Standardized diagnosis and management with cautious use of glucocorticoids: rethinking the management of non-arteritic anterior ischemic optic neuropathy_Chinese Journal of Ocular Fundus Diseases

Authors：

 Wei Shihui ¹ , Yan Yan ²

1. Senior Department of Ophthalmology, General Hospital of the People's Liberation Army, Beijing 100853, China;
2. Department of Ophthalmology, Eye and ENT Hospital of Fudan University, NHC Key Laboratory of Myopia, Key Laboratory of Myopia, Chinese Academy of Medical Science, Shanghai 200031, China;

Corresponding?author：

Wei Shihui, Email: weishihui@hotmail.com

Keywords：

Non-arteritic anterior ischemic optic neuropathy; Glucocorticoids; Cautious medication use; Diagnosis and treatment strategy; Editorial

DOI：

10.3760/cma.j.cn511434-20260407-00155

Video：

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Non-arteritic anterior ischemic optic neuropathy (NAION) is the most common acute optic neuropathy in patients over 50 years of age, yet no effective treatment supported by high-quality evidence is currently available. Inappropriate use of glucocorticoids is common in clinical practice, including using them as a diagnostic therapeutic trial, as routine treatment, and underestimating their systemic risks. From the perspective of the pathological mechanism, NAION is primarily caused by hypoperfusion-induced ischemia, with secondary inflammation occurring after the ischemic insult. This indicates that anti-inflammatory treatment is not the first choice for addressing the fundamental problem. The highest level of evidence indicates that systemic glucocorticoid therapy only accelerates the resolution of optic disc edema but does not improve long-term visual acuity or visual field outcomes. Moreover, it may exacerbate vascular risk factors such as hyperglycemia and hypertension, and may lead to adverse reactions, including peptic ulcers, osteoporosis, and infections. Neither intravitreal nor periocular steroid injection is supported by high-quality evidence. The diagnosis and management of NAION should focus on accurate diagnosis and control of risk factors. Routine use of glucocorticoids is not recommended; they may only be used with caution on an individualized basis in a few strictly selected cases, with close monitoring of adverse effects.

Citation： Wei Shihui, Yan Yan. Standardized diagnosis and management with cautious use of glucocorticoids: rethinking the management of non-arteritic anterior ischemic optic neuropathy. Chinese Journal of Ocular Fundus Diseases, 2026, 42(6): 469-473. doi: 10.3760/cma.j.cn511434-20260407-00155 Copy

