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ischemic optic neuropathy (stroke of the optic nerve)

Etiology: (risk factors) 1) hypertension (anterior*) 2) diabetes mellitus (anterior*) 3) combination of hypotension & anemia (posterior*) 4) arteritis, giant-cell arteritis ... (5% of patients > 65) 5) hyperlipidemia 6) head injury: traumatic optic neuropathy (posterior*) - blunt trauma to the superior orbital rim, lateral orbital rim, frontal area, or cranium 7) pharmaceuticals - sildenafil (Viagra) & other PDE5 inhibitors ? - semaglutide [5] * anterior vs posterior ischemic optic neuropathy Epidemiology: - age > 40 years [3] Pathology: 1) ischemia of posterior ciliary artery (anterior*) 2) infarction of the retrobulbar optic nerve (posterior*) - alternatively disease of the retina 3) head injury result in ischemia & edema Genetics: - allele B of platelet glycoprotein 1b-apha (GP1BA) is associated with susceptibility to nonarteritic anterior ischemic optic neuropathy Clinical manifestations: 1) visual impairment a) sudden painless monocular visual loss a) blurry vision b) visual field defects often involving superior & inferior fields 2) edema of optic disk with 1 day of visual symptoms 3) flame-shaped splinter hemorrhages 4) afferent pupillary defect - affected pupil does not constrict to light - both pupils will constrict to light upon the contralateral (unaffected) pupil - affected pupil will dilate if the unaffected is no longer constricted 5) vision is loss is generally worst at onset with little deterioration [3] 6) occasional mild improvement in vision with time Laboratory: 1) erythrocyte sedimentation rate 2) serum C-reactive protein (rule-out arteritis) Differential diagnosis: temporal arteritis Management: 1) referral to an ophthalmologist 2) generally no treatment available unless associated with arteritis 3) glucocorticoids to prevent blindness in second eye in patients with arteritis

General

optic neuropathy ischemia

Database Correlations

OMIM 258660

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 166
  3. Prescriber's Letter 12(6): 2005 Viagra and Vision Loss Detail-Document#: 210611 (subscription needed) http://www.prescribersletter.com
  4. O'Brien EK, eMedicine (Medscape) Optic Nerve Decompression for Traumatic Optic Neuropathy http://emedicine.medscape.com/article/868252-overview
  5. Hathaway JT, Shah MP, Hathaway DB et al Risk of Nonarteritic Anterior Ischemic Optic Neuropathy in Patients Prescribed Semaglutide. JAMA Ophthalmol. 2024 Jul 3. PMID: 38958939 https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2820255