLUSIONS: Among patients with neovascular AMD, those who receive a higher number of anti-VEGF injections have a significantly higher risk of developing ION compared with individuals who receive a lower number of injections.

Bilateral optic neuropathy related to severe anemia in a patient with alcoholic cirrhosis: a case report and review of the literature.

Anemia appears frequently in patients with alcoholic liver disease (ALD) but has never been linked to bilateral nonarteritic anterior ischemic optic neuropathy (NAION). A 65-year-old woman with a medical history of alcoholic cirrhosis was admitted for bilateral NAION. On admission, she was found to have a low arterial pressure and severe normocytic anemia (48 g/L). The anemia was related to chronic bleeding due to antral gastritis along with other factors associated with ALD. The applied treatment consisted of urgent transfusion followed by high doses of proton-pump inhibitors, iron and vitamin supplementation, and support in lifestyle measures. Her hemoglobin levels remained stable after 2 years but the patient still suffered from visual loss. This case highlights the link between anemia and bilateral NAION in ALD patients. The optic nerve head is prone to infarction in this context due to the vascularization characteristics of ALD. Hemoglobin levels should be monitored in ALD patients to avoid the severe complication of NAION.

Prevalence and incidence of non-arteritic anterior ischaemic optic neuropathy in South Korea: a nationwide population-based study.

AIMS: To determine the age and sex-specific prevalence and incidence of non-arteritic anterior ischaemic optic neuropathy (NAION) in South Korea. METHODS: This is a nationwide population-based study using data from the Korean national health claims database to identify patients with NAION using the registration programme database, which comprises ophthalmologist-confirmed NAION from 2011 through 2015. We evaluated prevalence and incidence rates using these data. RESULTS: Among 25 816 797 of entire population 40 years of age or older, 26 167 patients had NAION (47.8% men) during the 5-year study period. The prevalence in the general population 40 years of age or older was 102.87 (95% CI 95.22 to 110.53) per 100 000 people. In men, it was 111.10 (95% CI 101.19 to 121.02), and in women, it was 94.64 (95% CI 89.25 to 100.03) per 100 000 people. The prevalence increased with advancing age and peaked at 70-74 years in men and 65-69 years in women. The incidence in the general population 40 years of age or older was 11.35 (95% CI 10.37 to 12.33) per 100 000 person-years. In men, it was 14.89 (95% CI 12.26 to 16.91), and in women, it was 9.92 (95% CI 8.85 to 10.99) per 100 000 person-years. The incidence increased with advancing age and peaked at 80-84 years in men and 70-74 years in women. CONCLUSIONS: The prevalence and incidence estimates of NAION are comparable with those of Caucasians. These detailed estimates could promote understanding of the disease's pathophysiology and allow for appropriate planning within the healthcare system.

Bilateral non-arteritic ischemic optic neuropathy treated with HBO2 therapy: A case report of angiographic and electrodiagnostic findings.

INTRODUCTION: Non-arteritic anterior ischemic optic neuropathy (NAION) is one of the most widespread visually disabling diseases in the middle-aged and elderly population. It typically presents as acute painless unilateral vision loss in patients over 50 years of age. The fellow eye of NAION patients is often sequentially affected. Involvement of the second eye occurs within three years in approximately 45%-50% of patients. Currently there is no generally accepted treatment for NAION but a number of medical and surgical therapies have been proposed. REPORT OF A CASE: This is a case of non-contemporary bilateral non-arteritic anterior ischemic optic neuropathy (NAION) in a 66-year old woman treated with hyperbaric oxygen (HBO2) therapy after ineffective systemic corticosteroid therapy. Visual acuity (VA), visual evoked potentials (VEP) findings, perimetric examination results and angiographic images were recorded and analyzed before and after hyperbaric oxygen treatment. DISCUSSION: After several months from the optic nerve vascular injury, VA, VEP values, perimetric examination results and angiographic images revealed a very important recovery. These results maintained stable during the follow-up at about nine months. HBO2 therapy has been revealed to be a safe and efficacious adjunctive therapy, even after many months after the injury. While this case is promising, double-blind randomized controlled trials will be necessary to prove the efficacy of HBO2 in the treatment of NAION.

