Clinical presentation of ischemic optic neuropathies

ABSTRACT Introduction Ischemic optic neuropathies (IONs) are the leading cause of sudden, permanent optic nerve-related visual loss. Areas covered There are three types of anterior and posterior (retrobulbar) IONs: nonarteritic, perioperative, and arteritic. In this review, we discuss the clinical manifestations, management, and prognoses – visual and systemic – of each type. A literature search was conducted via MEDLINE (PubMed) 1 January 1973 to 1 April 2023. Expert opinion There is no consistently beneficial treatment for the nonarteritic IONs. Patients who have experienced either spontaneous nonarteritic anterior ION (NAION) or an acute optic neuropathy following uncomplicated cataract surgery should be warned that they may have an increased risk of a similar event in their fellow eye if they undergo cataract surgery in that eye. Early recognition of perioperative ION after non-ocular surgery is crucial so that anemia and hypotension can be corrected as soon as possible, hopefully resulting in visual improvement. Finally, arteritic ION requires early recognition and timely treatment with systemic corticosteroids to prevent subsequent visual loss in the fellow eye as well as the many other complications of giant cell arteritis. The interleukin-6 inhibitor tocilizumab can be used to reduce both the dose of steroids and the duration steroids are needed.