AJ Sikes Ophtho @ VA 11/4/11 Posterior Ischemic Optic Neuropathy (PION) Definition Rare loss of visual acuity/fields due to ischemia

mia of the retrobulbar optic nerve due to a variety of causes perioperative - during/after surgery arteritic - systemic vasculitis (usually giant cell) nonarteritic - no history of surgery or systemic arteritis (same risk factors as nonarteritic AION) may co-exist with ischemia of retina and optic nerve head due to the same causes vs. Anterior ION - ischemia of optic nerve head (abrupt and painless loss of vision usually unilaterally and in older patients); typically presents with swelling of the optic disc, extending for a short distance beyond the disc margin, and associated small, flame-shaped hemorrhages Epidemiology - rare, few studies Predisposing/Risk Factors Perioperative - large blood loss; spine surgery and radical neck dissection arteritic - for GCA, older age, heredity, Northern European ancestry, HLA-DR4, polymyalgia rheumatica, ? infectious trigger nonarteritic - similar to AION; vascular risk factors and comorbid vascular disease; possibly small cup (disk at risk) Clinical Manifestations No optic disk swelling during the acute stage of the disease Optic nerve atrophy with disc pallor over four to six weeks Optic disc cupping may develop later in arteritic, but not in surgical or nonarteritic afferent pupillary defect, unless bilateral involvement and impaired color vision altitudinal defect or central scotoma Perioperative - profoundly decreased visual acuity/fields, or blindness, unilaterally or more commonly bilaterally, occuring immediately post-operatively or in the postoperative period Arteritis - signs and symptoms characteristic of the particular arteritis, such as the classic scalp tenderness, jaw claudication and headaches of GCA; profound visual deficits Nonarteritic - Sometimes preceded by amaurosis fugax (temporary visual deficit) with less profound visual deficits Pathophysiology/etiology Normal physiology - anterior segment of optic nerve supplied by pial plexus from collateral branches of the ophthalmic artery and central retinal artery; posterior segment supplied by the pial capillary plexus (that derive from collateral branches of ophthalmic artery) that surrounds the nerve and the nerve is only penetrated by a small number of capillaries which makes it relatively poorly vascularized Pathophysiology - varies by type of PION perioperative - massive blood loss causes anemia or hypovolemic hypotension leading to infarction of optic nerve arteritic - vasculitis leading to thrombosis nonarteritic - associated with other vascular diseases, so pathophysiology is associated with same processes as atherosclerotic disease When nerve swells from initial ischemia, it undergoes further compressive injury due to its course through the optic canal Diagnosis Perioperative - usually obvious; deficit in visual acuity/field following blood loss in absence of disk swelling or peripapillary hemorrhage concurrent with visual loss Rule out:

other retrobulbar optic neuropathies - compressive, infiltrative lesions, optic neuritis; compressive/infiltrative more insidious onset; neuritis painful other peri-operative visual disturbances - CRAO, stroke, direct injury to eye, etc. complete ophtho exam - acuity, fields, pupils, slit-lamp, ophthalmoscopy Neuroimaging - contrast-enhanced MRI to rule out compressive or infiltrative optic neuropathy (enhancement of optic nerve in GCA, but not specific) Prevention/Management Perioperative - Prevention is paramount Modify surgical parameters - positioning (e.g., head up, minimize stasis), careful hemodynamic monitoring, limit controlled hypertension, transfuse anemic patients, staged operations for lengthy procedures Arteritic - manage as would the specific arteritis - initiate steroids if this is a possibility Nonarteritic - evaluate more carefully for systemic vascular disease and related risk factors and treat to reduce risk of recurrence in other eye or in other organs (aspirin and atherosclerosis risk factor management) Sources Nitti JT, Nitti GJ. Chapter 46. Anesthetic Complications. In: Morgan, Jr. GE, Mikhail MS, Murray MJ, eds. Clinical Anesthesiology. 4th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=895440. Accessed November 3, 2011. Riordan-Eva P, Hoyt WF. Chapter 14. Neuro-Opthalmology. In: Riordan-Eva P, Whitcher JP, eds. Vaughan & Asbury's General Ophthalmology. 17th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx? aID=3091596. Accessed November 3, 2011. Connolly SE, Gordon KB, Horton JC. Salvage of vision after hypotension-induced ischemic optic neuropathy. Am J Ophthalmol. 1994;117(2):235-42 http://www.ncbi.nlm.nih.gov/pubmed/8116753. Accessed November 1, 2011. Sadda SR, et al. Clinical spectrum of posterior ischemic optic neuropathy. Am J Ophthalmol. 2001; 132 (5): 743-50 http://www.sciencedirect.com/science/article/pii/S0002939401011990 Accessed November 1, 2011. Hayreh, SS. Posterior ischaemic optic neuropathy: clinical features, pathogenesis, and management. Eye. 2004;1881206 http://www.nature.com/eye/journal/v18/n11/full/6701562a.html Accessed November 1, 2011. Posterior ischemic optic neuropathy Uptodate.com