Combined etiology for bilateral and simultaneous optic neuropathy in a patient with ciancobalamin deficit and hepatitis C treated with peg-interferon and ribavirin.

We report the case of a 53-year-old female patient who developed bilateral sudden visual acuity loss after 15 weeks from the initiation of Peg-Interferon and Ribavirin treatment for hepatitis C. Debut was simultaneous and asymmetric, reported in the morning, at awakening. No pain or other symptom was reported by the patient. Results. At presentation, visual acuity was 0.2 in RE and 3/ 50 in LE. Pupillary reflexes were sluggish and severe dyschromatopsia was documented in both eyes (Ishihara plates). Fundus examination revealed bilateral pale optic disc edema, more prominent in LE, with splinter hemorrhages in the RNFL around the optic disk. Visual field exam demonstrated severe defects in 3 quadrants of the RE, whereas in the LE, it was impossible to perform the investigation due to VA<0.1. Neurologic evaluation was normal; other possible causes of systemic vasculitis were excluded by negative lab tests. Acute inflammatory markers (fibrinogen and ESR) and mild pancytopenia were the only documented laboratory changes in this patient. Anamnesis cleared the traditional risk factors for conventional AION (hypertension, diabetes, ischemic heart disease, and hypercholesterolemia). Cranial and orbital CT scan and MRI findings were normal. Patient was withdrawn from the Interferon and Ribavirin treatment and was administered methyl prednisolone pulse therapy (1g/ day) for 3 days, continued with oral Prednisone (60 mg/ day) tapered slowly for over 12 weeks. VA increased to 0.8 during treatment in the RE, but visual recovery in the LE was not as spectacular (0.16) as in the fellow eye. Modified latencies and amplitudes in evoked visual potentials examination during 4 months time emphasized bilateral optic atrophy. Optic nerve sufferance was amplified by a low level of vitamin B12, detected by chance at the last eye visit. Due to the general condition, dietary supplementation was not possible. Conclusion. A case of a patient with bilateral and simultaneous NAION caused by IFN and Ribavirin treatment for hepatitis C, who was also vitamin B12 deficient, was analyzed. Therefore, a combined etiology for optic atrophy was explained.

Non-arteritic anterior ischemic optic neuropathy (NA-AION) after intravitreal injection of bevacizumab (Avastin) for treatment of angoid streaks in pseudoxanthoma elasticum.

BACKGROUND: To report a case of nonarteritic anterior ischemic optic neuropathy (NA-AION) following intravitreal injection of bevacizumab (Avastin). METHODS: Interventional case report with an 18-month follow-up. RESULTS: A 51-year-old male with pseudoxanthoma elasticum presented with NA-AION 2 weeks after treatment with intravitreal of bevazicumab (Avastin) for choroidal neovascularisation secondary to angioid streaks. Except from a small optic disc without cupping he did not show further risk factors. DISCUSSION: Risk of NA-AION should be taken into consideration when deciding for intravitreal application of drugs including anti-vascular endothelial growth factors (VEGF) agents like bevacizumab (Avastin) in the treatment of retinal vascular diseases.

Optic disc and peripapillary morphology in unilateral nonarteritic anterior ischemic optic neuropathy and age- and refraction-matched normals.

