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Case Report

AcuteNonarteritic Anterior Ischemic Optic Neuropathy (NAION) after an Uncomplicated Cataract Surgery

*Correspondence to: Nurgül Örnek, Address: Kırıkkale Üniversitesi Tıp Fakültesi, Göz Hastalıkları Anabilim Dalı, 71450, Yahşihan, Kırıkkale, Turkey,Tel: +90 532 4309289; E-mail:

Article Information

Article Type: Case Report

Received : 16/08/2018
Accepted : 05/09/201 
Published : 15/09/2018



AcuteNonarteritic Anterior ischemic optic neuropathy (NAION) causes severe and irreversible visual loss as a result of microvascular hypoperfusion of opticnerve due to several risk factors like hypertension, diabetesmellitus, hypercholesterolemia, ischemicheartdisease, cerebrovasculardisease, hypotension, bloodloss, anemia, migraine, sleepapneasyndrome, smoking,medications (amiodarone, sildenafil), ocularsurgery, history of NAION in the fellow eye and crowded optic nerve head with small cup-to-discratio. Increased incidence of NAION after modern cataract surgery is an issue of controversy (1-2). Here in, we report a case of immediate type NAION without increased intra ocular pressure perioperativly and any detectable risk factors excepts mall cup-to-discratio at first day after an uncomplicated phacoemulsification cataract surgery.

A 66-year-old woman without any systemic diseases presented with bilateral cataracts. Best-corrected visual acuity (BCVA) was 20/50 in the right eye and 20/100 in the left eye. Intra ocular pressure (IOP)was 16/16mmHg and dilated fundus examination was normal except small areas of retinal pigment epithelial disturbances at extra foveal area in both eyes. Cup-to-discratio was 0.1 in both eyes. She under went an uneventful phacoemulsification and intra ocular lens implantation under topical (Proparakainhidroklorür 0.5%(Alcaine®)and intracameral anesthesia (Lidocaine 2% (Jetmonal®)) in the left eye. Topicalmoxifloxacine0.5% (Moxai®) and prednisoloneacetate %1 (Pred forte®) were initiated after surgery.

On the first postoperative day,she complained of decreased visual acuity in the operated eye. BCVA was 20/200. There was no corneal edema and IOP was 15 mmHg by Goldmann applanation tonometer. IOL was in the capsular bag and anterior segment was normal. Fundus examination show eda swollen optic disc.There was relative afferent pupillary defect (RAPD) . Color vision was impaired in this eye.Perimetry test (Octopus )revealed generalized absolutes cotoma with markedly reduced retinal sensitivity. Fundus flouresce in angiography showed optic disc hyperfluorescence at the latest age and small areas of window defects due to retinal pigment epithelium atrophy (Fig. 1).Subretinal fluid at papillo macular bundle (Fig. 2A) and increased retinal nerve fiber layer thickness at peripapillary area (Fig. 2B) were demonstrated by spectral domain optical coherence tomography. Laboratory investigations including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)measurements and clinical evaluation excluded arteritic ischemic optic neuropathy. There was no intracranial and intraorbital abnormality on MR imaging. The patient was diagnosed as NAION. 

Figure 1.Fundus florese in angiography of the left eye  on postoperative day 1 showing hyper fluorescence of the optic disc at the late stage.

Figure 2.Spectral domain optical coherence tomography of the left eye on postoperative day 1 showing subretinal fluid at papillo macular bundle (A) and increased peripapillar nerve fiber layer thickness at disc circle image (B). 

McCulley et al.(3) reported increased incidence of NAION risk after cataract extraction which is approximately 1 in every 2000 cases. Cataract extraction-associated NAION divided into immediate and delayed types according to the time from surgery to the event. Immediate type reported to occur in hours todays after surgery and episodes of increased intra ocular pressure occuring at the time of surgery or soon there after is proposed as possible causative factor for ischemic optic nerve damage (3,4). 

Hayreh was the first to published immediate type NAION in 13 patients following uncomplicated cataract extraction in 1980 (5). The patients in his cohort almost invariably had increased intra ocular pressure during the immediate postoperative period and this high IOP was critical to develop post cataract surgery NAION especially when optic nerve head circulation was vulnerable. In 2003, McCulley et al.(4)reported 18 eyes which developed NAION within a year of cataract surgery. Four out of 18 (22%)eyes developed NAION within 24 hours of surgery and markedly elevated IOP above 45 mmHg was documented in 3 of these eyes.One eye had not adequately documented IOP.

Half of NAION cases occured in the first week after surgery in a study by Al-Madani et al (1). They suggested that retrobulbar anesthesia might have caused NAION mostly in the first week after surgery. They did not report NAION in the first 24 hours in their series.

The case developed an immediate type NAION without any risk factors other than small cup-to-discratio. IOP was within normal levels perioperatively and phacoemulsification cataract surgery was performed uneventfully under topical and intracameral anaesthesia.Uncomplicated phacoemulsification surgery might be a risk factor for NAION. Surgeons should be aware of this rare, devastating and untreatable complication of modern cataract surgery because contralateral eyes are at increased risk and precautions should be taken  to protect the contralateral eye.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.



1 Al-Madani MV, Al-Raqqad NK, Al-Fgarra NA, Al-Thawaby AM, Jaafar AA. (2017) The risk of ischemic optic neuropathy post
   phacoemulsification cataract surgery. PanAfrMed J.;28:53. 
2 Moradi A, Kanagalingam S, Diener-West M, Miller NR. (2017) Post-cataract surgery optic neuropathy: Prevalence, incidence,
   temporal relationship, and fellow eye involvement. Am J Ophthalmol.;175:183-93.
3 McCulley TJ, Lam BL, Feuer WJ. (2001) Incidence of nonarteritic anterior ischemic optic neuropathy associated with cataract
4 McCulley TJ, Lam BL, Feuer WJ. (2003) Nonarteritic anterior ischemic optic neuropathy and surgery of the anterior segment:
   temporal relationship analysis. Am J Ophthalmol.;136(6):1171-2.
5 Hayreh SS. (1980) Anterior ischemic optic neuropathy. IV. Occurence after cataract extraction. Arch. Ophthalmol.;98(8):1410-6.


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