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To evaluate whether treatment with Citicoline in oral solution (OS-Citicoline) would increase visual function, retinal ganglion cells (RGCs) function, and neural conduction along visual pathways (neuroenhancement), and/or induce preservation of RGCs fibers' loss (neuroprotection) in non-arteritic ischemic optic neuropathy (NAION), a human model of neurodegeneration. Thirty-six patients with NAION and 20 age-matched controls were enrolled. Nineteen NAION patients received 500 mg/day of OS-Citicoline for a 6-month period followed by 3-month of wash-out (NC Group); 17 NAION patients were not treated (NN Group) from baseline to 9 months. In all subjects at baseline, and in NC and NN eyes at 6 and 9 months of follow-up, we assessed Visual Acuity (VA), Pattern Electroretinogram (PERG), Visual Evoked Potentials (VEP), retinal nerve fiber layer thickness (RNFL-T), and Humphrey 24-2 visual field mean deviation (HFA MD). Mean differences were statistically evaluated with ANOVA between Groups, and linear correlations were analysed with Pearson's test. At 6 months, significant differences between groups for all parameters were observed (ANOVA, p<0.01). In NC eyes, VA increased, PERG responses increased, VEP recordings improved and were significantly correlated with increases in HFA MD (p<0.01), and RNFL-T was unmodified or improved. In contrast, in NN eyes, VA, PERG, VEP responses, RNFL-T, and HFA MD were further worsened. Significant differences were still present at 9-month follow-up in the NN Group and after 3 months of OS-Citicoline wash-out in NC eyes. OS-Citicoline treatment induced neuroenhancement (improvement in RGCs function and neural conduction along visual pathways related to improvement of visual field defects) and neuroprotection (unmodified or improved RNFL morphological condition) in a human model of NAION involving fast RGCs degeneration. ClinicalTrials.gov NCT03758118.

Background To evaluate the effect of high-dose intravenous steroids, as well as normobaric oxygen therapy, in the management of recent onset non-arteritic anterior ischemic optic neuropathy (NAION). Method Ninety eyes of 90 patients diagnosed with NAION within 14 days of onset were included in this single masked randomized clinical trial. Thirty patients were randomized into each set as group 1 (control), group 2 (steroids), and group 3 (oxygen). Controls received placebo; group 2 received methylprednisolone 500 mg twice a day for 3 days followed by 2 weeks of oral prednisolone 1 mg/kg/day; group 3 received 100 % normobaric oxygen with mask, at a flow rate of 5 liters per minute for 1 hour twice a day for two weeks. Functional and structural outcomes were analyzed at 1 and 6 months following treatment. Best corrected visual acuity (BCVA) was the main outcome measure, and mean deviation (MD) of visual field (VF) test and peripaillary retinal nerve fiber layer thickness (PRNFLT) were secondary outcome measures. Results The mean BCVA at the time of presentation was 1.02 ± 0.63, 1.05 ± 0.7, and 0.76 ± 0.5 LogMAR in groups 1, 2, and 3, respectively ( p  = 0.293); corresponding values were 0.8 ± 0.45, 0.84 ± 0.45, and 0.58 ± 0.4 at month 1 ( p  = 0.127, 0.19, and 0.168, respectively). BCVA improved to 0.71 ± 0.46, 0.73 ± 0.36, and 0.59 ± 0.41 LogMAR at the 6-month follow-up point ( p  = 0.039, 0.048, and 0.195, respectively). The mean deviation (MD) at the time of presentation was 19.26 ± 7.02, 20.51 ± 4.68, and 19.3 ± 7.17 in the control, steroid, and oxygen groups, respectively ( p  = 0.65). Corresponding values at month 1 were 20.26 ± 8.52, 19.52 ± 7.08, and 18.3 ± 7.45, ( p  = 0.656); and at month 6 were 18.42 ± 8.17, 17.66 ± 6.44 and 16.53 ± 6.32, respectively ( p  = 0.635). PRNFLT at presentation was 166 ± 57, 184 ± 57, and 193 ± 65 micrometer in the control, steroid, and oxygen groups, respectively ( p  = 0.265); which decreased to 73 ± 11, 87 ± 26, and 79 ± 19 at the final foll-w up (all p  < 0.001). There were no statistically significant differences between the three groups in terms of final visual function and structure. Conclusion The lack of demonstrable improvement in the structural and functional outcomes of NAION with high-dose IV steroids, or normobaric oxygen, in this randomized controlled trial calls into question the administering of systemic steroid or normobaric oxygen in this condition.

