68-year-old man with vision loss in the right eye on awakeni | Figure 1
68-year-old man with vision loss in the right eye on awakening
What is the role of the primary care or emergency medicine physician?
- Refer to ophthalmology urgently to prevent further permanent visual loss in 1 or both eyes.
- Work up the patient for underlying etiologies (eg, giant cell arteritis, diabetes, hypertension, cardiac disease, sleep apnea) as indicated.
What is the role of the ophthalmologist?
- Assess visual acuity, visual fields, and extraocular motility (eg, diplopia).
- Perform a fundoscopic exam to assess for optic disc edema. Arteritic AION presents with chalky white optic disc edema and cupping.
- Differentiate between ischemic and nonischemic optic neuropathy using fundus fluorescein angiography.
- Work up the patient for underlying etiologies as indicated.
What is the treatment?
Patients with nonarteritic AION should be treated for underlying cardiovascular disease and/or aggravating risk factors. In select cases, corticosteroid therapy may also be considered in the acute setting.
Arteritic AION is managed with systemic corticosteroid therapy, starting with emergency high-dose intravenous steroids for 2-3 weeks, followed by a taper and lifelong low-dose regimen. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be monitored to guide steroid taper. Follow-up with a rheumatologist is recommended to consider a steroid-sparing agent.
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Diagnosis added by author
The image is consistent with a diagnosis of nonarteritic anterior ischemic optic neuropathy (AION). AION is a loss of vision due to interrupted blood flow to the optic nerve head. A common cause of permanent vision loss in patients older than 50, it is characterized by a sudden, painless decline of vision—either unilateral or bilateral—typically noticed upon waking. AION is characterized as arteritic or nonarteritic.