[Anterior ischemic optic neuropathy: Etiology, pathogenetic mechanisms and therapy]

Associations between thrombophilic risk factors and determinants of atherosclerosis and inflammation in patients with non-arteritic anterior ischaemic optic neuropathy

Non-arteritic anterior ischaemic optic neuropathy (NAION) is caused by ischaemia of the optic nerve head. The pathophysiology of NAION is unclear, and no proven effective treatment exists. Patients, methods: We analyzed thrombophilic risk factors and determinants of atherosclerosis and inflammation in 109 consecutive patients and 109 age- and sex-matched volunteers using a case-control design. Results: High levels of fibrinogen (>384 mg/dl; OR 3.2, p = 0.003), factors VIII:C (>183%; OR 2.6, p = 0.02), IX (>153%; OR 2.6, p = 0.026), XI (>142%; OR 3.4, p = 0.006), von Willebrand factor (activity >205%; OR 3.1, p = 0.005; antigen >194%; OR 3.5, p = 0.002), and triglycerides (>228 mg/dl; OR 2.8, p = 0.026), higher platelet counts (>294 000/[uni03BC]l; OR 2.5, p = 0.04), low levels of HDL cholesterol (<40 mg/dl; OR 2.7, p = 0.032), and an accelerated erythrocyte sedimentation rate (>20 mm/h; OR 4.4, p = 0.003) were associated with NAION. Conclusion: Our findings support the contention of a complex pathogenesis of NAION resulting from the coincidence of proatherogenic, prothrombotic and proinflammatory processes. The alterations described could be causative, side effects, or just coincidental findings.

[Optic disc swelling : A compilation of relevant differential diagnoses]

Optic disc oedema describes blurred optic disc margins. It describes an unspecific clinical sign with various possible underlying causal mechanisms. The correct diagnosis and the detection of the underlying disease is however of special clinical importance. This article summarizes the most important differential diagnoses and gives advice to find the correct diagnosis.

A Young Man With Severe and Disabling Complications of Septic Shock

A young man had severe septic shock with multiorgan failure due to necrotizing fasciitis caused by group A streptococcus after endoscopic repair of a preperitoneal inguinal hernia. He was treated with surgical exploration and antibiotics and resuscitated with fluids, vasopressors, and inotropic agents. He survived this critical illness, but when he woke up from sedation, his vision was lost in both eyes. Ophthalmological evaluation revealed minimal peripapillary retinal hemorrhages without signs of papillary edema. Visually evoked potentials were negative. Magnetic resonance imaging did not show a cause of the visual damage. The patient had bilateral ischemic optic neuropathy diagnosed. Two weeks later, unilateral sudden deafness also developed. The acquired blindness and hearing loss were unchanged after more than 1 year and seem to be permanent, severely disabling this young survivor of septic shock.

Recovery of visual function after administration of dabigatran etexilate

A 46-year-old Caucasian female underwent pars plana vitrectomy (ppv) for retinal detachment. After the procedure, the patient could only distinguish hand movements; the condition was tentatively diagnosed as nonarteritic anterior ischemic optic neuropathy. Conventional treatment with systemic corticosteroids and acetylsalicylic acid was ineffective and yielded substantial steroid-related side effects. Additional administration of 2 × 110 mg dabigatran etexilate (Pradaxa(®)), a novel direct thrombin inhibitor, resulted in a prompt and marked improvement of visual acuity, which indicated improved blood flow in the central vessels of the optic nerve. Dabigatran etexilate may provide a promising alternative for the treatment of postprocedural vision loss after ppv.

[Retrospective case analysis of ophthalmological and systemic risk factors in patients with retinal vascular occlusion]

OBJECTIVE

The aim was to determine systemic risk factors for acute central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO) and to evaluate the usefulness of systemic diagnostics in CRAO and CRVO.

METHODS

The study consisted of a retrospective chart review including 80 patients (CRAO 38, CRVO 42). All patients underwent systemic diagnostics including blood pressure measurement, blood cholesterol level, carotid Doppler imaging, transthoracic echocardiography (TTE), intraocular pressure measurement, glaucoma history and presence of thrombophilic factors. A systemic medical history was obtained.

RESULTS

Systemic hypertension was found in 76.3% CRAO and 75.6% CRVO patients. Abnormal cardiac findings were detected in 61% (CRAO) and 22% (CRVO). Abnormal carotid findings were detected in 44.1% for CRAO and 9.5% for CRVO. Pathological thrombophilic factors were found in both groups for approximately 15%.

CONCLUSIONS

TTE and carotid Doppler are important tools in the diagnosis of sources of emboli in patients with CRAO, while for CRVO abnormal findings are revealed by TTE and carotid Doppler less often. Thrombophilia should be ruled out in the absence of common risk factors, especially in younger patients and systemic hypertension should be adequately controlled.

Anterior ischemic optic neuropathy due to abdominal hemorrhage after laparotomy for uterine myoma

INTRODUCTION

This retrospective observational case report describes a very rare but dreadful ocular complication due to severe blood loss in association with a major surgical procedure. It is the first time that this complication is reported in gynecological surgery.

CASE REPORT

A previously healthy 41-year-old woman underwent hysterectomy because of large uterine myomas. Postoperatively, she was found to be severely anemic (hemoglobin 7.2 g/dl), but refused blood transfusion. Thirty-six hours after the first operation, relaparotomy was performed with extraction of a 1.5 l blood clot from the abdominal cavity. When she woke up from general anesthesia, the woman complained of visual loss in her left eye. At the time of visual loss, the hemoglobin level was 5.2 g/dl and the patient agreed to infusion of packed red blood cells. Ophthalmic examination revealed in the left eye an anterior ischemic optic neuropathy (AION). The optic disk was small, swollen and hyperemic (visual acuity at 8/10 with a superior altitudinal visual field defect). The right eye also had a small optic disk with a small cup (disk at risk), but no functional impairment. Despite blood transfusion, the left eye did not show any recovery and the optic disk had a pale appearance when examined after 3 years.

CONCLUSION

Development of AION in this case was due to severe blood loss accompanied by head-down surgery in an eye with so-called "disk at risk". Meticulous management of perioperative systemic hypotension and early correction of anemia may reduce the risk of perioperative visual loss.