Purpose There is currently no accepted treatment for Nonarteritic Anterior Ischemic Optic Neuropathy (NAION). One new therapeutic approach involves decreasing optic nerve edema with intravitreal bevacizumab in order to resolve a proposed compartment syndrome. Methods In this non-randomized controlled clinical trial, 1.25 mg intravitreal bevacizumab was compared with natural history. Patients were examined at baseline, 1, 3, and 6 months with a full neuro-ophthalmic exam, automated perimetry, and optic nerve optical coherence tomography (OCT) measurements. The primary outcome measure was change in mean deviation on Humphrey visual field testing. Secondary outcome measures were change in visual acuity and optic nerve OCT thickness. Incidence and type of complications were also recorded. Results Twenty-five patients were enrolled (17 treatment and 8 control). There was no significant effect of treatment on the primary outcome measure of mean deviation score ( P =0.4). There was similarly no effect of group assignment on the secondary outcome measures of change in mean Early Treatment Diabetic Retinopathy Study letters ( P =0.33) or nerve fiber layer thickness on OCT ( P =0.11). In the bevacizumab group, there was one case of a corneal abrasion and two cases of recurrent NAION. No other complications were noted. Conclusions We found no difference between bevacizumab and natural history for change in visual field, visual acuity, or optic nerve OCT thickness. Based on the current evidence we would not recommend the use of intravitreal bevacizumab to treat patients with the new onset of NAION.

Background To evaluate the visual and anatomic outcomes after systemic steroid treatment in non-arteritic anterior ischemic optic neuropathy (NAION). Methods Ten eyes from ten patients diagnosed with NAION and treated during the acute phase with 80 mg daily, tapering-down dose of corticosteroids were compared with a non-contemporary cohort of 27 patients that received no treatment. The visual outcomes of treated and untreated group were compared. Patients underwent complete ophthalmic examination including determination of Snellen visual acuity (VA), visual fields (VFs) (standard automated perimetry, Swedish Interactive Testing Algorithm 24–2 strategy), and optical coherence tomography (OCT) scanning of the optic nerve head at diagnosis, 6–8 weeks and 6 months after presentation. Results No statistical differences were found between steroid-treated and untreated NAION for the median change in VA (Mann–Whitney P =  0.28), median change in VF mean deviation (MD) and median change in VF pattern standard deviation (PSD) (Mann–Whitney P =  0.213 and P =  0.07 respectively). Statistical analysis showed no differences when comparing average RNFL loss ( P  = 0.871) and RNFL loss for superior, nasal, inferior and temporal optic disc quadrants between both groups. Complications occurred in three of the ten treated patients (30%); in one of them, steroid therapy had to be discontinued. Another two patients developed a NAION in their fellow eye after 2 and 3 months while on low-dose prednisone. No complications developed in the control group. The study was interrupted early due to a significantly higher rate of complications observed in the treated group ( P =  0.002) Conclusion High-dose systemic steroid treatment did not show any beneficial effect in visual and anatomic outcomes when given during the acute phase of NAION. Furthermore, it caused serious complications in a third of the patients treated.

