Non-arteritic anterior ischaemic optic neuropathy in Malaysia: a 5 years review.
ABSTRACT To evaluate the clinical presentations and visual outcomes of non-arteritic anterior ischaemic optic neuropathy (NAION).
A retrospective study was conducted involving 18 consecutive patients (20 eyes) with NAION attending Hospital Universiti Sains Malaysia from January 2005 until December 2009.
Most patients were Malay (94.4%), and followed by Chinese (5.6 %). The female-to-male ratio was 3.5:1. The age of patients ranged from 36 to 85 years (mean, 57.1 years). The main risk factors in systemic diseases were hypertension (55.5%), diabetes mellitus (44.4%), and ischaemic heart disease (11.1%). Most patients (77.8%) presented with acute loss of vision while gradual onset was in 22.3% of cases. Majority had visual acuity worse than 1/60 (80%). The most common fundoscopic findings were peripapillary splinter haemorrhage (90%), sectorial swollen optic disc (60%) and hyperemic disc (60%). During follow up, 20% of the patients showed stabilization in visual acuity, and 80% showed worsening of vision.
Majority of patients with NAION presented with acute poor vision involving middle-aged and elderly individuals. Hypertension and diabetes mellitus were among the main risk factors involved. NAION can lead to permanent visual loss despite treatment.
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ABSTRACT: Based on histopathology, electron microscopic corrosion cast studies, optic nerve blood flow studies, and clinical data, the pathogenesis of idiopathic nonarteritic ischemic optic neuropathy includes the following features: (1) structurally crowded optic discs are predisposed; (2) laminar and retrolaminar regions are the most common locations for infarction; (3) there is flow impairment in the prelaminar optic disc during the acute phase; (4) lack of consistent choroidal flow impairment and the retrolaminar location of infarcts suggest vasculopathy within or distal to the paraoptic branches of the posterior choroidal arteries; (5) diabetes is the most consistently identified vasculopathic risk factor; (6) impaired autoregulation of the disc circulation by atherosclerosis, with a possible contribution from serotonin and endothelin-mediated vasospasm, may play a role; and (7) progression may be caused by secondary cell death after the initial ischemic insult or compression from cavernous degeneration and mechanical axonal distortion.Journal of Neuro-Ophthalmology 07/2003; 23(2):157-63. · 1.81 Impact Factor
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ABSTRACT: To describe the systemic and visual characteristics and prognosis in patients with nonarteritic ischemicoptic neuropathy (NAION) undergoing different treatments. Retrospective chart review was performed in Kaohsiung Veterans General Hospital patients from 1995-2005 with a clinical diagnosis of NAION, including nonarteritic anterior ischemic optic neuropathy and posterior ischemic optic neuropathy (PION). There were 14 PION patients out of a total of 103 cases. The average age at disease attack was 61 years old, and the ratio of males to females was 1.24:1. Comorbid systemic diseases and visual function were recorded at both initial presentation and the later follow-up period. The final results were recorded and compared by the different treatments they received in 4 groups. In all, NAION usually affected people > 50 years old, without any difference between sexes. Presenting visual acuity, age, and different treatment modes had no direct influence on the final visual outcome. The most significant associated factor was hypertension. NAION is a serious illness; the visual deficit persists even with aggressive treatment.Journal of the Chinese Medical Association 03/2007; 70(2):61-4. · 0.89 Impact Factor
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ABSTRACT: Anterior ischemic optic neuropathy, infarction of the optic nerve head owing to inadequate perfusion through the posterior ciliary arteries, is a common cause of visual loss in adults but is rarely reported in children, in part because the diagnosis is overlooked. We report two cases of young children undergoing chronic peritoneal dialysis, who suffered bilateral visual loss from anterior ischemic optic neuropathy. Predisposing local anatomic and multiple systemic factors included a small optic nerve head with little cupping, possible intraocular hypertension, and systemic hypotension, hypovolemia, and anemia. The literature on anterior ischemic optic neuropathy is reviewed.Pediatric Neurology 06/2002; 26(5):358-64. · 1.50 Impact Factor
窑 Clinical Research 窑
Non-arteritic anterior ischaemic optic neuropathy in
Malaysia: a 5 years review
Department of Ophthalmology, School of Medical Sciences,
Universiti Sains Malaysia, Health Campus, 16150 Kubang Kerian,
Correspondence to: Wan Hazabbah Wan Hitam. Department of
Ophthalmology, School of Medical Sciences, Universiti Sains
Malaysia, Health Campus, 16150 Kubang Kerian, Kelantan,
·AIM: To evaluate the clinical presentations and visual
outcomes of non-arteritic anterior ischaemic optic neuropathy
·METHODS: A retrospective study was conducted involving
18 consecutive patients (20 eyes) with NAION attending
Hospital Universiti Sains Malaysia from January 2005 until
·RESULTS: Most patients were Malay (94.4%), and followed
by Chinese (5.6 %). The female-to-male ratio was 3.5:1. The
age of patients ranged from 36 to 85 years
years). The main risk factors in systemic diseases were
hypertension (55.5% ), diabetes mellitus
ischaemic heart disease(11.1%). Most patients
presented with acute loss of vision while gradual onset was in
22.3% of cases. Majority had visual acuity worse than 1/60
(80% ). The most common fundoscopic findings were
peripapillary splinter haemorrhage (90%), sectorial swollen
optic disc (60%) and hyperemic disc (60%). During follow
up, 20% of the patients showed stabilization in visual acuity,
and 80% showed worsening of vision.
