From the Guidelines
Bilateral anterior ischemic optic neuropathy (AION) diagnosis and treatment should prioritize immediate high-dose corticosteroid therapy for arteritic cases, and controlling cardiovascular risk factors for non-arteritic cases, as the most effective approach to prevent further vision loss and address underlying causes. The diagnosis of bilateral AION involves a comprehensive eye examination, including visual acuity testing, visual field assessment, pupillary response evaluation, and fundoscopic examination showing optic disc edema 1. According to the study by 1, the diagnostic accuracy of physical and laboratory findings for giant cell arteritis, which can cause arteritic AION, shows that temporal artery abnormalities, such as thickening or tenderness, have a high sensitivity and specificity, while laboratory findings like elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels also have diagnostic value. Key points to consider in the diagnosis and treatment of bilateral AION include:
- Immediate initiation of high-dose corticosteroid therapy, typically with intravenous methylprednisolone 1000mg daily for 3 days, followed by oral prednisone 1mg/kg/day, for arteritic AION to prevent further vision loss and address the underlying giant cell arteritis 1.
- Controlling cardiovascular risk factors, such as hypertension, diabetes, and hyperlipidemia, for non-arteritic AION to reduce the risk of recurrence.
- Aspirin 81-325mg daily may be prescribed to reduce the risk of recurrence in non-arteritic AION.
- Regular monitoring with visual field testing and fundoscopic examinations to assess stability and detect any new visual symptoms promptly.
- Patient education on the importance of reporting any new visual symptoms immediately, as involvement of the second eye can occur, particularly in arteritic cases. The study by 1 highlights the importance of evaluating patients for features informative for a final diagnosis of giant cell arteritis, beyond just headache, to ensure accurate diagnosis and timely treatment.
From the Research
Bilateral AION Diagnosis
- Bilateral Anterior Ischemic Optic Neuropathy (AION) can occur in patients, with a reported incidence of around 40% in some cases 2.
- The interval between the occurrence of AION in the first and second eye can vary from a few days to several years, with an average interval of 3 years 2.
- It is essential to identify whether the AION is arteritic or non-arteritic, as arteritic AION (A-AION) is an ophthalmic emergency that requires urgent treatment with high-dose steroid therapy to prevent further visual loss in one or both eyes 3, 4, 5.
Treatment of Bilateral AION
- For non-arteritic AION (NA-AION), treatment with systemic corticosteroid therapy within the first 2 weeks of onset may improve visual outcome, but there is no effective medical or surgical therapy to prevent the development of new NA-AION episodes 3, 6.
- Management of systemic risk factors, such as nocturnal arterial hypotension, hypertension, and diabetes, is crucial in preventing and managing NA-AION 3, 2, 6.
- Long-term anticoagulant therapy may be considered in some cases of NA-AION, although its effectiveness is still being studied 2.
- For arteritic AION, high-dose steroid therapy is essential to prevent further visual loss, and early recognition and differentiation from non-arteritic AION is critical 3, 4, 5.