Of course there isn’t yet conclusive evidence that steroids help with outcomes with NA-AION, but I believe that it likely does offer some benefit so I do offer it and employ it when the disk edema is significant 360 degrees but with only part of the field affected. I had a case recently who had a complete altitudinal defect with 20/20 vision and a very edematous nerve, the entire nerve, placed him on steroids and even Trental for good measure. He came in 3 weeks later with no subjective change in vision, but he had developed a new arcuate defect in the other half the field. Would he have turned out worse without treatment? Who knows. But 2 months out he’s 20/20 and the pallor of the dis is limited to half of the nerve and the field is stable. One anecdote.
Original Message:
Sent: 7/31/2025 7:07:00 PM
From: Matthew Kay
Subject: RE: Sudden drop in visual acuity in what initially appeared to be a NAION
I let the patient know that they may well deteriorate over the upcoming 2 or 3 weeks, But that unfortunately there is no accepted treatment. When they do get worse, they will often come into the office at their follow-up And tell me that I was right and they were at least prepared for it and not surprised. So I basically prepare them for the fact that they may get worse, But I don't like to subject them to The potential side effects of steroids for a condition which has no rationale to respond to prednisone therapy. I know that is very controversial however.
Matt
Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone
Original Message:
Sent: 7/31/2025 6:10:00 PM
From: Charles Rheeman
Subject: RE: Sudden drop in visual acuity in what initially appeared to be a NAION
My experience parallels yours. Worsening vision after the onset for Non-arteritic AION has been much higher than 15% in my private practice as well. These are the patients I tend to treat with prednisone when they present with 20/20 and not the ones with severe visual loss, just in case they get worse later, which will hopefully prevent the patient from asking why I didn’t do anything before he/she lost more vision.
Charles Rheeman
Original Message:
Sent: 7/28/2025 2:47:00 PM
From: Matthew Kay
Subject: RE: Sudden drop in visual acuity in what initially appeared to be a NAION
If you are in private practice like I am and often see patients within 72 hours of the onset of their visual loss, you will find that it is a lot greater than 15% of people w NAION who progress compared to onset. Most of the literature probably describes people who are not seen by a neuro ophthalmologist for ten days or so after their presentation Which would explain why the incidence of progressive N AI ON is described as being a lot lower in the literature than what I know to be the case.
Matt
Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone
Original Message:
Sent: 7/28/2025 2:42:00 PM
From: Scott Forman
Subject: RE: Sudden drop in visual acuity in what initially appeared to be a NAION
There is a 10-15% subset of patients with NAAION who suffer stepwise loss of visual acuity/field over several weeks. No everyone suffers a onetime loss and then remains stable.
+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=+=
Scott Forman, MD
Senior Fellow North American Neuro-ophthalmology Society
Adult and Pediatric Neuro-ophthalmology
Comprehensive Ophthalmology
Functional Medicine
Original Message:
Sent: 7/28/2025 2:27:00 PM
From: Michel Van Lint
Subject: RE: Sudden drop in visual acuity in what initially appeared to be a NAION
Thank you all for your feedback.
I realise everything points to a NAION, but the decrease in visual acuity from 1.0 to counting fingers had me hesitate.
Michel
Original Message:
Sent: 07-28-2025 13:53
From: Deborah Friedman
Subject: Sudden drop in visual acuity in what initially appeared to be a NAION
I missed this originally also, Scott. While impressive, It's on the wrong side (I'm surprised that optic nerve ipsilateral to the tumor is unscathed!).
Deb
Original Message:
Sent: 7/28/2025 11:52:00 AM
From: Scott Forman
Subject: RE: Sudden drop in visual acuity in what initially appeared to be a NAION
I believe tumoral compression is adding to NAION here to make the vision worse
SF
Original Message:
Sent: 7/28/2025 10:51:00 AM
From: Michel Van Lint
Subject: RE: Sudden drop in visual acuity in what initially appeared to be a NAION
Dear Dr. Forman,
I corrected my initial post:
Obviously, I meant to say optic disc edema. In my native language the term papilledema is not associated with intracranial hypertension, but has the same meaning as optic disc edema. We only have the term papilledema in Dutch (not optic disc edema). As such it is not a diagnosis in Dutch, but a description.
This is confusing. I don't normally make this mistake, but I am having sleep attacks lately and it is affecting my performance. Investigation is ongoing. Sincere apologies. I did not mean to get personal about myself, but the tone of your e-mail made me want to explain myself. We are all only human.
Michel
Original Message:
Sent: 07-28-2025 10:02
From: Scott Forman
Subject: Sudden drop in visual acuity in what initially appeared to be a NAION
Papilledema????
what is c/d ratio OU
why is this not NAAION?!
you let neurology Rx with 5 d solumedrol IV ?
scott Forman
Original Message:
Sent: 07-28-2025 08:49
From: Michel Van Lint
Subject: Sudden drop in visual acuity in what initially appeared to be a NAION
Hello,
Please find the case description below (male, 55 years-old). I was wondering, if you have any suggestions? Apologies for the long text.
I was thinking about a NAION, but his loss of visual acuity is atypical.
The loss of GCL is unfortunately not good.
The attached OCT compares 24 (worse) and 28 July (slightly better).
The visual field compares 24 (left, better) and 28 July (right, slightly worse)
Michel
A. In short:
Sudden visual loss in right eye
Inferior altitudinal defect with "macular sparing"
Papilledema right eye
Initial acuity 1.0, then rapidly worsened to counting fingers, then 0.05
No signs of infection, normal labs and CSF
Mild improvement after IV steroids
Left ethmoidal mass (but no compression seen on MRI)
Negative for anti-MOG, ANA, ANCA, and infection
anti-NMO still unknown
MRI spine: normal
No white matter lesions
B. The complete text:
Initial Presentation (04 July 2025):
The patient (male, 55yo) presented with sudden visual loss in the right eye and was found to have a mass in the left ethmoidal sinus.
Examination revealed:
Papilledema in the right eye
Inferior altitudinal visual field defect with macular sparing (right eye)
Visual acuity: 1.0 bilaterally
Left eye: normal
MRI brain showed the ethmoidal lesion was likely benign (e.g. fibrous dysplasia or ossifying fibroma), though a low-grade tumor could not be excluded. Biopsy was recommended.
Initial Management:
A diagnosis of NAION was considered likely, given the visual field defect and presentation upon awakening.
Despite the lack of proven efficacy, oral Medrol 64 mg was started due to:
In the acute setting I don't always find it straightforward to make the difference with an inflammatory cause
Low suspicion of infection (normal CRP, ESR)
Clinical Deterioration:
By 23/07/2025, vision in the right eye worsened from 1.0 to counting fingers, which is atypical for NAION.
This prompted reconsideration of the diagnosis and further evaluation for an inflammatory or autoimmune optic neuropathy.
Workup:
Neurology consult: lumbar puncture, spinal MRI → no evidence of demyelinating or inflammatory disease
IV Solumedrol (5 days) started 24–28/07/2025
Bloodwork: Negative for anti-MOG, ANA, ANCA, infectious serologies (HIV, syphilis, IGRA, toxoplasma). Anti-NMO still unknown
Spinal MRI: normal
CSF: unremarkable
Current Status (28/07/2025):
Vision slightly improved: counting fingers → 0.05 (right eye)
Visual field defect unchanged
Papilledema improving post-IV steroids (see attached images)
Differential Diagnosis:
NAION
Inflammatory/autoimmune optic neuropathy
Clinical worsening supports this
No serological or radiological confirmation
Mild improvement with IV corticosteroids supports possibility
Compression by ethmoidal lesion