·CONCLUSION: Majority of patients with NAION presented
with acute poor vision involving middle-aged and elderly
individuals. Hypertension and diabetes mellitus were among
the main risk factors involved. NAION can lead to permanent
visual loss despite treatment.
(44.4% ), and
Bawazir A, Gharebaghi R, Hussein A, Wan Hitam WH. Non-arteritic
anterior ischaemic optic neuropathy in Malaysia: a 5 years review.
(NAION) is a rare widespread visually disabling
disorder in the middle aged and elderly population
NAION is presumed to result from circulatory insufficiency
within the optic nerve head, but the specific mechanism of
the vasculopathy remains unproven. The annual incidence
of NAION has been estimated at 2.3 to 10.2 per 100 000 for
persons 50 years and older
clinical presentations and assess visual outcome in patients
presented with NAION.
MATERIALS AND METHODS
Subjects A retrospective study was conducted involving 18
Universiti Sains Malaysia, an academic tertiary care referral
centre, from January 2005 till December 2009.
The patients' particulars were obtained using
NAION database and the medical records. All patients were
evaluated in a standard fashion and underwent a systematic
comprehensive neuro-ophthalmic history and examination,
including visual acuity, checking for presentation of afferent
pupillary defect, dilated funduscopic examination with Slit
Lamp biomicroscopy, basic blood investigation and colour
fundus photographs. The exclusion criteria included any
evidence suggestive of temporal arteritis such as history of
scalp tenderness and patients with a history of multiple
sclerosis with or without optic neuritis, collagen vascular
disease, or any other systemic inflammatory disease. Patients
also were excluded if they had clinical features that
C-reactive protein level. A history of inflammatory or
examination. If other central nervous system lesions were
suspected, imaging study was arranged. Follow up were
performed from 6 months to 5 years. Patients who had
typical symptoms and signs of NAION including acute loss
of visual acuity, swelling of optic disc, blurring of disc
margins with or without haemorrhage and field defect on
computerised perimetry were selected for the study.
on-arteriticanterior ischaemicoptic neuropathy
. Our aim was to determine the
than NAION, such
NAION in Malaysia
陨灶贼 允 韵责澡贼澡葬造皂燥造熏
晕燥援 3熏 Jun.18, 圆园11 www. IJO. cn
Eighteen patients (20 eyes) were included in the study with
female-to-male ratio of 14: 4. Eighteen
were Malay followed by Chinese (5.6 %). The ages ranged
from 36 to 85 (mean, 57.1) years. The main risk factors in
systemic diseases were hypertension
mellitus (44.4%), and ischaemic heart disease
Moreover, four patients(22.2% ) had positive history of
smoking. The visual acuity ranged between 6/30 to
perception of light; majority of subjects were with vision of
worse than 1/60 (80%, Figure 1). Most patients (77.8%)
presented with acute loss of vision. Relative afferent
pupillary defect (RAPD) was positive in 15
while in the rest it was negative. The most common
fundoscopic findings were hypaeremic optic disc
peripapillary splinter haemorrhage (90%) and sectorial disc
pallor (60%). The visual outcome following treatment (at the
last follow up)ranged
deterioration (Figure 2); 14 patients (80%) had deterioration
and 4 patients(20% ) had stabilisation of vision despite
treatment. Results showed no improvement in terms of
visual acuity after treatment.