PURPOSE: To compare optic disc morphologic features and peripapillary retinal nerve fiber layer (RNFL) thickness between the unaffected eyes of patients with unilateral nonarteritic anterior ischemic optic neuropathy (NAION) and their affected eyes and the eyes of age- and refraction-matched normal control subjects. DESIGN: Cross-sectional comparative study. PARTICIPANTS: Thirty-one patients with unilateral NAION and 62 age- and refraction-matched normal control subjects. METHODS: Optic disc morphologic features and peripapillary RNFL thickness were evaluated in both eyes of patients with unilateral NAION and in one randomly chosen eye of the normal control subjects. MAIN OUTCOME MEASURES: Optic disc and cup parameters were measured using the Heidelberg Retina Tomograph II (Heidelberg Engineering GmbH, Dossenheim, Germany), and RNFL thickness was measured by scanning laser polarimetry with variable corneal compensation (GDx VCC; Carl Zeiss Meditec, Dublin, CA). RESULTS: There was no significant difference in the disc area between the NAION affected eyes and the unaffected fellow eyes. The cup area, cup-to-disc area ratio, cup volume, and cup shape measure were greater, whereas the peripapillary RNFL thickness was smaller in the former than the latter (P = 0.001 to approximately 0.043). When the unaffected eyes of patients with NAION and the age- and refraction-matched normal control eyes were compared, the disc area, cup area, cup-to-disc area ratio, cup volume, mean cup depth, and cup shape measure were smaller in the former (P = 0.0006 to approximately 0.03); there was no significant difference in the RNFL thickness between the two (P>0.06). CONCLUSIONS: A comparison of the eyes with NAION and the fellow eyes indicated that the cup was slightly larger in the former than in the latter, suggesting the acquired enlargement of the cupping after NAION develops. A comparison of the unaffected fellow eyes in patients with NAION and the age- and refraction-matched normal control eyes suggested that a smaller disc area and smaller cupping were predisposing risk factors for the development of NAION.

Optic disc topography and peripapillary retinal nerve fiber layer thickness in nonarteritic ischemic optic neuropathy and open-angle glaucoma.

OBJECTIVE: To evaluate the results of scanning laser tomography and scanning laser polarimetry (SLP) and the correlations with visual field damage (VFD) in eyes with nonarteritic ischemic optic neuropathy (n-AION) compared with eyes with open-angle glaucoma (OAG). DESIGN: Cross-sectional study. PARTICIPANTS: Thirty-three eyes of 33 patients with n-AION and 33 eyes with OAG whose age and VFD evaluated with the Humphrey field analyzer were matched to those of the n-AION eyes. MAIN OUTCOME MEASURES: The parameters of optic disc topography obtained with the Heidelberg Retina Tomograph II (HRT II) and retinal nerve fiber layer (RNFL) thickness with GDx with variable corneal compensation and the correlation to VFD. RESULTS: The cup area, cup-to-disc area ratio, and mean cup depth were significantly smaller, and the cup shape measure more negative, in the n-AION eyes than in the OAG eyes (P<0.001), whereas rim area was significantly greater (P<0.001). Multivariate analyses showed that none of disc area, rim area, and mean cup depth in the n-AION eyes and only rim area (P = 0.029) in the OAG eyes was significantly associated with mean deviation (MD). Ellipse average of RNFL thickness significantly correlated with MD in the n-AION eyes (P = 0.045) and in the OAG eyes (P = 0.022). CONCLUSIONS: Disc topography of eyes with n-AION was quantitatively characterized by small and shallow cupping and a relatively large rim area compared to eyes with OAG matched for age and VFD. In eyes with n-AION, significant correlation with VFD was found only for the RNFL thickness evaluated with SLP but not for the HRT II parameters.

Correlation between optic disc atrophy and aetiology: anterior ischaemic optic neuropathy vs optic neuritis.

