Posterior Ischaemic Optic Neuropathy (PION)

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Aetiology

  • Perioperative non-arteritic
    • Most commonly, occurs after heart surgery, spinal surgery, major thoracic or abdominal procedures
  • Arteritic (A-PION)
  • Non-arteritic (NA-PION)
    • Similar to NAION
    • Stenosis of the internal carotid artery, radiation damage

Findings

  • Acute, painless visual impairment uni-/bilaterally
    • Typically occurs within hours, sometimes days to weeks
    • Often perioperative, directly after awakening from surgery
  • Relative afferent pupillary defect (RAPD), if asymmetric
  • Visual field defects
  • Initially normal optic disc without disc swelling (contrary to AION)
    • Temporal disc pallor after approximately 6-8 weeks

Work-up

  • Perioperative
    • MRI of the head and orbit to rule out pituitary apoplexy, occipital stroke, or posterior reversible encephalopathy syndrome (PRES)
  • Arteritic (A-PION)
    • Similar to AAION
    • Laboratory tests: Complete blood count (thrombocytosis?), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)
    • consider ultrasound of the temporal artery and temporal artery biopsy
  • Non-arteritic (NA-PION)
    • Diagnosis by exclusion
    • Cardiovascular risk factors
    • consider carotid duplex sonography

Treatment

  • Perioperative: Treatment of hypovolemia/hypotension; otherwise, limited therapeutic options
    • Often bilateral, irreversible, severe vision loss
  • For arteritic origin: Steroids, as in giant cell arteritis

Differential diagnoses

Resources

  • EyeWiki Posterior Ischemic Optic Neuropathy
  • PION by Dr. Andrew G. Lee
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
  • Kanski‚Äôs Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)