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1. Hayreh SS. Ischemic optic neuropathy[J]. Prog Retin Eye Res, 2009, 28(1): 34-62. DOI: 10.1016/j.preteyeres.2008.11.002.
2. 中華醫學會眼科學分會神經眼科學組. 我國非動脈炎性前部缺血性視神經病變診斷和治療專家共識(2015年)[J]. 中華眼科雜志, 2015, 51(5): 323-326. DOI: 10.3760/cma.j.issn.0412-4081.2015.05.002.Ophthalmological Society of China, Neuro-Ophthalmology Group. Expert consensus on diagnosis and treatment of non-arteritic anterior ischemic optic neuropathy in China (2015)[J]. Chin J Ophthalmol, 2015, 51(5): 323-326. DOI: 10.3760/cma.j.issn.0412-4081.2015.05.002.
3. Arnold AC, Hepler RS, Natural history of nonarteritic anterior ischemic optic neuropathy[J]. J Neuroophthalmol, 1994, 14(2): 66-69.
4. Hayreh SS, Zimmerman MB. Nonarteritic anterior ischemic optic neuropathy: natural history of visual outcome[J]. Ophthalmology, 2008, 115(2): 298-305. DOI: 10.1016/j.ophtha.2007.05.027.
5. Huang HM, Wu PC, Kuo HK, et al. Natural history and visual outcome of nonarteritic anterior ischemic optic neuropathy in Southern Taiwan: a pilot study[J]. Int Ophthalmol, 2020, 40(10): 2667-2676. DOI: 10.1007/s10792-020-01448-8.
6. Nancy JN, Dickersin K, Kaufman D, et al. Characteristics of patients with nonarteritic anterior ischemic optic neuropathy eligible for the ischemic optic neuropathy decompression trial[J]. Arch Ophthalmol, 1996, 114(11): 1366-1374. DOI: 10.1001/archopht.1996.01100140566007.
7. Pane A, Miller NR, Burdon M. Blurred vision or field loss[M]//Pane A, Miller NR, Burdon M. The neuro-ophthalmology survival guide. 3rd ed. Philadelphia: Elsevier, 2024: 67-90.
8. Hayreh SS, Zimmerman B. Visual field abnormalities in nonarteritic anterior ischemic optic neuropathy: their pattern and prevalence at initial examination[J]. Arch Ophthalmol, 2005, 123(11): 1554-1562. DOI: 10.1001/archopht.123.11.1554.
9. Hamann S, Malmqvist L, Wegener M, et al. Young adults with anterior ischemic optic neuropathy: a multicenter optic disc drusen study[J]. Am J Ophthalmol, 2020, 217: 174-181. DOI: 10.1016/j.ajo.2020.03.052.
10. Arnold AC, Costa RM, Dumitrascu OM. The spectrum of optic disc ischemia in patients younger than 50 years (an Amercian Ophthalmological Society thesis)[J]. Trans Am Ophthalmol Soc, 2013, 111: 93-118.
11. Preechawat P, Bruce BB, Newman NJ, et al. Anterior ischemic optic neuropathy in patients younger than 50 years[J]. Am J Ophthalmol, 2007, 144(6): 953-960. DOI: 10.1016/j.ajo.2007.07.031.
12. Arnold AC, Hepler RS. Fluorescein angiography in acute nonarteritic anterior ischemic optic neuropathy[J]. Am J Ophthalmol, 1994, 117(2): 222-230. DOI: 10.1016/s0002-9394(14)73080-6.
13. Arnold AC, Badr MA, Hepler RS. Fluorescein angiography in nonischemic optic disc edema[J]. Arch Ophthalmol, 1996, 114(3): 293-298. DOI: 10.1001/archopht.1996.01100130289011.
14. De Dompablo E, Garcia-Montesinos J, Munoz-Negrete FJ, et al. Ganglion cell analysis at acute episode of nonarteritic anterior ischemic optic neuropathy to predict irreversible damage. A prospective study[J]. Graefe's Arch Clin Exp Ophthalmol, 2016, 254(9): 1793-1800. DOI: 10.1007/s00417-016-3425-8.
15. Akbari M, Abdi P, Fard MA, et al. Retinal ganglion cell loss precedes retinal nerve fiber thinning in nonarteritic anterior ischemic optic neuropathy[J]. J Neuroophthalmol, 2016, 36(2): 141-146. DOI: 10.1097/WNO.0000000000000345.
16. Mournet S, Sené T, Charbonneau F, et al. Early diffusion-weighted MRI at 3 Tesla detects ischemic changes of the optic nerve in anterior ischemic optic neuropathy[J]. Eur Radiol, 2022, 32(5): 3588-3596. DOI: 10.1007/s00330-021-08417-4.
17. Kupersmith MJ, Alban T, Zeiffer B, et al. Contrast-enhanced MRI in acute optic neuritis: relationship to visual performance[J]. Brain, 2002, 125(Pt 4): 812-822. DOI: 10.1093/brain/awf087.
18. Hur M, Madhavan AA, Hodge DO, et al. Comparison of 1.5 Tesla and 3.0 Tesla magnetic resonance imaging in the evaluation of acute demyelinating optic neuritis[J]. J Neuroophthalmol, 2022, 42(3): 297-302. DOI: 10.1097/WNO.0000000000001559.
19. Petroulia VD, Brügger D, Hoepner R, et al. MRI signs helpful in the differentiation of patients with anterior ischaemic optic neuropathy and optic neuritis[J]. Br J Ophthalmol, 2023, 107(1): 121-126. DOI: 10.1136/bjophthalmol-2021-319537.
20. Parikh M, Miller NR, Lee AG, et al. Prevalence of a normal C-reactive protein with an elevated erythrocyte sedimentation rate in biopsy-proven giant cell arteritis[J]. Ophthalmology, 2006, 113(10): 1842-1845. DOI: 10.1016/j.ophtha.2006.05.020.
