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Show PHOTO ESSAY Prolonged Premonitory Optic Disc Signs In Anterior Ischemic Optic Neuropathy Jonathan L. Prenner, MD, Atul Sharma, MD, Michael S. Ibarra, MD, Albert M. Maguire, MD, and Nicholas J. Volpe, MD FIG. 1 . Initial presentation. A: A pink mass is evident in the superotemporal portion of the right optic nerve. B: Fluorescein angiogram, early phase, shows filling of the mass. C: Fluorescein angiogram, late phase. The dye stains the optic disc. " preemptive" and " eruptive" disc edema has not been well documented in NAION. ( JNeuro- Ophthalmol 2002; 22: 110- 112) A 55- year- old man with a history of hypertension was referred for evaluation of an optic nerve abnormality in the OD. A complete eye examination four years earlier was normal. At presentation, the visual acuity was 20/ 20 OU, and the external and afferent examinations, including color vision, pupils, and Goldmann visual fields were normal. The fundus examination OD showed a fleshy appear- A patient displayed a pink mass on the right optic disc and normal visual function that was diagnosed as a capillary hemangioma. Seven months later, he developed typical features of nonarteritic anterior ischemic optic neuropathy ( NAION) in that eye. Such a long latency between Retina and Neuro- Ophthalmology, Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA ( JLP, AS, MSI). Address correspondence to Jonathan L. Prenner, MD, Scheie Eye Institute, University of Pennsylvania, 51 North 39th Street, Philadelphia, PA 19104, USA ^ 1 1 0 . pOL10.1097/ 01. WNO, Q. 0Q0018221,83526,. 29 J Neuro- Ophthalmol. Vol. 22, No. 2,. 2Q02 , Copyright © Lip pincott Williams & Wifkins. Unauthorized reproduction of this article is prohibited. PHOTO ESSAY JNeuro- Ophthalmol, Vol. 22, No. 2, 2002 x FIG. 2. Seven- month follow- up. A: Right optic nerve shows segmental swelling and a splinter hemorrhage. B: Goldmann visual field of OD shows an inferior altitudinal defect. C: Fluorescein angiogram, early phase. Right optic nerve fills with dye. D: Fluorescein angiogram, late phase. Right optic nerve stains with dye. ing pink " mass" with dilated blood vessels occupying the superotemporal optic nerve ( Fig. \ A). The left optic nerve was normal, as were both retinas. A laboratory evaluation including ESR, RPR, FTA-ABS, ACE, CBC, and hemoglobin A1C level was unremarkable. An ultrasound was normal except for disc elevation. Fluorescein angiography demonstrated patchy choroidal filling in the area surrounding the optic nerve ( Fig. IB). The area occupied by the lesion showed marked capillary prominence and vascular telangiectasias. The optic nerve stained late in the area of the lesion ( Fig. \ C). Based on the patient's excellent visual acuity, chronicity of the lesion, and behavior of the lesion during fluorescein angiography, a presumptive diagnosis of capillary hemangioma was considered. FIG. 3. Twelve- month follow- up. The right optic disc is pale; the " pink mass" has disappeared. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited JNeuro- Ophthalmol, Vol. 22, No. 2, 2002 PHOTO ESSAY On follow- up visits, the patient remained asymptomatic, and the disc appearance was unchanged. Seven months later, he noticed an area of blurring and visual loss in the inferior nasal quadrant of the OD. The visual acuity was 20/ 20, but an afferent pupillary defect ( APD) was present OD. The optic nerve showed segmental swelling and splinter hemorrhages typical of ischemic optic neuropathy ( Fig. 2A). A Goldmann visual field demonstrated an inferior al-titudinal defect ( Fig. 28). Fluorescein angiography showed patchy choroidal filling, subretinal hemorrhage and more marked staining of the optic nerve ( Figs. 2B, C). The OS remained normal. At one- year follow- up, the patient had 20/ 20 vision, a persistent field defect, an APD in the OD, and superior segmental disc pallor ( Fig. 3). Premonitory swelling in nonarteritic anterior ischemic optic neuropathy ( AION) is a well recognized phenomenon ( 1- 5). Patients with this condition are seen during an asymptomatic phase in which no visual dysfunction is measured, but the optic disc is swollen. Previous reports have demonstrated premonitory swelling in patients with a history of AION in fellow eyes or in patients with previous intraocular surgery ( 2,3). Hayreh described four patients with classic presentations of AION in one eye and asymptomatic disc edema in the fellow eye. These eyes eventually developed typical AION over 3 to 8 months ( 2). Gordon et al. ( 3) described two patients with asymptomatic disc edema, one with previous AION in the fellow eye, and one patient who had undergone cataract surgery. He suggested that these patients had a form of AION severe enough to disrupt axoplasmic flow, but mild enough to prevent visual acuity loss, visual field deficits, or dyschromatopsia ( 3). To our knowledge, this case represents the first report of a patient with documented asymptomatic optic disc edema who progressed to typical AION without a previous history of AION in the fellow eye and without a previous history of intraocular surgery. Our patient presented with an asymptomatic, bulbous- appearing optic nerve lesion similar to a capillary hemangioma. As reported by Hayreh, this initial state presumably represents a " mild ischemia," wherein axoplasmic flow is focally compromised, but ax-onal function is intact enough to preserve vision ( 2). Few descriptions of fluorescein angiography of patients in the premonitory swelling phase of AION have been provided. Hayreh described capillary dilation, microaneurysms, optic disc leakage, and optic disc staining during angiography ( 2). These angiographic features may help distinguish the early disc swelling of AION from that of optic nerve head capillary hemangioma. REFERENCES 1. Arnold AC, Helper RS. Fluorescein angiography in acute nonarteritic anterior ischemic optic neuropathy. Am J Ophthalmol 1994; 117: 222- 30. 2. Hayreh SS: Anterior ischemic optic neuropathy. V. Optic disc edema an early sign. Arch Ophthalmol 1981; 99: 1030- 40. 3. Gordon RN, Burde RM, Slamovits T. Asymptomatic optic disc edema. J Neuro- Ophthalmol 1997; 17: 29- 32. 4. Smith JL: Pseudohemangioma of the optic disc following ischemic optic neuropathy. J Clin Neuro- Ophthalmol 1985; 5: 81- 9. 5. Friedland S, Winterkorn JM, Burde RM. Luxury perfusion following anterior ischemic optic neuropathy. J Neuro- Ophthalmol 1996; 16: 163- 71. _ 112 . . _ . . . . © 2002 Lippincott Williams & WUkins , Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. |
