CASE REPORT
Neuro-Ophthalmology Society Journal, Case Report of Neuro-Ophthalmology 2021, Volume 01, Number 01.
E-ISSN. 2775-474X
SUCCESSFUL RISK FACTORS MANAGEMENT COMBINED WITH CORTICOSTEROID RESULTING GOOD OUTCOME IN NON-
ARTERITIC ISCHEMIC OPTIC NEUROPATHY PATIENTS A CASE SERIES
Hisar Daniel1, Syntia Nusanti1,2, M. Sidik1,2
1Ophthalmology Department, Faculty of Medicine, Indonesia University, Jakarta Indonesia
2Neuro-Ophthalmology Division, Cipto Mangunkusumo Hospital, Jakarta Indonesia Correspondence: Syntia Nusanti :[email protected]
ABSTRACT
Background: As a common cause of painless visual loss in adults, non-arteritic ischemic optic neuropathy (NAION) remains controversial in pathogenesis and treatment. Theories of vascular, systemic and ocular risk factors have emerged in recent years. Several studies to find the best management already done. Yet, there is no proven effective treatment.
Case Presentation: This was a retrospective study of 2 cases in CiptoMangunkusumo Hospital – Neuroophthalmology Division. Both cases were middle-aged female, with worsened visual acuity and visual fields. The onset was within weeks. Further investigations revealed abnormality in optic nerve head (ONH) anatomy, the so called “disk-at-risk” in fellow eye, perimetry, and laboratory results. We treated both cases by combining risk factor management and systemic steroid therapy.Both cases came with significant visual field defect in line with the ONH abnormalities. After3 months and 6 months of follow up, this combine treatment was able to improve visual field significantly.
Conclusion: Pathogenesis and treatment of NAION remains controversial. Regardless, our study found that by combining risk factors and steroid therapy may benefit in NAION patients.Thistreatment not only successful in the affected eye, but also may preserve felloweye.
Keywords: Non arteritic ischemic optic neuropathy, corticosteroids, hypercoagulability BACKGROUND
Non-arteritic anterior ischemic optic neuropathy (NAION) is an important cause of acute visual loss in the middle-aged and elderly populations1, (mean age 60 years) with an incidence that varies between2,3–
10,2:100.000.2 However, many aspects of this disease remain poorly understood. In particular the exact pathophysiology leading to infarction of the optic nerve head remains to be elucidated.
Furthermore, the efficacy of medical and surgical treatments for NAION are yet to be proven.2-6
Several established risk factors such as hypertension, diabetes mellitus, hypercholesterolemia, optic disc morphology and perioperative visual loss are widely known related to NAION. The history of phosphodiestrase-5 inhibitors and amiodarone consumption, obstructive sleep apnea, systemic hypotension, thrombophilia and inflammation, tobacco
use, elevated intraocular pressure, and post ocular surgery considered as the controversial risk factors.1-11
Though it is generally accepted that the pathophysiology of NAION resultsfrom ischemic injury to the optic nerve head,the precise vasculature affected and mechanism of ischemia remain controversial.2 Recently Hayreh et al conclude that in the vast majority of patients there is no actual occlusion of the vessels in the optic nerve head but only transient hypoperfusion. Later, he also found that NAION can be caused by hypoperfusion of central retinal artery that leads to axial infarction at anterior part of the optic nerve head.7,11
NAION is a common disease with lot of controversies in pathogenesis and management. Hence the NAION management is still challenging. Several studies suggest that treating risk factors in
CASE REPORT
NAION will add more benefits.1,18,21,22 Hopefully, this case report not only offer additional knowledge, but also will lead
another studies to promote updates in managing NAION at our center.
CASE PRESENTATION Case 1
A 48-years old woman, reported with sudden blurred vision of left eye after waking up in the morning 6 days before admission. Patient also complained about loss of her upper side vision. There was history of miscarriage without known cause, and use of birth control pills. There was no history of hypertension nor diabetes mellitus.
The first examinations revealed 6/6 visual acuity of both eyes, relative afferent pupillary defect (RAPD) at left eye, crowding right optic disc, and left opticdisc edema. Other ophthalmological examinations were remarkable. Visualfield examination (Humphrey HFAII-i750, 24-2.
Patients then assessed with NAION, and treated with Methylprednisolone (1 x 0,8 mg/kg body weight) 48 mg once daily (tapered off every week). After consultation with Hematology – Internal Medicine Departement we discovered a hypercoagulable state and dislipidemia in patient which are the risk factors in this case. Fondaparinux sodium (Arixtra®) 5 mg once daily, aspirin (Ascardia®) 80 mg once daily, and Simvastatin 10 mg once daily were added to the treatment.
