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Show Journal of Nciiw- Ophlhalmology IH(. l): I66- I6K, 1998. © 1998 Lippincoll Williams & Wilkins, Philadelphia Nonarteritic Anterior Ischemic Optic Neuropathy With Macular Edema Visual Improvement and Fluorescein Angiographic Characteristics Robert L. Tomsak, M. D., Ph. D., and Z. Nicholas Zakov, M. D. The objective of the study was to assess visual outcomes in patients who have nonarteritic anterior ischemic optic neuropathy ( NAION) with macular edema ( ME). Thirteen eyes ( 12 patients) with NAION and ME were observed for an average of 5.3 months after onset of visual loss. Intravenous fluorescein angiography was performed on 10 eyes. Fluorescein leakage was observed in 8 of 10 ( 80%) eyes. Leakage was nonfocal, minimal, and diffuse. Eleven of 13 ( 85%) eyes with ME improved. The average improvement was 2.3 Snellen lines. The presence of ME in patients with NAION may confer a better visual prognosis than reported in patients with NAION alone. Key Words: Intravenous fluorescein angiography- Macular edema- Nonarteritic anterior ischemic optic neuropathy. Approximately 50% to 60% of patients who have nonarteritic anterior ischemic optic neuropathy ( NAION) have a stable loss of vision: Approximately 10% have Manuscript received June 1997; accepted April 1998. From the Division of Ophthalmology, Mt. Sinai Medical Center, Cleveland, Ohio and Department of Ophthalmology, Case Western Reserve University School of Medicine, Cleveland, Ohio, U. S. A. Address correspondence and reprint requests to Robert L. Tomsak, Lakeland Eye Surgeons, 3600 Kolbe Road # 104, Lorain, Ohio 44053, U. S. A. some progression of visual loss during the initial 6 weeks, and the remaining 30% to 40% have visual improvement in a few months ( 1- 3). Visual improvement, when it occurs, is usually in the range of 2 to 3 Snellen lines ( 1- 3). Factors that determine the clinical course of the disease in a given patient are not known. We have observed that a subset of patients with NAION have associated macular edema ( ME). These patients seem to have a better visual prognosis than previously reported. Herein we report the visual outcome and fluorescein angiographic characteristics in patients with NAION and ME. METHODS We evaluated 13 eyes in 12 patients with NAION and ME ( 6 men and 6 women; mean age, 62 years; range: 47- 83 years). Five eyes were in patients with diabetes, and 3 eyes were pseudophakic ( risk- factor group). Both diabetes and pseudophakia are risk factors for macular edema. However, our patients did not have retinal angiopathy, and the pseudophakic eyes did not have signs of the Irvine- Gass syndrome. Furthermore, NAION occurred in the pseudophakic eyes at least 6 months or more after cataract surgery. FIG. 1. A and B. Late fluorescein angiographic views in two cases showing disc leakage, staining, and macular edema. J 66 NONARTERITIC ANTERIOR ISCHEMIC OPTIC NEUROPATHY 167 120 105 90 75 60 345 240 255 270 285 300 RIGHT 120 105 90 75 60 FIG. 2. ( A) Patient 3: initial visual field by Goldmann method, right eye. Visual acuity 20/ 200. l/ 4e and l/ 2e isopters shown. ( B) Patient 3: Final visual field by Goldmann method, right eye 56 days later. Visual acuity 20/ 30. l/ 4e and l/ 2e isopters shown. Complete ophthalmologic examinations were performed in all patients. Results in all fit the diagnostie criteria for NAION: appropriate age; sudden, painless loss of vision accompanied by visual field loss; and optic disc edema. No patient