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Younger individuals not immune to NAION
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SEATTLE – Nonarteritic anterior ischemic optic neuropathy typically presents in older individuals, but an optometry resident shared a case report where the condition was diagnosed in a 32-year-old man, here at Optometry’s Meeting.
The African-American patient was referred to the clinic for papilledema of the left eye, Kelli Theisen, OD, a primary care and ocular disease resident at the Illinois College of Optometry and Illinois Eye Institute, reported during a “live poster session.” Theisen and colleagues’ case report was also presented in a poster here at the meeting.
The patient had peripheral blur lasting 2 weeks, dulling of color vision in the left eye and clear central vision, Theisen said. His medical history was unremarkable, he was a former smoker and reported occasional alcohol use. He also reported mild discomfort of both eyes in the right gaze only.
“I first attempted color testing with the red cap desaturation method,” Theisen said in her presentation. “In the right eye he was 100%, and in the left eye he was 80%. He was able to achieve all shapes on screening plates in both eyes.”
The right optic nerve head was sharp, distinct, flat and well diffused, she continued. The left optic nerve head showed some disc edema without disc hemorrhaging. Optical coherence tomography confirmed a swollen left optic nerve head. The ganglion cell analysis showed no thinning. Raster showed elevation to the left optic nerve head, and the left visual field showed a superior altitudinal visual defect.
Two differential diagnoses were nonarteritic ischemic optic neuropathy (NAION) and optic neuritis, Theisen said. Other possible diagnoses included arteritic anterior ischemic optic neuropathy, a compression lesion and toxic optic neuropathy.
Kelli Theisen
“NAION is usually painless,” she said. “There are predisposing risk factors. Optic neuritis usually happens in younger individuals; 92% of patients have pain.
“We needed MRI of the brain and orbits with and without contrast,” she added, “to look for enhancement of the optic nerve and demyelination in the brain for possible multiple sclerosis. The patient’s OCT in guided progression analysis kept progressing.
She noted that it was some time before the patient was able to have the MRI done.
“The MRI did not show any white matter lesions suggesting any demyelinated events,” Theisen said. “The orbits did not show any longitudinal enhancement of the left optic nerve. We then requested labs to rule out syphilis and sarcoidosis.”
The formal diagnosis was NAION, for which there is no accepted treatment, she said.
Results of the Optic Neuropathy Decompression Trial in 1989 found that acuity improved more in the observation group, Theisen said. It decreased more in patients who underwent optic nerve decompression surgery.
“For patients older than 50 years, have ESR and CRP tested to rule out giant cell arteritis,” she said. “If they have it, they can go blind in the fellow eye in 24 hours if not treated with steroids.”
In this case, after 4 months, repeat testing showed the patient’s visual field improved.
“Research shows that in 40% of cases, visual field improves,” Theisen noted.
“It’s important to identify vascular risk factors,” she said. “Edema usually resolves in 8 weeks. We should also educate patients regarding risk of recurrence.
“Be suspicious of giant cell arteritis in cases of optic nerve disc head edema,” she continued. “Get differentials in atypical presentations. Be persistent in coordinating testing with the primary care physician. The patient’s acuity entering was 20/20. I learned the importance of using color plates vs. red cap screening test.” – by Nancy Hemphill, ELS, FAAO
Reference:
Sergott RC, et al. Arch Ophthalmol. 1989;107(12):1743–1754.
Disclosure: Theisen reports no relevant financial disclosures.