At 2 weeks follow up there was improvement in superior visual field. After one month treatment we performed Humphrey re-examination and revealed significant improvement in patient’s left visual field (VFI 98%). And at 2 months follow up there was no sign of RAPD.
Figure 1. Case 1: Fundus photography before treatment.
Figure 2. Case 1: (A) Visual field examination of left eye before treatment.
(B) Visual field examination of left eye after 1 month of treatment with steroid and risk factors management
A B
CASE REPORT
Case 2
A 46 years old woman reported with Blurred right eye vision suddenly after woke up in the morning since 3 weeks before admission. She was referred from fellow ophthalmologist for further investigation for her right eye. She had similar symptom at her left eye 3 months before admission, but she left it untreated.
She noticed a dark shadow at her upper visual field, while in the fellow eye the shadow was diffusely blocked her vision. There was no ocular pain with and without movement, headache, and joint pain
She had a history of using contraception (injection) for 10 years, history of hospitalization 1 month prior to admission with 3 days injection therapy which she could not recall the medication. She was diagnosed with cardiovascular disease 3 years prior to admission. She routinely took Aspilet® 1 x 80 mg, ranitidin 2 x 150 mg, prednisone 2 x 5 mg, Trental® 1 x 400 mg from previous ophthalmologist and internist. She denied having diagnosed with diabetes and hypertension.
TABLE 1. Patients characteristics at time of admission
CASE 1 CASE 2
Age 48 yo 46 yo
Sex Female Female
Onset time before admission
6 days 3 weeks
Chief complain Sudden painless blurredvision, superior visual field blockage
Sudden painless blurred vision, superior visual field blockage
Laterality Unilateral(lefteye) Unilateral (righteye)
Visual acuity (affected eye) Visual acuity (fellow
eye)
6/6E 6/18 uncorrected withpinhole
6/6E 0,5/60
Intraocularpressure Within normal limit Within normal limit
RAPD(affected eye) + +
Funduscopy
Swollen disc, hyperemic Swollen disc, hyperemic,small CDR, crowding disc Fellow eye
funduscopy Visual field defect
(affected eye) Visual field defect
(fellow eye) Other systemic
disease Laboratory
Crowding disc, small CDR Crowding disc, pale, CDR 0,1
Superior altitudinal Diffuse field defect Within normal limit Diffuse field defect
Denied Denied
Increased lipid profile Examination Increased lipid profile,increased
coagulation factor (fibrinogen, D-dimer)
hyperreactivity of internal and external coagulation factors
(high level of adenosine diphosphate/ADP)
CASE REPORT
First examination revealed 6/18 (uncorrected with pinhole) right eye visual acuity (VA), and 0,5/60 at left eye. The intraocular pressure (IOP) was within normal limit in both eyes. RAPD was present at her left eye, and mild lens haziness at both eye.
Fundus examination of right eye revealed a hyperemic optic nerve head (ONH), crowding disc with small cup-to-disc ratio (CDR) 0,1.
Her left eye fundus examination showed a pale disc, distinct edge, and with crowding disc. Visual field (VF) test using Humphrey HFA II-i 750 (24-2 threshold) revealed severely depressed fields at her both eyes (right eye VFI 11%, left eye VFI 5%). She already performed brain magnetic resonance imaging (MRI) from previous hospital and the result was remarkable.
Patient was assessed with NAION right
eye, papil atrophy left eye due to history of NAION. She was treated with Methylprednisolone 32mg once daily (0,8 mg/kg body weight) – tapered off every week. After further investigation by Hematology – Internal Medicine Department, we discovered a high level of adenosine diphosphate/ADP, and dislipidemia. Similar to the first case, the risk factors in the second case were dislipidemia and hypercoagulable state.
Then, she was given warfarin (Simarc®) 5 mg once daily, clopidogrel 75 mg once daily, and atorvastatin. Right eye VA improved after 1 week of medication, and after 1 month the VF was improved. In contrary there was only a minimal sign of improvement at her left eye.
Figure 3. Case 2: Fundus photography at first admission
Figure 4. Case 2 : Visual field test of both eyes before treatment
Figure5. Case2: Visual field test of both eyes at 1 month(A) and 6 months(B) after treatment with steroid and risk factors management.
