Ischemic Optic Neuropathy and Temporal Arteritis

Two days before an eye examination, a 56-year-old man started to have difficulty in focusing his right eye. The morning of the examination, the patient noted a dark spot in his vision in this eye.

He had not had an eye examination for several years and did not wear glasses. He had a history of gastroesophageal reflux disease, for which he took omeprazole. He took an occasional aspirin for minor aches and pains. He had quit smoking 2Z\x years previously.

On examination, his uncorrected visual acuity was 20/20 in each eye. A trace afferent pupillary defect was noted in his right eye. His intraocular pressure and slit-lamp examination results were normal. A dilated fundus examination revealed disc edema involving the superior aspect of the right optic nerve (A). The left optic nerve appeared normal (B). A computerized visual field analysis identified an incomplete inferior altitudinal defect in the right eye (C). The left visual field was normal (D).

The patient's seated blood pressure was 165/99 mm Hg in the right arm and 150/98 mm Hg in the left arm. His erythrocyte sedimentation rate (ESR); complete blood cell count; anticardiolipin profile; lipid profile; and levels of homocysteine, C-reactive protein (CRP), and fasting serum glucose were all normal.

The patient scheduled an appointment with his primary care physician for further evaluation and management of his hypertension.

Nonarteritic anterior ischemic optic neuropathy (NAION) generally occurs in patients older than 50 years. It usually presents with a painless unilateral loss of vision that is greatest at onset but that sometimes progresses. Altitudinal, inferior nasal, and cecocentral visual field defects are common, as is an afferent pupillary defect in the involved eye.

Patients with NAION often have a history of hypertension, diabetes, hyperlipidemia, cerebrovascular disease, sleep apnea syndrome, increased blood viscosity, or vasospastic disorders. Temporal arteritis and arteritic ischemic optic neuropathy may be ruled out with ESR and CRP measurements.

There is no effective treatment for NAION. Any underlying systemic disease must be controlled to minimize the risk of NAION in the uninvolved eye.