The pathological process in NAION is loss of perfusion
affecting the ciliary circulation to the optic nerve head,
causing axonal swelling leading to capillary dilatation and
fluid leakage. When the axons die some weeks later, pallor
becomes evident leading to optic atrophy. NAION typically
occurs in white races after the age of 50 years, with most
series reporting an average age between 60 and 70 years,
but cases in older or younger patients were documented
This is the first ever study performed in Malaysia, mostly
Malay in race (94.4%), with the ages ranged from 36 to 85
years(mean of 57.1 years). Our study confirmed that
NAION in the young is not uncommon and represents 33.3%
of patients younger than 50 years. Females were more
affected compare to males with the ratio of 3.5:1 which is
not similar to the most of previous studies. It is interesting to
quote that the incidence rate of NAION among men and
women were almost equal in the previous studies[7,8].
NAION has been reported to be associated with many
conditions that may predispose to decreased optic nerve
head perfusion. Examples of risk factors are role of
vasculopathic diseases, such as diabetes, hyperlipidaemia,
hypertension, hyperhomocysteinaemia, and prothrombotic
hypertension, compared with 34% to 47% in other studies[9,10]
and 44% of our patients had diabetes mellitus, compared
with 10% to 24% in other studies
were quite similar compared with the similar study in
(55.5% ), diabetes
. Fifty-five percent of our patients had systemic
[9,10]. However, our results
Figure 1 Visual acuity at presentation of NAION tested on
Snellen visual acuity chart (CF: Counting finger; HM: Hand
movement; PL: Perception of light)
Figure 2 Progression of vision in NAION patients
Figure 3 Photograph shows features of NAION with splinter
haemorrhages in the right eye
Figure 4 Photograph shows a pale optic disc
Taiwan in the Asian population. In this study, initial visual
acuities in all affected eyes were poor ranging from 6/30 to
light perception. At initial presentation, around 80% of the
patients had a visual acuity of 1/60 or worse and 75% had a
positive RAPD. However, Beri et alreported better visual
acuity at initial presentation 6/12 or better. Studies showed
in most cases of NAION, vision worsens progressively over
2 weeks and then remains stable over time
reported by Atkins et al
left with visual acuity worse than 6/60. During follow-up
20% of patients in our study showed little and no
improvement of final visual acuity and 80% had worsening
Several limitations of the present study should be addressed,
most of which relate to its retrospective, hospital based and
selection bias. Because of the low incidence of NAION, an
adequately controlled prospective study would be difficult
but worthy of further workup especially in measuring ocular
parameters and visual field changes in a rare disease like
In summary, NAION may commonly affect middle-aged and
elderly population in our area. Most of the patients presented
with acute loss of vision. NAION was associated with
systemic problem mainly hypertension and diabetes mellitus
and may lead to permanent visual loss despite treatment.
1 Jonas JB. Optic disc morphology and NAION.
. In a study
, more than 50% of patients were
2 Arnold AC. Pathogenesis of nonarteritic anterior ischemic optic neuropathy.
3 Hattenhauer MG, Leavitt JA, Hodge DO, Grill R, Gray DT. Incidence of
nonarteritic anterior ischemic optic neuropathy.
4 Cullen JF, Por YM. Ischaemic optic neuropathy: the Singapore scene.
5 Chutorian AM, Winterkorn JM, Geffner M. Anterior ischemic optic neuropathy in
children: case reports and review of the literature.
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implications of anterior ischemic optic neuropathy.
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neuropathy. VII. Incidence of bilaterality and various influencing factors.
8 Guyer DR, Miller NR, Auer CL, Fine SL. The risk of cerebrovascular and
cardiovascular disease in patients with anterior ischemic optic neuropathy.
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neuropathy in patients younger than 50 years.
10 Hayreh SS, Joos KM, Podhajsky PA, Long CR. Systemic diseases associated
with nonarteritic anterior ischemic optic neuropathy.
11 Lin MC, Hsu FM, Sheu SJ. Nonarteritic ischemic optic neuropathy.
12 Atkins EJ, Bruce BB, Newman NJ, Biousse V. Treatment of nonarteritic anterior
ischemic optic neuropathy.
NAION in Malaysia