A B
CASE REPORT TABLE 2. Post-treatment follow up
DISCUSSION
NAION typically affects individuals between the ages of 55-70 with average age of onset between 57-67 years, however the condition may develop at any age. It was reported that 11-23%ofNAION patients referred totertiary care neuro- ophthalmic services were less than 50 years old. A study in Cipto Mangunkusumo Hospital showed that 58,8% of the patients were male, and 68,4% older than 50 years old (range 21 – 80 years old).23 The age characteristic was similar in two studies in South East Asia region.24,25In line with our cases, our patients were below 60 years old Differences in several studies regarding to sex predilection may show that there is no sex specificity in NAION.3,4,6,22,25
Several factors were suggested for this disease: some are more acceptable and well documented, while others are anecdotal case reports. At first, in our cases there were no history of systemic disorders. After further laboratory test, we found that both cases have an increasedin lipid profile, and hypercoagulability state. The developed risk factors in ourcases were adjacent to recent study. Aritonanget al found that dyslipidemia was the most contributed risk factors in unilateral NAION (68%), along with systemic
hypertension, hypercoagulability, diabetes mellitus, smoking, stroke, and cardiovascular disease.23
NAION has reported to be related with post-partum hemorrhage, severe pre- eclampsia and ruptured ectopic pregnancy in obstetric patients. Our first case came with history of miscarriage.The mechanism is due to acute severe hemorrhage as in miscarriage, would trigger release of endogenous vasoconstrictors (angiotensin, epinephrineandvasopressin) that may lead to vasoconstriction of parapapillary vessels and resultant ischemia of the optic nerve head with or without severe hypotension.
Thus, presumably causing change in optic nerve head anatomy.27,28 Both of our patients have a small cup-to-disc ratio with crowding disc. This ‘crowded’ morphologic appearance is believed to predispose the optic nerve head to ischemia because of presumed structural crowding of the approximately 1 million axons at the level of the lamina cribrosa and has therefore been described as a ‘disc-at-risk’.3,1
NAION typically presents with acute, unilateral loss of VA and/or VF. The visual loss in NAION is first noted upon awakening, and may progress over several
CASE REPORT hours to days, and rarely even weeks. The
VA may range from 20/15 to no light perception.2, 5, 6, 10, 24, 25,34-36.
In our cases, they present with unilateral visual loss. The time of onset was 6 days and 3 weeks before admission. Several studies reported that the time of onset was varies in NAION between hours to weeks.2,5,6,24,36 Both cases noticed sudden visual loss after wake up in the morning, a hallmark in NAION. Yet their main concern was VF loss at superior side. These were in line with study by Aritonang et al that mentioned that 85,08% NAION cases in CiptoMangunkusumo Hospital were unilateral, and 50,9% came due to their sudden visual field loss.23
In contrast to VA, VF defects are a universal occurrence.1,4,37 The severity of VF loss is a reflection of the amount of axonal loss due to ischemia, and that in turn depends upon these verityofischemia – the more marked the ischemic damage, the earlier and more marked the destruction of the axon.7, 38 With respect to the VF defect in NAION, the most common are aninferior altitudinal or arcuate defect.1,2,4,11
In case 1 patient present with superior altitudinal defect, and case 2 had severely depressed VF. The VF defect characteristic in our cases is in line with studies in NAION.
A funduscopic result in acute NAION reveals optic disc edema, frequently associated with peripapillary flame-shaped hemorrhages.
Cotton-wool spots may also be present in NAION, though retinal exudates are rare.
The disc edema in NAION typically resolves within 4 to 6 weeks, and is replaced by sectoral or diffusepallor. A common feature in patients with NAION is a physiologically small cup to disc ratio in the contralateral eye, on the order of 0.3 or less, known as a
“disc at risk”. In our cases, both came with a swollen disc, hyperemic ONH, and one patient had atrophy of the disc. Both cases present with crowding disc in the fellowe ye suggesting a disc at risk.2,5,8,38,42-44
Patients presenting with presumed NAION above 50 years old should undergo a complete blood count test, erythrocyte
sedimentation rate, and C-reactive protein to rule out AAION.2,5 Both of our patients had an increased level of lipid profile. In case 1 revealed an increased level of fibrinogen, D-dimer, and low-density lipoprotein (LDL), the other with hyperreactivity of intrinsic and extrinsic factors. The internal medicine department took part in managing these patients by giving anticoagulant and statin derivates.
Haas et al described that fibrinogen has been recognized as an Independent risk factor for cardiovascular disease, stroke and peripheral arterial occlusive disease, which contribute to atherogenesis via multiple mechanisms that will lead to thrombotic vascular occlusion.45 Lipid fractions in particular LDL and triglycerides, are determinants of hemorheology.
