Bilateral Sequential Non-arteritic Anterior Ischemic Optic Neuropathy (NAION)

Abstract

This is a case report of a rare case of bilateral sequential non-arteritic anterior ischemic optic neuropathy (NAION). A 50-year-old Indian gentleman, who is a known case of diabetes and an active smoker, presented with a right eye painless inferior visual field defect upon waking up from sleep. Fundoscopy revealed swollen right optic disc with peripapillary splinter hemorrhage while Humphrey visual field (HVF) showed right inferior altitudinal scotoma. Computed tomography of the brain and orbit proceeded to rule out compressive lesions. Thus, a diagnosis of right eye NAION was made. Three months later, he complained of a worsening visual field of the right eye. His right eye's optic disc was pale; however, the left was hyperemic and swollen with peripapillary splinter hemorrhage. HVF showed right eye tunnel vision while the left eye displayed inferior arcuate scotoma. Further investigation revealed suspicious enhancement of both intra-orbital optic nerves in magnetic resonance imaging suggestive of bilateral optic neuritis. Diagnosis of bilateral atypical optic neuritis was made. Thus, the patient was loaded with intravenous methylprednisolone 1 g/day for five days and subsequently oral steroid in tapering doses along with topical brimonidine tartrate 0.2%. Despite that, his left eye's visual field progressively deteriorated to inferior altitudinal scotoma. Subsequently, the lumbar puncture test performed was unremarkable while repeated MRI of the spine and brain showed no focal enhancing lesion. The patient revealed that he had a history of taking phosphodiesterase type 5 (PDE5) inhibitor (tadalafil) on and off over the past year. Diagnosis of bilateral sequential NAION was made and he was co-managed with the endocrine team to optimize his diabetic status. His subsequent visual field remained static with right eye tunnel vision and left eye inferior altitudinal scotoma. In conclusion, progressive NAION of the same eye or fellow eye is rare and mandates further investigations. It is important to identify and manage all the systemic and local risk factors to prevent further attacks. Although there is no rigid evidence stating that intake of PDE5 inhibitors can directly lead to NAION, patients with co-existing predisposing risk factors should be warned about possible ischemic ocular side effects of PDE5 inhibitors.

Non-arteritic anterior ischaemic optic neuropathy (NA-AION) and COVID-19 vaccination

“…In men, the use of sildenafil/tadalafil (a phospodiesterase (PDE-5) inhibitor)) may also contribute to the occurrence of NA-AION 22 23. PDE-5 inhibitors are also weak inhibitors of phosphodiesterase type six functions in phototransduction.…”

Non-Arteritic Anterior Ischemic Optic Neuropathy Associated With the Use of Phosphodiesterase Type 5 Inhibitors: A Literature Review

“…In African Americans, it is less prevalent and is most common in Caucasians probably since African Americans are more likely to have a large physiologic cup and less likely to have a crowded disc, which is the leading predisposing factor for creating NAION [ 25 ]. NAION is a progressive disease in nature, and the rate of contralateral eye involvement is 15-20% in the following five years [ 26 , 27 ].…”

“…The lack of confirmatory tests makes NAION diagnosis difficult, especially when there is bilateral sequential involvement [ 27 ]. It can be difficult to distinguish NAION from arteritic AION during the initial evaluation [ 30 ].…”

“…A gadolinium-enhanced MRI of the orbits should be performed in certain cases to differentiate between NAION, and inflammatory optic neuropathy and most often will show enhancement of the optic nerve head in inflammatory neuropathies [ 25 ]. MRI findings, especially during the acute phase, can be non-specific [ 27 ].…”

“…A study of optic nerve sheath decompression for the treatment of NAION found that it was "not an appropriate treatment for NAION and showed that it was harmful" [ 22 ]. Although topical brimonidine has been suggested to have neuroprotective properties, it has not been statistically proven to improve VA when compared to placebo [ 27 ].…”