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Letters to the Editor

Corticosteroid Therapy in Nonarteritic Anterior Ischemic Optic Neuropathy

Hayreh, Sohan Singh MD, MS, PhD, DSc, FRCS, FRCOphth

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Journal of Neuro-Ophthalmology: September 2017 - Volume 37 - Issue 3 - p 349-350
doi: 10.1097/WNO.0000000000000557
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Kupersmith et al (1) in their recent article stated that the conclusions of my study (2), showing beneficial effects of systemic corticosteroids in nonarteritic anterior ischemic optic neuropathy (NAION), was “inaccurate,” and they listed several reasons for that. But if these authors had carefully read, with an unbiased mind, my detailed published rebuttals to those criticisms (3), they would have found that my conclusions were based on definite scientific evidence. This shows that their criticisms about my study are not valid.

For more than 4 decades, I have found a built-in bias, without any scientific rationale, among neuroophthalmologists against the use of corticosteroid therapy in NAION, as is evident from the above and the following examples.

In early 1970s, when I applied to the National Institutes of Health to run a multicenter clinical trial about the use of corticosteroids therapy in patients with NAION, the project was rejected on the grounds that there was “no scientific rationale for corticosteroid therapy in NAION.” I have discussed that scientific rationale fully elsewhere (2,3).

In justification of their comments, Kupersmith, Miller, and Levin cited 2 studies (4,5) showing no beneficial effects of corticosteroid therapy in NAION. But, as I have pointed out (6), the study by Rebolleda et al (4), based on only 10 treated patients, was highly flawed, which invalidated its conclusion. Pakravan et al (5) treated 30 patients with high-dose intravenous corticosteroids, using a treatment protocol basically similar to that used in optic neuritis. But it is well established that etiologically NAION and optic neuritis are different diseases, and that simple fact and the study design used in this study invalidates their conclusion. In contrast, in my study, oral corticosteroid therapy (in 312 treated and 301 untreated patients) was used until optic disc edema resolved, that is, for about 8 weeks. Thus, comparing study designs and the numbers of patients in the 2 cited studies with those of my large study is like comparing apples and oranges. It is unfortunate that Kupersmith, Miller, and Levin apparently attach more importance to those 2 highly flawed studies supporting their bias than to my large, systematic, comprehensive study.


1. Kupersmith MJ, Miller NR, Levin LA. New treatments in Neuro-Ophthalmology: the role for evidence. J Neurophthalmol. 2017;37:1–2.
2. Hayreh SS, Zimmerman MB. Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy. Graefes Arch Clin Exp Ophthalmol. 2008;246:1029–1046.
3. Hayreh SS. Ischemic optic neuropathies—where are we now? Graefes Arch Clin Exp Ophthalmol. 2013;251:1873–1884.
4. Rebolleda G, Pérez-López M, Casas-Llera P, Contreras I, Muñoz-Negrete FJ. Visual and anatomical outcomes of non-arteritic anterior ischemic optic neuropathy with high-dose systemic corticosteroids. Graefes Arch Clin Exp Ophthalmol. 2013;251:255–260.
5. Pakravan M, Sanjari N, Esfandiari H, Pakravan P, Yaseri M. The effect of high-dose steroids, and normobaric oxygen therapy, on recent onset non-arteritic anterior ischemic optic neuropathy: a randomized clinical trial. Graefes Arch Clin Exp Ophthalmol. 2016;254:2043–2048.
6. Hayreh SS. Treatment of non-arteritic anterior ischemia optic neuropathy with high-dose systemic corticosteroid therapy. Graefes Arch Clin Exp Ophthalmol. 2013;251:1029–1030.
© 2017 by North American Neuro-Ophthalmology Society