Disturbance of lipid metabolism leads to a loss of elasticity of red cells, and LDL increases platelet aggregation, resulting
together in impairment of
microcirculation.13,20,45-48. Vascular risk factors are considerably having a significant relationship in both cases. In line with this opinion, hypercoagulational so seen as one of major risk factors in our center (44,9%).23 The controversies of NAION pathogenesis led to no definitive or recommended treatment management. The most common pathogenesis theories of NAION are infarction in retrolaminar portion of ONH which supplied by short posterior cilliary arteries. There is also agreement that a compartment syndrome with axonaledema occurred in a structurally crowded disc.
Other theories that have been suggested include reduction in blood flow from a combination of nocturnal hypotension, impaired autoregulation of the microvascular supply, vascular occlusion, and venous insufficiency.1,4-7,9-11,22,35,36,41
There are several alternative therapies for NAION, and systemic steroid is one of it. Systemic steroids would improve the blood flow and reduce capillary compressions in the optic nerve head. In these cases, both patients were given
CASE REPORT systemic steroid (methylprednisolone 0,8/kg
BW/day). The rationale for the use of steroids in NAION is based on a study from the late 1960s, which postulated that treatment of NAION with steroids would reduce capillary permeability, thereby inducing faster resolution ofdiscedema. This study reported improvement in VAin11 of 13 (85%) patients treated with systemic steroids (60 mg/day prednisone), compared to five of 11 patients (45%) not treated with steroids.12, 19, 22, 49, 50
A large study (694 eyes) in 2008 showed that systemic steroid treatment was effective in patients with NAION with initial visual acuity was 20/70 or worse, and improvements were seen if treated within two weeks of onset.36,42 Their observation revealed that those who had worse initial VF defect and VA were associated with a faster resolution of disc edema with systemic steroid therapy in NAION compared to the untreated group.
The treated group with steroid therapy within 2 weeks of the onset showed the median time to optic disc edema resolution was 6.8 weeks, mean while the untreated group was 8.2 weeks.At6 months follow up there were VA and VF improvement in the treated group.19,22,36,42
The complications of systemic steroid in were minor if precautionary measures were taken.Treatment with prednisone with a dose of 80mg/day and tapered the dose over several weeks, probably is the most common treatment tried in patients with NAION.3,51 Huang et al concluded that systemic methylprednisolone may play a role in rescuing a rodent model of NAION.
Anatomic axon recovery, retinalganglion cells (RGC) survival rate and visual function improvement noted in their flash visual- evoked potentials (FVEP) study was
demonstrated with systemic
methylprednisolone treatment. The rescue effects may be through the dual actions of anti-apoptosis as evidenced by less apoptotic cells in the RGC layers of the retinas,andanti-inflammationintotheoptic
nerve.49
Both of our cases have an increased level of coagulation factors and dyslipidemia. The consideration of anticoagulant therapy and statin were based on the high level of fibrinogen, platelet aggregation and low-density lipoprotein (LDL), which contribute to increased risk of vascular thrombotic occlusion and microcirculation impairment.
In line with that, Haas et al found that reducing those parameters of about 50%
improves the hemorheological active substance. Haas et al study focused on heparin-induced extracorporeal LDL/fibrinogen precipitation (HELP) system offers the opportunity of selective, immediate and safe elimination of fibrinogen, total cholesterol, LDL and triglycerides by means of extracorporeal circulation.21,45 Subsequently their study revealed a significant visual field improvement in those treated with HELP.
Ramunni et al determined whether acute reduction of plasma fibrinogen and serum low-density lipoprotein (LDL) cholesterol is effective for treatment of NAION. In 11 patients showed asignificant improvement in visual acuity, visual field, and remained stable after 3 months.52 Anti- coagulant therapy may role in secondary prevention of fellow eye involvement. There does not
seem to be any evidence
fororagainsttheuseofanti-coagulation as an acute therapy as inourcases.13,18,45,50
Prognosis in our cases were associated with the developed risk factors. Managing dyslipidemia and hypercoagulability were successfully improved visual field loss. In case 1 treatment was successfully recovered the symptoms in the affected eye, and RAPD resolved. While in case 2 we managed to improve fellow eye condition, because the affected eye already had severe visual loss. Considerably both cases were showing sufficient results after follow up, in accordance to several studies we strongly suggest annual follow up to evaluate any risk of recurrence.
CASE REPORT
CONCLUSION
It would appear that as a common optic neuropathy there is “no proven effective therapy” in NAION. By managing the underlying risk factors, we may achieve improvement. The role of corticosteroids, dyslipidemia treatmentand anticoagulant have a role to prevent both primary and secondary mechanism as in our cases.
Exploring coagulation status and combining risk factors control and systemic steroid might consider as an update in NAION management. Duration of onset, timing and type of therapy, other risk factors management are some variables that challenge for further investigation.
Therefore, prospective study analyzing those variables may add valuable information in managing NAION.
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