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Looking for any brilliant ideas on how to prevent second eye visual loss

  • 1.  Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 19:48
    A healthy 68 yo woman with absolutely no vascular risk factors and a recent hemoglobin A1c of 4.7 was sent into our emergency room this evening by an ophthalmologist for a diagnosis of a swollen disc

    She happens to be one of our emergency room attendings

    she awoke this morning with unilateral visual loss, which turns out to be an altitudinal field defect in that eye. This is painless. She has no giant cell symptoms. The work up is pending, but the other eye which she feels is normal and which had a normal visual field today has pallid edema as well.

    She is 20/25 in each eye

    And of course she started wegovy five months ago


    We will get the scans and the blood work, but I’m rather certain this is going to be GLP1 induced simultaneous ischemic optic neuropathy with one eye being sub clinical at this point

    I was going to give her solumedrol while waiting for the work up and to hopefully minimize the edema in the second eye as well as aspirin

    She turns out to be aspirin and NSAID allergic so I’m going to give her 400 of Trental

    I don’t think we know the natural history of a potentially Wegovy induced case where both eyes are swollen and only one eye has symptoms

    If any of you have seen this profile, please let me know and more important if anyone has a good idea on how to protect the swollen yet visually normal eye I’d like to hear from you

    Thanks

    Sent from my iPhone


  • 2.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 20:04
    If she takes antihypertensives, have take them in the morning if her internist is amenable. Consider latanoprost at bedtime. 





  • 3.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 20:08
    No hypertension
    Sent from my iPhone



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  • 4.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 20:46
    For an anecdotal case, I had a case that I am still actively following. Typical a i o n in presenting symptomatic eye w GLP1 use for a few months prior ( perhaps 4-5) Fellow optic nerve was swollen and behaved like a pre-ischemic papillopathy (incipient AION) with absolutely normal fields. I put them on steroids initially. Obviously, full work up as any of you would do was negative. Optic nerve edema resolved in initial eye. I was hoping for second eye swelling to hopefully resolve without visual loss. After about three months developed inferior altitudinal defect in second eye. Still holding onto twenty twenty with split fixation in second eye. I started steroids again for what it is worth. I have been tapering the steroids. Not sure if there is anything to do other than control vasculopathic risk factors.
    Matt



    Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone






  • 5.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 20:56
    Thanks,Matt


    Sent from my iPhone



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  • 6.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 23:48
    Edited by Shikha TALWAR 11-07-2025 00:03

    (Dr Kay's case) I was wondering if the swelling in the incipient NAION eye resolve with steroids before going on to develop the field defect? Usually, every kind of swelling responds to steroids structurally if not functionally, unless it's a pseudooedema or true papilloedema or an infiltration.

    If it's due to GLP1 use we may learn something about the pathogenesis from this interesting case.  



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    Shikha
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  • 7.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 04:09
    If there is an altitudinal defect then most probably infarction has occurred , steroid resolve edema and will probably prevent further pressure from edema on a disc that mostly is crowded with small scleral canal as a ocular risk factor , when thing are not clear I immediately order Doppler of the carotids , this week I had two cases but with rather longer history of vague visual loss and bilateral pale disc with systemic work up not showing evident abnormality , both came with affected carotid Doppler , also I starting to make transcranial Doppler a routine request in my diagnostic paradigm of those somewhat vague cases 



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  • 8.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 06:40
    The swelling in the second eye persisted throughout the use of steroids for the 1st eye and for quite awhile Even after steroids were discontinued and then ultimately, they developed second eye  involvement as above. The swelling is resolving now, but not completely gone and the inferior pole remains mildly swollen, but reducing without superior field involvement as of yet. ��



    Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone




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  • 9.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 06:55
    For Dr Kay's case I wouldn't use steroids , I know that this sounds a little strange but I would use anti glaucoma medications , especially CA inhibitors , brinzolamide, I noticed it causes resolution of disc edema faster , I ve been using this for sometimes now and had noticeable success without any side effects , there was a poster in the last NANOS that confirmed my view on this , years ago I used 24 hours acting beta blocker in a paper for the prophylaxis of the second eye in NAION over a median period of about 18 months and I was very successful, beta blocker only Lowe IOP, but CA inhibitors improve hemodynamics of the optic nerve head as proved by Doppler studies , that is what I do 



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  • 10.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 08:23

    Thanks Dr Kay!
    Now we too will look at the rate of oedema resolution in GLP1 associated NAION, and also if the disc was small and at risk , time of onset ( morning/ evening/random)etc

    We can create a proforma ( questionnaire ) to fill when we see these cases. The senior neuroophthalmologists ( Some understand the optic disc perfusion with great insights) can guide the proforma creation. If we want to understand the pathophysiology some key questions in the history and examination in every case need to be recorded.

    most of the papers are retrospective studies. This way it can be analysed proactively.



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    Shikha
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    Original Message


  • 11.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 08:42

    This is an excellent Idea especially about the use of steroids , the timing , the dose , the effect on risk factors and the rout of administration 



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  • 12.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 09:00
    We are actually looking at some of the possible mechanisms for this presentation. I might also suggest an alternative approach to the use of steroids, since increased capillary leakage may or may not resolve with steroid treatment. Why not try minocycline, which is a microglial activation inhibitor? We, and Valerie Touitou's group found that, although minocycline does not enhance recovery when given after NAION development, administration of minocycline 3d prior to model induction enhanced recovery and RGC preservation by 40%.
    Steve Bernstein





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  • 13.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 09:05
    Would you post the paper here Dr Bernstein , it would be interesting to read 





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  • 14.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 09:14

    Woah!
    Neurobiology, molecular research input!

