今日の臨床サポート

虚血性視神経症

著者: 中馬秀樹 宮崎大学 感覚運動医学講座眼科

監修: 沖波聡 倉敷中央病院眼科

著者校正/監修レビュー済:2022/03/30
患者向け説明資料

概要・推奨   

  1. 非動脈炎性虚血性視神経症に対して、さまざまな治療法が試みられているが、どれも少数例でその効果は受け入れられていない。効果があると思われた視神経鞘切開減圧術も多施設の無作為抽出研究において逆に有害であることが判明した(推奨度3)
  1. 動脈炎性虚血性視神経症では、赤沈の亢進と急性期反応蛋白であるC-reactive protein (CRP)値の上昇が診断に有用である(推奨度1)
  1. 動脈炎性虚血性視神経症では、適切に施行された側頭動脈生検であれば、感度、特異度ともには95%以上である(推奨度1)
アカウントをお持ちの方はログイン
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
中馬秀樹 : 特に申告事項無し[2022年]
監修:沖波聡 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、非動脈炎性虚血性視神経症の危険因子を追加した(疾患情報)。 

病態・疫学・診察

疾患情報  
  1. 虚血性視神経症(ischemic optic neuropathy、ION)とは、視神経への血液供給が妨げられて起こる視神経の損傷である。動脈炎性と非動脈炎性がある。発症頻度が高いのは非動脈炎性で、両眼失明の危険があるのは動脈炎性である。
  1. 動脈炎性虚血性視神経症は、高齢者に発症し、側頭動脈炎に合併するものが多く、側頭部の圧痛、顎跛行(jaw claudication)、近位筋痛を伴う。
  1. 非動脈炎性虚血性視神経症(non-arteritic ischemic optic neuropathy、NAION)は、高齢者に発症し(動脈炎性よりは低年齢)、急性無痛性片眼性視力低下(起床時に気づくことが多い)を来し、経過は卒中型である。
  1. 動脈炎性虚血性視神経症は、赤沈の亢進、CRP亢進、汎血球減少が特徴である。
  1. 非動脈炎性虚血性視神経症は、特異的な臨床および検査所見はなく、経過も含めてあくまでも臨床的、総合的に診断する。
  1. 動脈炎性虚血性視神経症は、無治療では数週以内に高率に僚眼へ発症し、発症後ではステロイド薬の効果はみられない。
  1. 動脈炎性虚血性視神経症は、初発時にステロイド薬加療することで僚眼への発症を予防することができる。
  1. 非動脈炎性虚血性視神経症は、10~20%に僚眼へ発症し、同一眼に再発するのは5%以下である。
  1. 非動脈炎性虚血性視神経症は、現時点では有効な治療法はなく、僚眼への発症を予防する方法もない。
  1. 非動脈炎性虚血性視神経症は、喫煙など動脈硬化性因子の他、睡眠時無呼吸症候群、血清ホモシスチンの上昇、視神経乳頭ドルーゼン、白内障術後、偏頭痛、インターフェロンα、Erectile Dysfunction(ED)治療薬、アミオダロンが危険因子とされる。
問診・診察のポイント  
  1. 動脈炎性虚血性視神経症:
  1. 側頭部の圧痛、jaw claudication、近位筋痛の有無を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

Takashi Fujikado, Takeshi Morimoto, Kenji Matsushita, Hiroshi Shimojo, Yoshitaka Okawa, Yasuo Tano
Effect of transcorneal electrical stimulation in patients with nonarteritic ischemic optic neuropathy or traumatic optic neuropathy.
Jpn J Ophthalmol. 2006 May-Jun;50(3):266-73. doi: 10.1007/s10384-005-0304-y.
Abstract/Text PURPOSE: To determine whether transcorneal electrical stimulation (TES) can improve the visual function of patients with nonarteritic ischemic optic neuropathy (NAION) or traumatic optic neuropathy (TON).
METHODS: Eight consecutive patients at the Osaka University Hospital were studied. TES (600-800 microA, 20 Hz, 30 min) was applied once each to three eyes with NAION and to five eyes with TON, using a contact lens-type stimulating electrode. The primary outcome measurement was the change in visual acuity at 1 to 3 months after TES. An improvement in visual acuity was defined as a change of > or =0.3 log (minimum angle of resolution) (logMAR) units. The side effects of TES were also investigated.
RESULTS: After TES application, the visual acuity improved in two patients with NAION and in four patients with TON. Visual acuity did not worsen in any of the eyes. Only a mild superficial punctuate keratopathy was observed in all eyes immediately after TES, and it healed by the next day.
CONCLUSIONS: Visual acuity can be improved after TES without major complications in some patients with NAION or TON. These results suggest that TES should be considered as a new treatment for eyes with optic neuropathy.