21. Kermani TA, Schmidt J, Crowson CS, et al. Utility of erythrocyte sedimentation rate and C-reactive protein for the diagnosis of giant cell arteritis[J]. Semin Arthritis Rheum, 2012, 41(6): 866-871. DOI: 10.1016/j.semarthrit.2011.10.005.
22. Von der Emde L, Petzinna SM, Herwig-Carl MC, et al. Advances in diagnosing and treating giant cell arteritis: new hope for arteritic anterior ischemic optic neuropathy[J]. Surv Ophthalmol, 2026, 71(2): 483-497. DOI: 10.1016/j.survophthal.2025.06.009.
23. Tisavipat N, Stiebel-Kalish H, Palevski D, et al. Acute optic neuropathy in older adults: differentiating between MOGAD optic neuritis and nonarteritic anterior ischemic optic neuropathy[J/OL]. Neurol Neuroimmunol Neuroinflamm, 2024, 11(3): e200214[2024-03-28]. https://pubmed.ncbi.nlm.nih.gov/38547435/. DOI: 10.1212/NXI.0000000000200214.
24. Jarius S, Ruprecht K, Kleiter I, et al. MOG-IgG in NMO and related disorders: a multicenter study of 50 patients. Part 1: frequency, syndrome specificity, influence of disease activity, long-term course, association with AQP4-IgG, and origin[J/OL]. J Neuroinflammation, 2016, 13(1): 279[2016-09-26]. https://pubmed.ncbi.nlm.nih.gov/27788675/. DOI: 10.1186/s12974-016-0717-1.
25. Sechi E, Buciuc M, Pittock SJ, et al. Positive predictive value of myelin oligodendrocyte glycoprotein autoantibody testing[J]. JAMA Neurol, 2021, 78(6): 741-746. DOI: 10.1001/jamaneurol.2021.0912.
26. Hayreh SS. Blood supply of the optic nerve head and its role in optic atrophy, glaucoma, and oedema of the optic disc[J]. Br J Ophthalmol, 1969, 53(11): 721-748. DOI: 10.1136/bjo.53.11.721.
27. Hayreh SS. The blood supply of the optic nerve head and the evaluation of it - myth and reality[J]. Prog Retin Eye Res, 2001, 20(5): 563-593. DOI: 10.1016/s1350-9462(01)00004-0.
28. Beck RW, Servais GE, Hayreh SS. Anterior ischemic optic neuropathy. Ⅸ. cup-to-disc ratio and its role in pathogenesis[J]. Ophthalmology, 1987, 94(11): 1503-1508.
29. Burde RM. Optic disk risk factors for nonarteritic anterior ischemic optic neuropathy[J]. Am J Ophthalmol, 1993, 116(6): 759-764. DOI: 10.1016/s0002-9394(14)73478-6.
30. Beri M, Klugman MR, Kohler JA, et al. Anterior ischemic optic neuropathy. Ⅶ. Incidence of bilaterality and various influencing factors[J]. Ophthalmology, 1987, 94(8): 1020-1028. DOI: 10.1016/s0161-6420(87)33350-0.
31. Chatziralli IP, Kazantzis D, Chatzirallis AP, et al. Cardiometabolic factors and risk of non-arteritic anterior ischemic optic neuropathy: a systematic review and meta-analysis[J]. Graefe's Arch Clin Exp Ophthalmol, 2022, 260(5): 1445-1456. DOI: 10.1007/s00417-021-05522-4.
32. Liu B, Yu Y, Liu W, et al. Risk factors for non-arteritic anterior ischemic optic neuropathy: a large scale meta-analysis[J/OL]. Front Med (Lausanne), 2021, 8: 618353[2021-10-04]. https://pubmed.ncbi.nlm.nih.gov/34671609/. DOI: 10.3389/fmed.2021.618353.
33. Knox DL, Kerrison JB, Green WR. Histopathologic studies of ischemic optic neuropathy[J]. Trans Am Ophthalmol Soc, 2000, 98: 203-220. DOI: 10.1016/s0002-9394(01)00943-6.
34. Sun S, Gong Y, Li D, et al. Vitreous proteomic insights into the pathogenesis of nonarteritic anterior ischemic optic neuropathy[J/OL]. Exp Eye Res, 2025, 256: 110407[2025-04-28]. https://pubmed.ncbi.nlm.nih.gov/40306398/. DOI: 10.1016/j.exer.2025.110407.
35. Saxena R, Singh D, Sharma M, et al. Steroids versus no steroids in nonarteritic anterior ischemic optic neuropathy: a randomized controlled trial[J]. Ophthalmology, 2018, 125(10): 1623-1627. DOI: 10.1016/j.ophtha.2018.03.032.
36. Hayreh SS, Zimmerman MB. Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy[J]. Graefe's Arch Clin Exp Ophthalmol, 2008, 246(7): 1029-1046. DOI: 10.1007/s00417-008-0805-8.
37. Prokosch V, Thanos S. Visual outcome of patients following NAION after treatment with adjunctive fluocortolone[J]. Restor Neurol Neurosci, 2014, 32(3): 381-389. DOI: 10.3233/RNN-120292.
38. Pakravan M, Sanjari N, Esfandiari H, et al. The effect of high-dose steroids, and normobaric oxygen therapy, on recent onset non-arteritic anterior ischemic optic neuropathy: a randomized clinical trial[J]. Graefe's Arch Clin Exp Ophthalmol, 2016, 254(10): 2043-2048. DOI: 10.1007/s00417-016-3451-6.
39. Radoi C, Garcia T, Brugniart C, et al. Intravitreal triamcinolone injections in non-arteritic anterior ischemic optic neuropathy[J]. Graefe's Arch Clin Exp Ophthalmol, 2014, 252(2): 339-345. DOI: 10.1007/s00417-013-2499-9.
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