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  • 1.  Odds of NAION after vitrectomy?

    Posted 01-22-2026 03:09

    I have a female 81 year-old patient who developed a NAION with inferior altitudinal visual field loss in her left eye a week after cataract surgery.

    Cardiovascular work-up was normal, although there was a hypereosinophilia and a disc-at-risk.

    Now she is in need of a vitrectomy for the fellow right eye rather sooner than later because of a vitreomacular traction with retinal cysts on OCT.

    I don't suppose there is much we can do to reduce the odds of a NAION happening for the right eye? (although it may be less common after a vitrectomy?)

    Michel



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  • 2.  RE: Odds of NAION after vitrectomy?

    Posted 01-22-2026 06:18
    Put the patient on Brimonidine  preop .. it certainly can't hurt.
    Sent from my iPhone





  • 3.  RE: Odds of NAION after vitrectomy?

    Posted 01-22-2026 07:22
    I recommend carbonic anhydrase drops brinzolamide or dorzolamide for their ability to improve disc hemodynamics besides lowering IOP for those cases 
    One thing when the work up is normal it may be intermittent attack of elevated BP , so I recommend monitoring BP on daily basis because it is sometimes the enemy within , the stress of the surgery itself causes elevated BP





  • 4.  RE: Odds of NAION after vitrectomy?

    Posted 01-22-2026 10:09
    When I operate on these patients there is understandably a lot of counseling. I consider trying to keep the intraocular pressure low enough to avoid unnecessary problems with perfusion pressure on a crowded nerve. In cataract surgery this means low flow settings with an IOP max goal of 40-45.Unfortunately you can't really set this in a vitrectomy.  I use miostat at the end of the case and consider diamox orally for the first couple days. To maximize perfusion into the eye I put them into slight trendellenberg during surgery--it might increase IOP a little but it keeps the blood in the brain so it might help perfusion of the eye when iop is higher. Maybe that is advice to give since you don't have "low flow" vitrectomy settings. 

    Kim 





  • 5.  RE: Odds of NAION after vitrectomy?

    Posted 01-22-2026 10:14
    The mechanisms of optic nerve injury after cataract surgery and vitrectomy are likely different with mild overlap.

    Cataract surgery: NAOIN most commonly due to compartment syndrome of the optic nerve head complicating irvine-gass syndrome (post-op CME). This is related to prostaglandin upregulation from iris irritation during surgery. Less common factors include IOP spikes and trauma from retrobulbar blocks

    Vitrectomy: most common is ischemia from high IOP during surgery and if gas bubble then after surgery, as well as risk from RNFL avulsion during membrane peeling, trauma from retrobulbar block, and rarely disc edema associated with Irvine gass (typically iris is not manipulated during vitrectomy). If you are worried about Irvine-gass (higher risk in glaucoma patients and those with multiple eye surgeries, you could pretreat with topical NSAID and steroid or even consider a short course of oral steroid... Especially if the patient has a history of uveitis or autoimmune condition.

    It's unclear if there is increased risk of NAION from vitrectomy in this patient. I'm not sure an oral CAI will help much. If anything, lowering ICP and having increased IOP might reduce optic nerve head perfusion and increase risk of vision loss.

    While vitrectomy is the most successful and commonly used treatment for decreased vision from vitreomacular traction, of the patient is functioning well the traction could be observed or intravitreal injection of ocriplasmon could be considered.

    Best, 

    Drew





  • 6.  RE: Odds of NAION after vitrectomy?

    Posted 01-22-2026 11:22
    NAAION in the peri-operative cataract period is often due to uncontrolled hypertension.
    Scott Forman







  • 7.  RE: Odds of NAION after vitrectomy?

    Posted 29 days ago

    Dear all,

    Thank you very much everyone for your quick responses. I feel so lucky to be a member of NANOS. 

    Michel

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  • 8.  RE: Odds of NAION after vitrectomy?

    Posted 29 days ago
    Thank you for that sentiment!
    Sent from my iPhone





  • 9.  RE: Odds of NAION after vitrectomy?

    Posted 29 days ago
    We are all lucky to have this wonderful gathering 
    Thank you for posting