1. A New Look
Prof Dr Sherif Ahmed Kamel Amer
MD ophthalmology, Cairo University, ICO.Ophth.
Professor & Head of The Ophthalmology Department,
Faculty of Medicine, Beni Suef University.
Supervisor of The Neuro-Ophthalmology
Clinic, National Eye Center (Rod El Farag).
Consultant Neuro_Ophthalmologist, Magrabi Eye
Hospitals, Egypt

2.  The classic syndrome consists of an acute
vascular insult to the optic nerve leading to
infarction of the optic nerve head.
 The disease presents with a sudden and
painless deterioration of vision, usually
discovered on waking in the morning, and
involving mostly the lower part of the visual
field in one eye

3.  1.Anterior ischemic optic neuropathy (AION):
Affects anterior part of the optic nerve.
 2.Posterior ischemic optic neuropathy
(commonly abbreviated to PION): This is a rare
type due to acute ischemia of posterior part of
the optic nerve.

4.  Arteritic AION (A-AION): This is the most
serious type and is dueto giant cell arteritis
(GCA).
 Non-arteritic AION (NA-AION): This is the
usual and the most common one, and consists
of all cases other than GCA

5.  Predisposing Factors: systemic or local (in the
eye and/or optic nerve head).
 Precipitating Factors: These act as the final
insult, resulting in ischemia of the ONH and
AION. A fall of BP during sleep (nocturnal
arterial hypotension) is an important factor in
this category

6.  The disk at risk
(subclinical
ischemia) shows the
following signs:
 Small scleral canal
 Crowding of nerve
fibers (Obliterated
Cup).
 Disc hyperemia
25%-40% of fellow eyes are
expected to develop NA-AION

7.  Optic disc swelling without any visual loss;
this indicates an early sign of non-arteritic
AION.
 Optic disc edema usually lasts for several
months unlike those seen initially with
visual loss.

8.  It is an infrequent but important subtype of
NA-AION.
 Further loss of vision may be experienced
days or weeks after the initial decrease in
vision.
 In some, a new ischemic episode may be the
cause of the further visual loss.
 Rarely, especially if the loss is intermittent
and gradual, a reversible loss may be seen
that can improve spontaneously.

12.  The number of cases with bilateral simultaneous
presentation with 20 cases having bilateral
simultaneous acute vascular optic neuropathy.
2
8
2
20
0 5 10 15 20 25
Diabetic
papillopathy
Chronic
Subacute
Acute
The Mode Of Presentation of Eyes With Bilateral Simultaneous
Vascular Optic Neuropathies

18. Diabetic
Papillopathy

20. 5
20
17
47
0
5
10
15
20
25
30
35
40
45
50
normal disc disk at risk incipient post ischemic
The Condition Of The Optic Nerve of The Other Eye in Cases Presenting
With Acute Unilateral Vascular Optic Neuropathy

24. 2.70%
4.60% 4.60%
22.20%
43.50% 53.70%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
The Total Cummulative Percent Of Major Systemic Risk Factors In Cases
With vascular Optic Neuropathy

25.  Vascular optic nerve diseases are a group of
diseases caused by deficient vascular supply of
the optic nerve on acute or chronic basis and
take different presentations and courses.
 The term ischemic optic neuropathy with it
subdivision anterior or posterior or arteritic
and non-arteritic is very far beyond explaining
the correct classification of these group of
diseases.

26.  Diabetic patients showed four types of
presentations:
 (a) the typical acute presentation with pale swelling
and altitudinal field defects
 (b) diabetic papillopathy with marked disc swelling
without pallor
 (c) disc swelling with disc pallor without history of
the acute stage, and
 (d) disc swelling with disc pallor without history of
the acute stage, and with neovascularization of the
disc (NVDs). Presentations other than the acute stage
were always bilateral while the acute presentation
was unilateral and bilateral.

27.  Diabetic eyes show the following stages of
vascular optic nerve disease disease: (a) disc at
risk (b) incipient stage (c) diabetic papillopathy
(d) Acute vascular optic neuropathy (e) chronic
disease with or without NVDs (f) post ischemic
neuropathy.
 Another special point for eyes associated with
diabetes is the higher incidence of bilateral
simultaneous ischemic acute optic neuropathy.
 The severity of involvement of both eyes was
always variable.

28.  A new look to the clinical classification is
mandatory in order to make an early
detection of subclinical cases for possible
prophylaxis of susceptible cases.
 The current classification of vascular optic
neuropathies is seriously deficient and does
not describe different stages of the disease..

29.  Prodromal Vscular Neuropathy :
 Disc at risk
 Fellow discs
 Discs in patients with longstanding,
uncontrolled risk factor, or more
than one risk factor.
 Incipient Vascular Neuropathy: Nerve
head with swelling without visual loss.

30.  Subacute Vascular Neuropathy:
 Optic disc swelling without pallor associated
with nerve fiber layer hemorrhages and
transient attacks of blurring of vision or
transient field defects.

31.  Chronic (Slowly Progressive) Vascular
Neuropathy:
 Dry chronic vascular optic neuropathy: slowly
progressive disc ischemia without disc edema not
passing through the acute stage.
 Vascular neuropathy due to anemia
 Wet chronic vascular optic neuropathy: slowly
progressive disc ischemia with disc edema with or
without pallor not passing through the acute stage
 Diabetic vascular neuropathy; Papillopathy

32.  Acute Vascular Neuropathy:
–Mild with BCVA of 66-612
–Moderated with BCVA of 618-636
–Acute profound with BCVA of 660 or less
–Acute recurrent.

33.  Post Ischemic Optic Neuropathy
 – On top of acute.
 – On top chronic.