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Catherine Chiu An asymptomatic patient presents with a superior altitudinal defect OD and an inferior altitudinal defect OS. A discussion of AION vs. NAION will clarify pertinent clinical findings to apply to patient care. I. Case History: 83 year old white male presents for an ocular health exam with no visual complaints and admits to a history of constriction of retinal blood vessels three years ago. A. Ocular history: unremarkable except for floaters which are stable B. Medical history: (+) hypertension with heart involvement, atherosclerosis, hypercholesterolemia, hypothyroid, coagulation defect, prostate cancer C. Medications: levothyroxine, metropolol, niacin, simvastatin II. Pertinent Findings: A. Clinical: BCVA OD: 20/20-, OS: 20/20-2 Pupils: PERRL (-) APD CVF: OD FTFC, OS FTFC EOM: Full and smooth OU SLE: unremarkable expect for Nuclear sclerosis OU IOP: OD 19mmHg, OS 20 mmHg DFE: Vitreous – Clear OD, OS Disc – OD 0.55, OS 0.45 with rim pallor OU Macula – Clear OD, OS Vessels: Attenuation of arterioles OD, OS Periphery: Drusen OD, OS 24-2 Visual Field: OD Superior altitudinal defect OS Inferior altitudinal defect Pachymetry: OD 535, OS 537 B. Radiology: CT-Scan: Normal pressure hydrocephalus (NPH) C. Neurology: No abnormal findings, NPH ruled out because patient did not present with the triad of ataxia, dementia and incontinence, repeat of CT-Scan required III. Differential Diagnosis: 1. Non-arteritic anterior ischemic optic neuropathy (NAION) 2. Arteritic anterior ischemic optic neuropathy (AAION) IV. Diagnosis and Discussion: -VF findings, DFE, and a good VA strongly suggests pt had an ischemic incident causing AION -AAION: - sudden visual loss, altitudinal visual field loss, afferent papillary defect (APD), optic disc edema - any vasculitis, such as giant cell arteritis (GCA) - arteritic occlusion of the posterior short ciliary arteries - results in nearly complete loss of vision - occurs in older adults - symptoms include painful jaw muscle spasms, scalp tenderness, unintentional weight loss, fatigue, myalgias and loss of appetite - contralateral eye involvement within 1-2 weeks after first eye event - blood tests reveal elevated erythrocyte sedimentation rate (ESR), C reactive protein (CRP) and platelet count (thrombocytosis) -NAION: - occlusion of ciliary arteries by thrombi or emboli causing temporary hypoperfusion of the anterior portions of the optic nerve and choroid - contralateral eye involvement months to years after first eye event - cardiovascular conditions such as arterial hypertension, diabetes and atherosclerosis - crowded disc or small physiologic cupping - painless symptoms - can occur in young and older adults V. Treatment: - Work up with PCP to control hypertension and other cardiovascular risk factors - Follow up with neurologist with additional CT-Scan findings - Educated patient to be aware of any vision changes or vision loss - Monitored through periodic visual field exams VI. Conclusion: - patient admitted to nasal blur of vision in the right eye followed by nasal blur of vision in the left eye a day later three years ago, but never had a decrease of VA since the incident - patient most likely had NAION due to medical history of hypertension, atherosclerosis, and hypercholesterolemia