• ESR raised
normal in 20% of cases
usually > 50 mm/hr
• CRP raised
• FFA delayed or absent filling of the choroidal circulation
• Alkaline phosphate level in serum raised
• ANA positive
• Temporal artery biopsy(definitive diagnosis)
3cm long specimen to avoid skip lesions
Occult GCA: not to forget
Ocular involvement without associated signs and symptoms but with raised ESR and temporal artery biopsy positive for GCA.
Treatment forClinical hints for diagnosis and treatment of AAION
• Systemic steroids is the main stay.
• IV methyl prednisolone 1–2 g/day for 3 days
• oral prednisolone 80 mg/day 1st 3 days
• oral prednisolone 60 mg x 3 days
• 40 mg x 4 days
• Taper by 5 mg/week till 10 mg/day ( within 6 wks)
• Maintenance dose of 10 mg/day for 12 months
•Throughout the treatment the signs, symptoms and ESR is monitored.
• Tocilizumab ( immunosuppressive used in RA and JIA ) recently approved for GCA
• anti platelets can be tried
• liaise with cardiologist is mandatory
Clinical hints for diagnosis and treatment of AAION power point presentations:
Anterior ischemic optic neuropathy AAION
1. Jagdish Dukre
2. INTRODUCTION Anterior ischemic optic neuropathy (AION) is the most common cause of acute optic neuropathy in older age groups. AION is a potentially blinding disorder. Field defects typical of ischemic optic neuropathy were first described by Knapp in 1875. Miller and Smith first used the term ʺischemic optic neuropathyʺ in 1966, and Hayreh later added the term ʺanterior.ʺ In 1924, Uhthoff first described severe visual loss, with field defects and swollen optic discs.
3. Clinical Features AION presents with rapid onset of painless, unilateral visual loss manifested by decreased visual acuity, visual field, or both. The level of visual acuity impairment varies widely, from minimal loss to no light perception, and the visual field loss may conform to any pattern of deficit related to the optic disc. An altitudinal field defect is most common, but generalized depression, broad arcuate scotomas, and cecocentral defects also are seen. A relative afferent pupillary defect invariably is present with monocular optic neuropathy.
4. The optic disc is edematous at onset, and edema occasionally precedes visual loss by weeks to months. Although pallid edema has been described as the hallmark of AION, it is common to see hyperemic swelling, particularly in the nonarteritic form.
5. The disc most often is swollen diffusely, but a segment of more prominent involvement frequently is present, and either focal or diffuse surface telangiectasia is not unusual and may be quite pronounced. Commonly, flame hemorrhages are located adjacent to the disc, and the peripapillary retinal arterioles frequently are narrowed.
6. Clinical Classification of AION Depending upon the underlying cause, AION is of two types 1) Arteritic : This is the most serious type and is due to giant cell arteritis. 2) Non-arteritic: This is the most common one, and consists of all cases other than those due to giant cell arteritis.
7. Arteritic Anterior Ischemic Optic Neuropathy AAION
8. Pathogenesis AAION results from short posterior ciliary artery (SPCA) vasculitis and the resultant optic nerve head infarction. Human autopsy studies of acute AAION show optic disc edema with ischemic necrosis of the prelaminar, laminar, and retrolaminar portions of the nerve and infiltration of the SPCAs by chronic inflammatory cells. Segments of these vessels in some cases were occluded by inflammatory thickening and thrombus.
9. Fluorescein angiographic data support the histopathological evidence of involvement of the SPCAs in AAION. Delayed filling of the optic disc and choroid is a consistent feature extremely poor or absent filling of the choroid has been depicted as a characteristic of AAION It has been suggested as one useful factor by which to differentiate AAION from NAION. Delayed completion of choroidal fluorescein filling that averages 30–69seconds has been reported in AAION, compared with a mean of 5–13seconds in NAION.
10. Ocular Manifestations Typically, AAION develops in elderly patients, with a mean age of 70years, with severe visual loss (visual acuity < 6/60 in the majority). AAION is almost three times more common in women than in men. It may be preceded by transient visual loss similar to that of carotid artery disease and when present, is highly suggestive of arteritis. Pallor, which may be severe, chalky-white, is associated with the edema of the optic disc more frequently in AAION than in the nonarteritic form.
Clinical hints for diagnosis and treatment of AAION Videos:
Ischemic Optic Neuropathies
Clinical hints for diagnosis and treatment of AAION