BACKGROUND: The morphologic features of swollen disc in the acute stage of optic neuritis and anterior ischaemic optic neuropathy (AION) have been extensively investigated in contrast to the morphologic features of optic disc atrophy after these events. OBJECTIVE: : A prospective study to evaluate the morphologic features of optic disc atrophy 6 months or more after optic neuritis and nonarteritic AION. PATIENTS AND METHODS: A total of 35 optic discs after nonarteritic AION (n=27) and 24 after optic neuritis (n=19) in otherwise healthy subjects have been evaluated by direct fundoscopic examination with a +90 diopters lens and optic disc photography. The average age of patients at the onset of AION was 57.8 years (range: 38-80) and at the onset of optic neuritis was 32.6 (range: 19-46). The female:male ratio was 18 : 17 in the former and 15 : 9 in the latter. The evaluated parameters included: degree of rim pallor (0 to +3), location of rim pallor, height of rim above the retina, depth and width of cup, peripapillary retinal artery to vein (A : V) ratio, and peripapillary pigment epithelial atrophy. A comparison was made also with 17 age-matched normal discs of 17 patients. Statistical significance was calculated with chi(2) and Fisher's exact test. RESULTS: Most of the discs after AION were paler (+2: 70%, +3: 26%) than after optic neuritis (normal colour: 8%, +1: 58%, P< or =0.007). Rim segmental involvement after AION was usually either superior 'altitudinal' (53%) or inferior 'altitudinal' (29%), whereas after optic neuritis, it was usually either temporal-central (papillomacular) (42%) or diffuse temporal (42%, P<0.0001). Discs had lower A : V ratio (1 : 3, 40%) after AION compared with optic neuritis (1 : 3, 8%) (P=0.007). There were no significant differences between the two groups in height of the rim, cupping, and peripapillary atrophy. CONCLUSIONS: : A combination of the degree of rim pallor, location of rim pallor, and A : V ratio may be of value in assessing the aetiology of optic disc atrophy when no previous clinical data are available and a compressive lesion has been ruled out.

Anterior ischemic optic neuropathy in children: case reports and review of the literature.

Anterior ischemic optic neuropathy, infarction of the optic nerve head owing to inadequate perfusion through the posterior ciliary arteries, is a common cause of visual loss in adults but is rarely reported in children, in part because the diagnosis is overlooked. We report two cases of young children undergoing chronic peritoneal dialysis, who suffered bilateral visual loss from anterior ischemic optic neuropathy. Predisposing local anatomic and multiple systemic factors included a small optic nerve head with little cupping, possible intraocular hypertension, and systemic hypotension, hypovolemia, and anemia. The literature on anterior ischemic optic neuropathy is reviewed.

Optic disc morphology after arteritic anterior ischemic optic neuropathy.

OBJECTIVE: To evaluate the appearance of the nerve head in patients after giant cell arteritis-induced arteritic anterior ischemic optic neuropathy (A-AION). DESIGN: Noncomparative clinical case series. PATIENTS: The study comprised 29 patients who presented with unilateral A-AION and temporal artery biopsy-proven giant cell arteritis. Stereoscopic optic disc photographs, taken of both the affected and unaffected eyes at the onset of the disease and after a follow-up period of 20.10 +/- 25.36 months (median, 11 months; range, 2-102 months), were morphometrically evaluated. MAIN OUTCOME MEASURES: Size and shape of the optic disc, neuroretinal rim, optic cup, and alpha and beta zones of parapapillary atrophy. RESULTS: In the eyes after A-AION, at the end of the study, the neuroretinal rim was significantly (P = 0.002) smaller, and the optic disc cup area was significantly (P = 0.001) larger than those of the contralateral unaffected eyes. Alpha zone and beta zone of parapapillary atrophy did not vary significantly (P > 0.50). CONCLUSIONS: A-AION, like glaucomatous optic neuropathy, results in neuroretinal rim loss and optic disc cupping. However, in contrast to glaucoma, A-AION is not associated with an enlargement of parapapillary atrophy. The reasons and mechanisms responsible for these similarities and dissimilarities are discussed. Marked clinical, morphologic, and histopathologic similarities in optic disc cupping and loss of neuroretinal rim between A-AION and glaucomatous optic neuropathy are highly suggestive of a common mechanism for the development of the two diseases (i.e., ischemia of the optic nerve head). The subject is discussed at length.