Anterior ischemic optic neuropathy

Classification according to ICD-10
H47.0	Optic Nerve Affections, Not Elsewhere Classified - Ischemic Optic Nerve Neuropathy
ICD-10 online (WHO version 2019)

As papillae apoplexy , Optikomalazie or anterior ischemic optic neuropathy ( AION ) (imprecise and colloquially: Eye infarction ) refers to the acute occlusion of the optic nerves supplying ophthalmic artery in tin-Haller-vessel coronary, after which the optic nerve head blood supply too little and thus insufficient oxygen and nutrients is supplied. This clinical picture represents an emergency situation.

Disease mechanism

The lack of oxygen due to the acute onset of insufficient blood flow to the optic nerve head leads to damage to the nerve fibers. This leads to a sudden deterioration in vision in one eye . If an AION occurs, medical help should be sought as quickly as possible, as the damage cannot be reversed after a few hours.

AION is usually caused by a vascular obstruction ( embolism ) in the context of atrial fibrillation or endocarditis or advanced arteriosclerosis , as occurs especially in people with diabetes mellitus . Less often, a decrease in blood volume or blood clotting disorders can lead to AION. In 90% of patients with AION, diseases of the cardiovascular system such as high blood pressure (60–70%) or diabetes mellitus (25%) can be found as triggers of AION. Inflammation of the blood vessels ( vasculitis , e.g. giant cell arteritis ) can also lead to AION and must be treated specifically. A distinction is therefore made between an AION with an inflammatory cause and an AION without an inflammatory cause ( non-arteritic anterior ischemic optic neuropathy , NAAION ).

A non-arteritic anterior ischemic optic neuropathy is also discussed in connection with Viagra and other so-called PDE-5 inhibitors for the treatment of erectile dysfunction . Affected men are usually older than 50 years. Farsightedness also seems to be a risk factor for an AION. AION can also occur in rare cases during surgery, probably due to a drop in blood pressure and anemia. The role of particularly low nocturnal and early morning blood pressure values ​​during sleep (systolic below 100, diastolic below 60 mm Hg) as well as the negative influence of increased intraocular pressure values, which presumably both promote the risk of vascular occlusions on the optic nerve, are also discussed.

A deep vascular occlusion of the optic nerve leads to the rare clinical picture of posterior ischemic optic neuropathy , PION .

Clinical picture, examination

Those affected by an AION notice a sudden, significant loss of visual acuity affecting one eye. The affected eye can even lose sight completely, causing the affected eye to go blind in that eye. If the affected eye is illuminated with a light source, the direct pupil reaction, as an expression of an afferent pupillary disorder, is very sluggish or absent and the pupil does not become narrower. However, the consensual pupillary reaction is normal; H. the affected pupil contracts normally when the other eye is illuminated. The diagnosis of AION is primarily made fundoscopically . Typically, the optic nerve head is not clearly delineated as a result of edema. Often the optic nerve head is also pale as an expression of the circulatory disorder. The finest bleeding is visible in and around the papilla. In perimetry , a restriction of the can the visual field ( scotoma ) show. Finally, a dye representation of the vessels (fluorescence angiography) u. U. a reduced blood supply to the optic nerve head can be detected.

Suspicion of inflammatory cause (s. O.) Has to histological u diagnosis. An arterial biopsy of the temporal artery may be performed. Laboratory tests such as ESR and CRP , as well as an MRI of the head can also be helpful.

therapy

There is currently no uniform therapy scheme. Various methods are used with the aim of improving the blood flow to the eye: lying the patient flat, massaging the eyeball, thinning the blood with infusions ( hemodilution ), acetazolamide , beta blockers , anticoagulant with low molecular weight heparin and acetylsalicylic acid . The current therapy usually consists in the administration of blood circulation-enhancing drugs, for example calcium antagonists for vasodilation, a massage of the eye, a lowering of intraocular pressure by paracentesis of the anterior chamber or high pressure oxygen therapy . The importance of lysis therapy has not yet been clarified. Inhibiting blood coagulation ( anticoagulation ) must be considered depending on the cause. The effectiveness of the therapies currently offered has not yet been scientifically proven (see also evidence-based medicine ).

An inflammatory cause, such as giant cell arteritis, must be specifically treated with high-dose, long-term cortisone therapy.

course

Often, despite the rapid start of therapy, the original vision can no longer be restored. With central artery occlusion of the retina, therapy can improve vision in only 1–8% of patients. Patients who suffer from AION are at an increased risk of having a stroke or heart attack because of the similar risk factors. Up to 18% of patients develop rubeosis iridis after AION .

The causal diseases leading to the event or the risk factors promoting it will usually lead to internal and neurological follow-up examinations.

literature

• Guidelines from BVA (Professional Association of Ophthalmologists Germany eV (BVA)) and DOG (German Ophthalmological Society), guideline No. 29, Anterior ischemic optic neuropathy (AION) http://augeninfo.de/leit/leitlinie.php?nr = leit29
• Matthias Sachsenweger: Ophthalmology (= dual series ). 2nd, completely revised and expanded edition. Georg Thieme, Stuttgart et al. 2003, ISBN 3-13-128312-2 , pp. 316-317.
• Sohan Singh Hayreh: Ischemic Optic Neuropathies. Springer, 2011. ISBN 978-3-642-11849-4 (print); ISBN 978-3-642-11852-4 (eBook)

Individual evidence

1. ↑ GE Lang, SJ Lang: Venous and arterial vascular occlusions of the retina. In: Ophthalmology up2date. Vol. 2, No. 1, 2012, ISSN  1616-9719 , pp. 15-32, doi : 10.1055 / s-0031-1298144 .
2. ↑ D. Pahor, B. Gracner: Far-sightedness as a risk factor for patients with non-arteritic anterior ischemic optic neuropathy. In: Clinical monthly sheets for ophthalmology. Vol. 225, No. 12, 2008, ISSN  0023-2165 , pp. 1070-1074, doi : 10.1055 / s-2008-1028000 .
3. ↑ P.-F. Kaeser, F.-X. Borruat: Perioperative Visual Loss: A Rare Complication of General Surgery. In: Clinical monthly sheets for ophthalmology. Vol. 225, No. 5, 2008, pp. 517-519, doi : 10.1055 / s-2008-1027348 .
4. ↑ Mai T. Pham, Rachel E. Peck, Kendall RB Dobbins: Nonarteritic ischemic optic neuropathy secondary to severe ocular hypertension masked by interface fluid in a post-LASIK eye. In: Journal of Cataract & Refractive Surgery. 39, 2013, p. 955, doi : 10.1016 / j.jcrs.2013.04.027 .
5. ↑ B. Katz, RN Weinreb, DT Wheeler, MR Klauber: Anterior ischaemic optic neuropathy and intraocular pressure. In: The British journal of ophthalmology. Volume 74, Number 2, February 1990, pp. 99-102, PMID 2310734 , PMC 1042000 (free full text).
6. ↑ H. Wilhelm: Procedure in the event of unclear visual impairment - a "brief guide". In: Clinical monthly sheets for ophthalmology. Vol. 229, No. 11, 2012, pp. 1103-1107, doi : 10.1055 / s-0032-1315310 .

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !