Hypotensive Ischemic Optic Neuropathy

    • Infarction of the optic nerve caused by acute systemic hypotension
    • Arises most commonly after prolonged prone-position lumbar spine surgery, cardiac and other non-ophthalmic procedures, acute septic and non-septic systemic hypotension
    • Vision loss may spontaneously improve
    • No effective treatment
    • Core features
      • Painless vision loss in one eye or both within days of systemic hypotension
      • Visual acuity and/or nerve fiber bundle visual field loss
      • Afferent pupil defect unless both eyes are affected equally
      • Optic discs appear normal ophthalmoscopically or show acquired elevation
      • No other pertinent clinical findings
      • Orbit and brain MRI may be normal or show restricted diffusion in the orbital segment of the affected optic nerves
    • Arteritic ischemic optic neuropathy
    • Typical optic neuritis
    • Atypical optic neuritis
    • Compressive optic neuropathy
    • Radiation-induced optic neuropathy
    • Chiasmal and retrogeniculate vision loss (but should show hemianopic rather than nerve fiber bundle visual field defects)
    • Perform MRI to exclude alternative retrobulbar causes
    • Perform lumbar puncture only if there was no preceding episode of systemic hypotension
    • Correct systemic hypotension to prevent further vision loss
    • Trap: do not prescribe hyperbaric oxygen treatment, which is often invoked in desperation but has been proven to be ineffective
    • Vision may improve within weeks but substantial vision loss usually persists

    Optic Nerve And Chiasm Disorders

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