had symptoms of giant cell arteritis at presentation nor did any patient have such symptoms develop during the follow- up period. Two patients had laboratory evaluations for temporal arteritis; the results were negative. Average follow- up was 5.3 months ( range, 1.75- 15.75 months). A total of 13 eyes in 12 patients seen for evaluation of NAION had ME noted during ophthalmoscopy. Macular edema was subtle in 10 of 13 eyes and obvious in 3. Five of 13 eyes had visible macular hard exudates. Intravenous fluorescein angiography was performed on 10 eyes an average of 12 days after onset of visual loss ( range, 2- 22 days). RESULTS In the group that underwent fluorescein angiography, 8 of 10 eyes had evidence of leakage. Leakage was minimal, mild, and nonlocal ( Fig. 1 A and B). Eleven of 13 ( 85%) eyes improved a mean of 2.3 Snellen lines ( range, - 8 to + 9 lines). Mean improvement was 2.6 lines in the five eyes in the risk factor group. The non- risk- factor group averaged 1.8 lines of improvement. Follow- up visual fields were available in four patients GS Grayscale - 3D - 20 - lO O 10 20 30 VA Value Table In [ dB] - 30 - 20 - 10 O lO 20 30 30- 5 2 9, 1 0 - S3 7 ,9 27 21 25 ,, 23 ;;• 17 23 21 25 21 21 20 22 ^ 2? ^ * ": l ^ 3 2 ^ 20 12 14 10 20 15 17 19 2D CO Comparison in [ dB] - 3D - 20 - lO O 10 20 30 3 0 - MD2 7 ,9 ' o- " - MD3 9 . 3 1 + 0 4 :; 9 + 1 1 L 4 + 6 6 e 6 lO 0 12 lO 7 e © 1 • 6 + IS 12 GS Grayscale - SO ~ 20 - lO O lO 20 30 VA Value Table in [ dB) 20 25 27 19 27 ZS 20 23 25 ... ZZry^ P 27 JS 23 S IJIJ | 1< J ^ 3 23 10 14 23 " 26 2B 27 S3 22 2J 22 DC Defect Curve -> rank CO Comparison in [ dB] ~ 30 - 20 - 10 O lO 20 30 MD2 2 . G o- MD3 5 . 2 + + + + 6 + + lO ! id9 + + + + + 6 + + 5 17 12 FIG. 3. ( A) Patient 2: Initial visual field by Octopus ( Interzeag AG Schleinen- Zurich, Switzerland) technique, left eye ( G1X program mean sensitivity, 19.4 dB). Visual acuity 20/ 60. ( B) Patient 2 Final visual field by Octopus technique, left eye 68 days later ( G1X program; mean sensitivity, 23.6 dB). Visual acuity 20/ 30. ./ Neiiro- Ophlhalmol, Vol. IK No. I I9V8 168 R. L. TOMSAK AND X N. 7AKOV ( kinetic fields in two; automated threshold Fields in two). In three of four eyes, visual fields improved somewhat ( Figs. 2 and 3). In the fourth patient, threshold automated perimetry was stable, although visual acuity improved 2 Snellen lines. Two patients hail resolution of longstanding MF within 13 to 30 days of beginning therapy with diclofenac drops ( Voltaren; Ciba Vision Ophthal-mics, Duluth, CiA, U. S. A.). DISCUSSION Ours was a preliminary study with a small sample size. However, our patients with NAION and MF had much more frequent improvement in visual acuity ( 85%) than that reported in patients with NAION alone ( 30- 4070 ( 1- 3). The typical magnitude of improvement was consistent with thai reported, although two ol" our patients had improvements of 7 and 9 Snellen lines. It is probable that the more frequent improvement in visual function in our patients was related to resolution of MF. Our visual field data, although limited, are consistent with this explanation, in that the pattern of visual field improvement was not as striking as the improvement in visual acuity ( Figs. 2 and 3). Various treatments were used in an uncontrolled manner in our patients, and no clear- cut trends were observed. However, one patient had persistent MF for 6 months, despite treatment with oral prednisone and ac-ela/ olamide. The ME cleared completely after 1 month of