AimTo evaluate the effect of intravitreal injection of erythropoietin for the treatment of non-arteritic anterior ischaemic optic neuropathy (NAION).MethodsIn this prospective interventional case series, 31 eyes of 31 patients with NAION were included. Patients received intravitreal injection of 2000 unit (0.2 cm3) of erythropoietin within 1 month of the onset of the disease. Visual acuity and visual field were recorded before injections and 1 week, 1 month, 3 months and 6 months after the injections.ResultsThe mean duration of symptoms before injections was 11.2±5.5 days. Six months after injections, visual acuity improved in 27 eyes (87%), and 17 eyes (54.8%) had ≥3 lines of visual improvement. The mean preinjection visual acuity was 1.01±0.88 logMAR and 0.58±0.58 logMAR (p<0.001) at last follow-up. Visual acuity improvement occurred in 61.2% of patients within the first month. It followed a biphasic pattern in which there was continuous improvement up to 3 months and then started to deteriorate, although it remained significantly better than baseline until the last follow-up. No patient lost any lines of visual acuity compared with the baseline values. The mean of mean deviations of visual field was −19.6±5.7 dB at baseline and −18.6±6.3 dB (p=0.6) at last follow-up.ConclusionsIntravitreal injection of erythropoietin may be safe and effective in the treatment of NAION. The effect may last for a few months and then decline.

Background In non-arteritic anterior ischemic optic neuropathy (NA-AION), no treatments have demonstrated to be effective in recovering visual loss in randomized clinical trials. Oral steroids have been evaluated, and small series of intravitreal triamcinolone acetonide (IVTA) injection in NA-AION have been reported. The purpose of our study was to report the visual outcome and morphological changes in response to a single IVTA injection as a treatment for patients with NA-AION. Patients and methods The charts of 36 patients with visual symptoms and optic disc swelling caused by NA-AION were evaluated. Twenty-one patients had received 4 mg IVTA and were compared with 15 non-treated patients. Visual acuity (VA), retinal nerve fiber layer thickness and static visual field were evaluated after 6 months. Results VA improvement at 6 months is statistically better in the treated group than in the non-treated group ( p  = 0.0035). In the treated group, there was a significant inverse correlation between the delay of the injection and the visual acuity achieved at 6 months (p <  0.0083**, r  = −0.56). A significant improvement of the visual field was noted in the injected group when compared with the non-treated group at 6 months ( p <  0.0028). Discussion In this retrospective study, patients receiving IVTA in the acute phase of NA-AION have better improvement of VA and visual field during the follow-up period of 6 months. However, only a large randomized controlled trial may enable to evaluate the benefits of IVTA Injections on visual outcome in NA-AION.

This article reviews the diagnosis, pathophysiological features, and prognosis of ischemic optic neuropathy, a relatively common cause of visual loss in older patients, including visual loss after cardiac surgery. It must be distinguished from inflammatory optic neuritis. Disorders of the optic nerve represent a relatively common cause of visual loss. The optic nerve is a white-matter tract that relays information from the retina to the brain areas of visual processing. Whenever there is damage to an optic nerve, from whatever cause, it is termed an “optic neuropathy.” Unlike inflammatory optic neuritis, which is the most common optic neuropathy in young patients, ischemic optic neuropathy (ION) is the result of vascular insufficiency, not of inflammation. ION refers to all ischemic causes of optic neuropathy. Although IONs are considered to be equivalent to a “stroke of the optic nerve,” . . .

