Is there a monoclonal antibody therapy that can be used to treat non‑arteritic anterior ischemic optic neuropathy (NAION) in an older adult with sudden painless vision loss?

No Monoclonal Antibody Therapy Exists for NAION

There is no monoclonal antibody therapy approved or supported by evidence for the treatment of non-arteritic anterior ischemic optic neuropathy (NAION), and in fact, there is no proven effective treatment of any kind for this condition. 1, 2

Critical First Step: Rule Out Giant Cell Arteritis

Before accepting a diagnosis of NAION, you must urgently exclude arteritic anterior ischemic optic neuropathy (AION) from giant cell arteritis (GCA), which is a true ophthalmologic emergency requiring immediate high-dose corticosteroids to prevent irreversible bilateral blindness. 1

• Obtain ESR and CRP immediately in all patients ≥50 years presenting with acute painless monocular vision loss 2
• Query for temporal artery symptoms: temporal tenderness, jaw claudication, scalp pain, weight loss, proximal myalgia, or fever 1, 2
• Never miss arteritic AION – delayed corticosteroid treatment leads to permanent bilateral blindness 1

Why No Monoclonal Antibodies Work

The evidence provided discusses monoclonal antibodies (specifically anti-TNF agents like infliximab and adalimumab) only in the context of inflammatory uveitis from conditions like Behçet's syndrome 3, which is a completely different disease process from NAION. NAION is an ischemic infarction of the optic nerve head, not an inflammatory condition. 4

• Bevacizumab (a monoclonal antibody against VEGF) was specifically studied in a prospective trial for NAION and showed no benefit on visual field mean deviation (P=0.4), visual acuity (P=0.33), or optic nerve fiber layer thickness (P=0.11) 5
• The theory was that bevacizumab might reduce optic disc edema and resolve a proposed "compartment syndrome," but this approach failed 5

What You Should Do Instead

Acute Management

The American Academy of Ophthalmology confirms there is no level I data supporting any specific acute intervention for NAION. 1 Various proposed treatments have failed to demonstrate consistent benefit in controlled studies. 1

• Do not perform ocular massage or anterior chamber paracentesis – observational data suggest these may worsen outcomes 2
• Avoid empirical corticosteroids unless GCA is confirmed; steroids have limited and debatable evidence in NAION 6

Systemic Vascular Workup

Treat NAION as you would a stroke – it shares similar thromboembolic pathophysiology. 1

• Measure blood pressure, fasting glucose, and hemoglobin A1c in every NAION patient 2
• Evaluate for carotid stenosis, cardiac sources of emboli, and hypercoagulable states 1
• Implement intensive control of diabetes, hypertension, and hyperlipidemia to lower the risk of fellow-eye involvement 2

Secondary Prevention

• Consider antiplatelet therapy (aspirin) – while not proven to prevent fellow-eye NAION, it has proven benefit for stroke prevention in this high-risk vascular population 6
• Smoking cessation is recommended as part of risk factor modification 2

Follow-Up

• Schedule follow-up at 4–6 weeks to evaluate any visual improvement and determine if additional investigations are needed 2
• Serial visual field testing and OCT monitoring of retinal nerve fiber layer thickness 2

Common Pitfalls

• Do not confuse lack of proven treatment with lack of need for urgent evaluation – the systemic workup remains essential even though no treatment exists for NAION itself 1
• Do not assume all acute painless vision loss in elderly patients is NAION without ruling out central retinal artery occlusion, retinal detachment, or intraocular hemorrhage 2
• Do not overlook associated risk factors: PDE-5 inhibitors have been associated with NAION (though evidence shows no statistically significant increased risk), and high-altitude travel has been linked to NAION development in some cases 1