PMID 16767383
Jeffrey L Bennett, Scott Thomas, Jeffrey L Olson, Naresh Mandava
Treatment of nonarteritic anterior ischemic optic neuropathy with intravitreal bevacizumab.
J Neuroophthalmol. 2007 Sep;27(3):238-40. doi: 10.1097/WNO.0b013e31814b273d.
Abstract/Text
PMID 17895825
Sohan Singh Hayreh, M Bridget Zimmerman
Non-arteritic anterior ischemic optic neuropathy: role of systemic corticosteroid therapy.
Graefes Arch Clin Exp Ophthalmol. 2008 Jul;246(7):1029-46. doi: 10.1007/s00417-008-0805-8. Epub 2008 Apr 11.
Abstract/Text OBJECTIVE: To investigate systematically the role of systemic corticosteroid therapy in non-arteritic anterior ischemic optic neuropathy (NA-AION).
METHODS: The study consists of a cohort of 613 consecutive patients (696 eyes), first seen in our clinic from 1973 to 2000. Of this cohort, 312 patients (364 eyes) voluntarily opted for systemic steroid therapy, and 301 (332 eyes) for no treatment. At first visit, all patients in both groups had a detailed ophthalmic and medical history, and comprehensive ophthalmic evaluation. Visual evaluation was done by recording Snellen visual acuity, and visual fields with a Goldmann perimeter. The same ophthalmic evaluation was performed at each follow-up visit. Patients in the steroid-treated group were initially given 80 mg Prednisone daily for 2 weeks, and then tapered down to 70 mg for 5 days, 60 mg for 5 days, and then cutting down by 5 mg every 5 days. Visual outcome in the two groups was compared
RESULTS: Median follow-up was 3.8 years. At 6 months from onset of NA-AION, of the eyes with initial visual acuity 20/70 or worse and seen within 2 weeks of onset, there was visual acuity improvement in 69.8% (95% confidence interval (CI): 57.3%, 79.9%) in the treated group, compared to 40.5% (95% CI: 29.2%, 52.9%) in the untreated group (odds ratio of improvement: 3.39; 95% CI:1.62, 7.11; p = 0.001). Comparison of visual field defect at 6 months from onset of NA-AION, among those seen within 2 weeks of NA-AION onset with moderate to severe initial visual field defect, there was improvement in 40.1% (95% CI: 33.1%, 47.5%) of the treated group, and 24.5% (95% CI: 17.7%, 32.9%) of the untreated group (odds ratio: 2.06, 95% CI: 1.24, 3.40; p = 0.005). In both treated and untreated groups, the visual acuity and visual fields kept improving up to about 6 months from onset of NA-AION, and very little thereafter.
CONCLUSION: This study suggested that NA-AION eyes treated during the acute phase with systemic corticosteroids resulted in a significantly higher probability of improvement in visual acuity (p = 0.001) and visual field (p = 0.005) than in the untreated group. Both visual acuity and visual fields improved up to 6 months after onset of NA-AION.

PMID 18404273
Abstract/Text OBJECTIVE: To assess the safety and efficacy of optic nerve decompression surgery compared with careful follow-up alone in patients with nonarteritic anterior ischemic optic neuropathy (NAION).
DESIGN: The Ischemic Optic Neuropathy Decompression Trial (IONDT) is a randomized, single-masked, multicenter trial.
SETTING: Twenty-five US clinical centers.
PARTICIPANTS: The IONDT ceased recruitment on October 20, 1994, on the recommendation of its Data and Safety Monitoring Committee. The preliminary results presented herein are based on data as of September 8, 1994, from 244 patients with NAION and visual acuity of 20/64 or worse. One hundred twenty-five patients had been randomized to careful follow-up, and 119 had been randomized to surgery, with 91 and 95, respectively, having completed 6 months of follow-up.
INTERVENTION: Patients in the surgery group received optic nerve decompression surgery and follow-up ophthalmologic examinations; those in the careful follow-up group received ophthalmologic examinations at the same times as the surgery group.
MAIN OUTCOME MEASURES: Gain or loss of three or more lines of visual acuity on the New York Lighthouse chart at 6 months after randomization, as measured by a technician masked to treatment assignment.
RESULTS: Patients assigned to surgery did no better when compared with patients assigned to careful follow-up regarding improved visual acuity of three or more lines at 6 months: 32.6% of the surgery group improved compared with 42.7% of the careful follow-up group. The odds ratio (OR) for three or more lines better, adjusted for baseline visual acuity and diabetes, was 0.74 (95% confidence interval [CI], 0.39 to 1.38). Patients receiving surgery had a significantly greater risk of losing three or more lines of vision at 6 months: 23.9% in the surgery group worsened compared with 12.4% in the careful follow-up group. The 6-month adjusted OR for three or more lines worse was 1.96 (95% CI, 0.87 to 4.41). No difference in treatment effect was observed between patients with progressive NAION and all others.
CONCLUSION: Results from the IONDT indicate that optic nerve decompression surgery for NAION is not effective, may be harmful, and should be abandoned. The spontaneous improvement rate is better than previously reported.