    Minocycline 100 mg per day for how long? It's much safer than steroids.Hope it doesn't cause IIH as doxy in some.

    Please keep the ideas coming , we are taking notes!

    Thanks!



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    Shikha
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    Original Message


  • 15.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 09:59
    I already have definitely seen cases in young people using minocyclin with PTC many times and I think many here in the group did , but if it had potential for cases of NAION , this definitely worth attention 





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  • 16.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 12:11

    What if the patients who get better actually have papillitis and not NAION or incipient NAION? Right drug for the wrong indication.



    ------------------------------
    Andrew Carey
    Associate Professor
    Wilmer Eye Institute, Johns Hopkins Medicine
    Baltimore MD
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    Original Message


  • 17.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 12:20
    I did an FA today- she has areas of luxury perfusion and areas that do not perfuse well on the disc with visual loss, and unfortunately, areas of poor perfusion on the disc where there has been no visual loss.

    Both optic nerves are clear on a high-quality MRI


    ESR, CRP neg, no sx GCA- but I will make her go through a TA biopsy



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  • 18.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 14:45
    I have nothing further to offer, except to say that a long time I’ve treated these AION one eye and incipient AION on the other steroids and Trental. AFAIK there’s no evidence-based proof that these effective though there are the studies about steroids and AION that suggest it may be so. The Trental has common-sense reasons to believe it may help improve perfusion while waiting for the edema to resolve and hopefully save remaining nerve, and side effects are rare, and only GI related.

    I’ve done this in desperate situations with severe loss of vision in one eye in the past from any cause, and edematous fellow nerve with significant field loss due to NA-AION in the other. Why not to offer it in ALL cases is the next question.

    Mitch


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  • 19.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 18:09
    Why would you pursue a TAbx in this case? You would not have a normal field with normal optic nerve function if the second eye was from G. C a and there are no symptoms with normal acute phase reactants. Sometimes
    You have to take the approach of "don't just do something,  stand there"
    Matt


    Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone




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  • 20.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 18:47
    If you ignored the right eye and just looked at the left eye in this woman who it turns out told me early this afternoon that she has had rheumatologic symptoms for several years have seen several rheumatologist and doesn't have a defined diagnosis you would get a temporal artery biopsy

    And my rule still is that any patient who has bilateral ischemic optic neuropathy in a very short period of time is giant cell arthritis until proven otherwise
    Sent from my iPhone



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  • 21.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-12-2025 14:54
    Would you biopsy a 60 year old with disk at risk and sequential AION with normal inflammatory markers, though?

    Mitch


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  • 22.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-12-2025 17:51
    I had a similar case.
    Sequential vision loss that looked like NAION in a 60yo woman with COPD(?prev diagnosed) however while on oral steroids for one week she reported significant improvement on body-aches (she never complained of headaches or shoulder-hip pain, by the way) AND she reported improved coughing spells.

    I did send TAB and it did show macrophages at the elastic lamina and EL disruption in most of the sections
    -i was not expecting that

    She is now on actemra due to side effects of steroids
    -TAB results were useful to justify steroid continuation and subsequent actemra
    -she did improve her vision


    CM Prospero Ponce MD






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  • 23.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-12-2025 18:13
    Hi ; yes I had a patient with ion OD , inferior altitudinal VF defect, normal VF OS, no TA symptoms,normal inflammatory markers, placed him on steroids anyway . About 3-4 weeks later the optic nerve OS start to develop hyperemia , order a TA biopsy which was positive! Patient is in low dose steroids and Rinvoq , doing well !

    Sent from my iPhone


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  • 24.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-12-2025 19:09
    Does she have clinical dx of GCA?
    Scott Forman



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  • 25.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-12-2025 18:47
    Thanks
    Sent from my iPhone



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  • 26.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-07-2025 12:20
    And thanks for everyone's thoughts.



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  • 27.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 21:06
    Larry

    But why the pallid disc edema? 
    I would be concerned about GCA and consider a TAB. Also do infiltrative work up with CSF given bilaterality, which I am assuming you are.

    Would not expect GLP1  to cause pallid disc edema...have you seen that? 

    Sangeeta







  • 28.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 21:10
    Yes, of course will do that work up and yes, I've seen pallid edema in GLP 
    Sent from my iPhone



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  • 29.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 21:10
    Russ: I also used to talk about antihypertensive medicine, not being given in the evening. However, there are recent recommendations from the medical community, indicating that people who take it at night have less strokes. I wonder if the group has any idea about changing our recommendations to prevent nocturnal hypotension a proposed mechanism for NAION.

    I recently had a 45 year-old woman on the same medication with bilateral simultaneous NAION. Too soon to tell what the natural history is

    Peter.
    Sent from my iPhone



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  • 30.  RE: Looking for any brilliant ideas on how to prevent second eye visual loss

    Posted 11-06-2025 22:21
    The TIME trial showed no difference in stroke or cardiac events with morning or night dosing. It was a larger study than the Hygia Chromotherapy study which found night dosing safer. 

    Since nocturnal blood pressure is usually lower than daytime BP and IOP higher during sleep, I feel that I may be reducing the risk of poor disc perfusion during sleep, thus possibly reducing risk of naion. 

    All theoretical, but probably very low risk to the patient.

    Russ Edwards




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