treatment with diclofenac eye drops ( Voltaren; Ciba) four limes a day. Macular edema is not noted as a finding in the clinical profile and natural history of NAION ( 4- 6), in fluorescein angiography in NAION ( 7), or in ischemic optic neuropathy associated with giant cell arteritis ( 8,9). However, in two reports regarding optic neuropathy associated with macular star figures ( 10,11) 6 of 37 patients with NAION were noted to have macular star figures. Unfortunately, no further comment is made about these cases. The investigators slate, however, that macular star figures are not associated with fluorescein leakage as a rule ( 10). Other investigators have recognized that optic disc edema may accompany MF in aphakic and pseudophakic eyes and may mimic NAION ( 12). However, the clinical symptoms and signs of ME after cataract surgery arc far different from those ol" NAION. In the former disorder, visual loss is gradual, disc edema is mild and diffuse, peripapillary hemorrhages are absent, visual field loss is limited to relative central scotomas, and a relative afferent pupillary delect is not observed. Our experience is that the MF associated with NAION is often subtle and can be missed unless carefully excluded by Hruby lens or contact lens fundus examination. This edema most likely represents " spillover" into the papillomacular bundle from primary disc edema. In summary, patients who have MF associated with NAION seem to have a greater chance of improvement than those with NAION alone. This visual improvement appeals to be related in part to resolution of coexisting Mli. Pharmacologic treatment of ME in these patients seems warranted. REFERENCES 1. Ycc IX Selky AK. Purvis VA. Outcome of surgical and nonsurgical management of nonarterilic anterior ischemic optic neuropathy. Trcms Am Ophthalmol Sue 1993: 91: 227 43. 2. Ischemic Optic Neuropathy Decompression Trial Research Group. Optic nerve decompression surgery lor nonarterilic anterior ischemic optic neuropathy ( NAION) is not effective ami may be harmful. JAMA 1995: 273: 625. 3. Arnold AC llepler RS. Natural history of nonarterilic of nonar-teritie anterior ischemic oplic neuropathv. ./ Ncnro- Ophthalntol 1994: 14: 66- 9. 4. lioghen DR. ( ilascr . IS. Ischaemic optic neuropathy: the clinical profile and natural history, Ilrain 1975; 98: 689- 708. 5. Repka MX. Savino IM. Schal/ N. I. Sergoll KC Clinical profile and long- term implications of anterior ischemic oplic neuropathy. Am J Ophthalmol 1983: 96: 478- 83. ( i. Pllenbcrger C Jr, Keltner. ll., Uurtle RM. Acute oplic neuropathy in older patients. Arch Neurol 1973: 28: 182- 5. 7. Arnold AC. Ilcplcr RS. Fluorescein angiography in acute nonar-leritic anterior ischemic oplic neuropathv. Am J Ophthalmol 1994; I 17: 222 30. 8. Mack 11( 1. O'Day .1, Oniric . IN. Delayed choroidal perfusion in giant cell arteritis. ./ Clin Ncttro- Ophlhalmol 1991: 1 1: 221- 7. 9. Siatkouski RM. ( lass JDM. ( ilascr JS. et al. Fluorescein angiography in the diagnosis of giant cell arteritis. Am J Ophthalmol 1993: 1 15: 37- 63. 10. Wang A ( i, l. iu . I I I , I. in 0 l„ Yen M Y . Macular star in optic neuropathy. Am J Ophthalmol 1995: 27: 107 1 2. 1 I. Bra/ is PW. l, ce A( i. Oplic disc edema with a macular star. Mayo Clin I'roc 1996: 71: 1 162- 6. 12. Slavin Ml.. Lopinto R. I. Pryvvcs AS. Rosen DA. Oplic disc edema with aphakic cystoid maculopalhy masquerading as ischemic optic neuropathy. ./ Clin Ncttro- Ophlhalmol 1985; 5: 180- 4. ./ ScitKi- OplillMlnial. Ytil. IS, N„. .<. IWS |
