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Aetiology

• Perioperative non-arteritic
  • Most commonly, occurs after heart surgery, spinal surgery, major thoracic or abdominal procedures
• Arteritic (A-PION)
  • giant cell arteritis
  • similar to A-AION
• 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

• Retrobulbar neuritis / MOG / NMO
  • “Enhancement” in MRI
  • Normal choroidal perfusion in fluorescein angiography

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’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)