A New Look

Prof Dr Sherif Ahmed Kamel AmerMD ophthalmology, Cairo University, ICO.Ophth.

Professor & Head of The Ophthalmology Department, Faculty of Medicine, Beni Suef University. Supervisor of The Neuro-Ophthalmology

Clinic, National Eye Center (Rod El Farag).Consultant Neuro_Ophthalmologist, Magrabi Eye

Hospitals, Egypt

The classic syndrome consists of an acute vascular insult to the optic nerve leading to infarction of the optic nerve head.

The disease presents with a sudden and painless deterioration of vision, usually discovered on waking in the morning, and involving mostly the lower part of the visual field in one eye

1.Anterior ischemic optic neuropathy (AION): Affects anterior part of the optic nerve.

2.Posterior ischemic optic neuropathy (commonly abbreviated to PION): This is a rare type due to acute ischemia of posterior part of the optic nerve.

Arteritic AION (A-AION): This is the most serious type and is dueto giant cell arteritis (GCA).

Non-arteritic AION (NA-AION): This is the usual and the most common one, and consists of all cases other than GCA

Predisposing Factors: systemic or local (in the eye and/or optic nerve head).

Precipitating Factors: These act as the finalinsult, resulting in ischemia of the ONH andAION. A fall of BP during sleep (nocturnalarterial hypotension) is an important factor inthis category

The disk at risk (subclinical ischemia) shows the following signs:

Small scleral canal

Crowding of nerve fibers (Obliterated Cup).

Disc hyperemia

25%-40% of fellow eyes are

expected to develop NA-AION

Optic disc swelling without any visual loss;this indicates an early sign of non-arteriticAION.

Optic disc edema usually lasts for severalmonths unlike those seen initially withvisual loss.

It is an infrequent but important subtype of NA-AION.

Further loss of vision may be experienced days or weeks after the initial decrease in vision.

In some, a new ischemic episode may be the cause of the further visual loss.

Rarely, especially if the loss is intermittent and gradual, a reversible loss may be seen that can improve spontaneously.

The number of cases with bilateral simultaneous presentation with 20 cases having bilateral simultaneous acute vascular optic neuropathy.

2

8

2

20

0 5 10 15 20 25

Diabeticpapillopathy

Chronic

Subacute

Acute

The Mode Of Presentation of Eyes With Bilateral Simultaneous Vascular Optic Neuropathies

Diabetic Papillopathy

5

20

17

47

0

5

10

15

20

25

30

35

40

45

50

normal disc disk at risk incipient post ischemic

The Condition Of The Optic Nerve of The Other Eye in Cases Presenting With Acute Unilateral Vascular Optic Neuropathy

2.70%4.60% 4.60%

22.20%

43.50% 53.70%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

The Total Cummulative Percent Of Major Systemic Risk Factors In Cases With vascular Optic Neuropathy

Vascular optic nerve diseases are a group of diseases caused by deficient vascular supply of the optic nerve on acute or chronic basis and take different presentations and courses.

The term ischemic optic neuropathy with it subdivision anterior or posterior or arteritic and non-arteritic is very far beyond explaining the correct classification of these group of diseases.

Diabetic patients showed four types of presentations:

(a) the typical acute presentation with pale swelling and altitudinal field defects

(b) diabetic papillopathy with marked disc swelling without pallor

(c) disc swelling with disc pallor without history of the acute stage, and

(d) disc swelling with disc pallor without history of the acute stage, and with neovascularization of the disc (NVDs). Presentations other than the acute stage were always bilateral while the acute presentation was unilateral and bilateral.

Diabetic eyes show the following stages of vascular optic nerve disease disease: (a) disc at risk (b) incipient stage (c) diabetic papillopathy (d) Acute vascular optic neuropathy (e) chronic disease with or without NVDs (f) post ischemic neuropathy.

Another special point for eyes associated with diabetes is the higher incidence of bilateral simultaneous ischemic acute optic neuropathy.

The severity of involvement of both eyes was always variable.

A new look to the clinical classification ismandatory in order to make an earlydetection of subclinical cases for possibleprophylaxis of susceptible cases.

The current classification of vascular opticneuropathies is seriously deficient and doesnot describe different stages of the disease..

Prodromal Vscular Neuropathy :

Disc at risk Fellow discs Discs in patients with longstanding,

uncontrolled risk factor, or more than one risk factor.

Incipient Vascular Neuropathy: Nerve head with swelling without visual loss.

Subacute Vascular Neuropathy:

Optic disc swelling without pallor associatedwith nerve fiber layer hemorrhages andtransient attacks of blurring of vision ortransient field defects.

Chronic (Slowly Progressive) VascularNeuropathy:

Dry chronic vascular optic neuropathy: slowlyprogressive disc ischemia without disc edema notpassing through the acute stage.

Vascular neuropathy due to anemia

Wet chronic vascular optic neuropathy: slowlyprogressive disc ischemia with disc edema with orwithout pallor not passing through the acute stage

Diabetic vascular neuropathy; Papillopathy

Acute Vascular Neuropathy:

–Mild with BCVA of 6\6-6\12

–Moderated with BCVA of 6\18-6\36

–Acute profound with BCVA of 6\60 or less

–Acute recurrent.

Post Ischemic Optic Neuropathy

– On top of acute.

– On top chronic.