Purpose The purpose is to study the effect of Enhanced Extracorporeal Counterpulsation (EECP) in patients with non-arteritic anterior ischaemic optic neuropathy (NAION). Methods EECP is a noninvasive, mechanical, and circulatory support therapy. Sixteen patients with unilateral NAION were treated with EECP (twelve 1-h daily treatment sessions for each patient). Color Doppler imaging (CDI) was applied to measure the mean flow velocity (MFV), peak-systolic velocity (PSV), end-diastolic velocity (EDV) of the ophthalmic artery (OA) and central retinal artery (CRA). Intraocular pressure (IOP) was measured by Goldmann applanation tonometry. Measurements were collected before and immediately after the first and the last sessions of EECP in both eyes, and they were compared with the baseline measurement before EECP. The measurements were also compared between the NAION eyes and the normal fellow eyes. Visual acuity (VA) and visual field (VF) were assessed before EECP and after the last EECP. Results EECP progressively increased blood flow velocities of the OA and CRA and progressively decreased IOP in both eyes ( P  < 0.05). After the first session of EECP, there was a 16 ± 5.3 % increase in EDV and a 13.9 ± 9.5 % increase in MFV of the OA, and a 17.1 ± 2.5 % increase in PSV, a 21.2 ± 9.3 % increase, in EDV and a 16.5 ± 3.3 % increase in MFV of the CRA in NAION eyes. After the last EECP treatment, there was a 16.8 ± 6.7 % increase in EDV and a 14.0 ± 5.1 % increase in MFV of the OA, and a 17.7 ± 12.3 % increase in PSV, a 23.1 ± 6.3 % increase in DSV, and a 21.1 ± 8.4 % increase in MFV of the CRA in NAION eyes ( P  < 0.05). The change of the PSV, EDV, and MFV in the CRA were more significant in NAION eyes than that of their fellow eyes ( P  < 0.05). VA was improved and VF mean deviation was decreased in NAION eyes after the last EECP treatment ( P  = 0.003 and 0.049, respectively), and VA improvement was correlated positively with the blood flow parameter. Conclusions EECP could be a clinically effective and safe treatment for NAION.

Objective To review treatment modalities that have been studied in acute non arteritic anterior ischemic optic neuropathy (NAION). Methods We performed a comprehensive literature search of English language publications in the last 5 years, with human species and NAION. Articles were reviewed to identify those that described original research on treatment of acute NAION. Study type, setting, duration, interventions, and results were extracted and articles were reviewed for biases and limitations. Results We identified 22 kinds of treatment varying by compound and modality. These include topical, intravitreal, and systemic drugs as well as surgical approaches. Evidence for efficacy ranges from expert opinion to randomized control trials. Conclusions Although several treatments are utilized in practice, none of these have high quality evidence of efficacy to improve visual outcomes.  Continued collaborative research is necessary to complete high quality studies in order identify effective therapies for this rare and blinding disease.

Non-arteritic anterior ischemic optic neuropathy (NAION) is the most common cause of non-glaucomatous optic neuropathy in older adults. Optical coherence tomographic angiography (OCT-A) is an emerging, non-invasive method to study the microvasculature of the posterior pole, including the optic nerve head. The goal of this study was to assess the vascular changes in the optic nerve head and peripapillary area associated with NAION using OCT-A. Retrospective comparative case series. We performed OCT-A in 25 eyes (7 acute and 18 non-acute) in 19 patients with NAION. Fellow, unaffected eyes were analyzed for comparison. Patent macro- and microvascular densities were quantified in the papillary and peripapillary regions of unaffected, acutely affected, and non-acutely affected eyes and compared across these groups according to laminar segment and capillary sampling region, and with respect to performance on automated visual field testing. In acutely affected eyes, OCT-A revealed a reduction in the signal from the major retinal vessels and dilation of patent superficial capillaries in the peripapillary area. By contrast, non-acutely affected eyes showed attenuation of patent capillaries. The peripapillary choriocapillaris was obscured by edema in acute cases, but was similar between non-acute and unaffected eyes. The degree of dilation of the superficial microvasculature in the acute phase and attenuation in the non-acute phase each correlated inversely with visual field performance. The region of reduced patent capillary density correlated with the location of visual field defects in 80% of acute cases and 80% of non-acute cases. OCT-A reveals a dynamic shift in the superficial capillary network of the optic nerve head with strong functional correlates in both the acute and non-acute phases of NAION. Further study may validate OCT-A as a useful adjunctive diagnostic tool in the evaluation of ischemic optic neuropathy.