Ischemic Optic Neuropathy

Mark J. Morrow, MD, FAAN Neuro-ophthalmology p. 1215-1235 October 2019, Vol.25, No.5 doi: 10.1212/CON.0000000000000767
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PURPOSE OF REVIEW Vision is often threatened or lost by acute ischemic damage to the optic nerves. Such pathology most often affects the anterior portion of the nerve and is visible on funduscopic examination. Ischemic optic neuropathy is associated with typical vascular risk factors and with one systemic disease in particular: giant cell arteritis (GCA). This article provides an overview of the three major classes of ischemic optic neuropathy, including information on risk factors, differential diagnosis, evaluation, and management.

RECENT FINDINGS Optical coherence tomography provides precise anatomic imaging in ischemic optic neuropathy, showing neural loss weeks before it is visible on examination. Refinements of optical coherence tomography reveal optic nerve microvasculature and may assist in understanding pathogenesis and verifying diagnosis. New diagnostic algorithms and cranial vascular imaging techniques help define the likelihood of GCA in patients with ischemic optic neuropathy. Finally, intraocular drug and biological agent delivery holds promise for nonarteritic ischemic optic neuropathy, whereas newer immunologic agents may provide effective steroid-sparing treatment for GCA.

SUMMARY It is essential to recognize ischemic optic neuropathy upon presentation, especially to determine the likelihood of GCA and the need for immediate steroid therapy. A broad differential diagnosis should be considered so as not to miss alternative treatable pathology, especially in cases with retrobulbar optic nerve involvement.

Address correspondence to Dr Mark J. Morrow, Department of Neurology, Harbor-UCLA Medical Center, 1000 W Carson St, Box 492, Torrance, CA 90509, [email protected].

RELATIONSHIP DISCLOSURE: Dr Morrow reports no disclosure.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Morrow discusses the unlabeled/investigational use of medications for the treatment of ischemic optic neuropathy, none of which are approved by the US Food and Drug Administration.

© 2019 American Academy of Neurology.