PMID 7844872
R C Sergott, M S Cohen, T M Bosley, P J Savino
Optic nerve decompression may improve the progressive form of nonarteritic ischemic optic neuropathy.
Arch Ophthalmol. 1989 Dec;107(12):1743-54.
Abstract/Text Optic nerve sheath decompression surgery improved visual function for 12 of 14 patients with progressive nonarteritic ischemic optic neuropathy (NAION). Visual recovery was maintained in all patients during a follow-up period of 6 to 18 months (average, 11 months). Seven patients had experienced a previous NAION in the eye that was not operated on that did not improve spontaneously. Surprisingly, 2 of these 7 eyes with long-standing decreased vision demonstrated some visual improvement after surgery on the contralateral, acutely affected eye. Spontaneous visual improvement did not occur in an age- and sex-matched control group of 12 patients with similar entry-level visual acuity and field loss. Only 1 of 3 patients with sudden, nonprogressive visual loss secondary to NAION improved after surgery. In a control group with nonprogressive NAION, 2 of 15 eyes (14 patients) demonstrated spontaneous improvement. Optic nerve sheath decompression improves visual loss due to progressive NAION, a disorder without any previously effective therapy. However, for acute, nonprogressive NAION, surgery for a small number of patients did not improve the natural history of the disease.

PMID 2597065
Abstract/Text Optic nerve sheath decompression was performed in seven patients with nonarteritic anterior ischemic optic neuropathy. Visual function was evaluated by measurement of visual acuity with standardized Early Treatment Diabetic Retinopathy Study charts, color vision testing, quantitation of relative afferent pupillary defects with neutral-density filters, and Goldmann and Humphrey perimetry. Visual acuity improved markedly in all patients (at least doubling of the visual angle); the peripheral visual field expanded by at least 20 degrees (as measured by Goldmann perimetry) in six patients. Three patients also experienced marked improvement in color vision, relative afferent pupillary defect, and foveal sensitivity. Our experience supports the possible beneficial effect of optic nerve sheath decompression in patients with nonarteritic anterior ischemic optic neuropathy.

PMID 2025169
D M Jacobson, T L Slamovits
Erythrocyte sedimentation rate and its relationship to hematocrit in giant cell arteritis.
Arch Ophthalmol. 1987 Jul;105(7):965-7.
Abstract/Text We separated 24 patients with biopsy-proved giant cell arteritis into three groups based on erythrocyte sedimentation rates (ESRs) at clinical presentation: low, 1 to 40 mm/h; high, 41 to 80 mm/h; and very high, greater than 80 mm/h. The presence of anemia in the very high ESR group compared with the low ESR group was the only statistically identified difference. A linear regression analysis confirmed a high degree of inverse correlation between ESR and hematocrit in the subject population. There was no difference in ischemic ocular complications among the three groups. These findings emphasize that the diagnosis of giant cell arteritis should be made predominantly on clinical suspicion with less reliance on the ESR as a diagnostic criterion. Furthermore, the degree of ESR elevation does not predict which patients are at increased risk for the development of ocular complications. Finally, the ESR may not reliably indicate active disease in patients with normal hematocrit values.

PMID 3606457
S S Hayreh, P A Podhajsky, R Raman, B Zimmerman
Giant cell arteritis: validity and reliability of various diagnostic criteria.
Am J Ophthalmol. 1997 Mar;123(3):285-96.
Abstract/Text PURPOSE: To ascertain the validity, reliability, sensitivity, and specificity of various signs and symptoms of and diagnostic tests for early diagnosis of giant cell arteritis.
METHODS: From 1973 to 1994, we studied 363 patients who had temporal artery biopsy for suspected giant cell arteritis. All patients underwent detailed clinical evaluation and had erythrocyte sedimentation rates determined; since 1985, 223 patients had their C-reactive protein values estimated. Erythrocyte sedimentation rate and C-reactive protein levels were also estimated in 749 and 138 control subjects, respectively. Signs and symptoms of giant cell arteritis, erythrocyte sedimentation rate, and C-reactive protein levels among patients with positive and negative biopsies were compared.
RESULTS: Of the 363 patients, temporal artery biopsy was positive in 106 and negative in 257. The odds of a positive biopsy were 9.0 times greater with jaw claudication (P < .0001), 3.4 times greater with neck pain (P = .0085), 2.0 times greater with an erythrocyte sedimentation rate of 47 to 107 mm/hour (P = .0454), 3.2 times greater with C-reactive protein above 2.45 mg/dl (P = .0208), and 2.0 times greater for age 75 years or more (P = .0105).
CONCLUSIONS: Clinical criteria most strongly suggestive of giant cell arteritis include jaw claudication, C-reactive protein above 2.45 mg/dl, neck pain, and an erythrocyte sedimentation rate of 47 mm/hour or more, in that order. C-reactive protein was more sensitive (100%) than erythrocyte sedimentation rate (92%) for detection of giant cell arteritis; erythrocyte sedimentation rate combined with C-reactive protein gave the best specificity (97%).

PMID 9063237
T R Hedges, G L Gieger, D M Albert
The clinical value of negative temporal artery biopsy specimens.
Arch Ophthalmol. 1983 Aug;101(8):1251-4.
Abstract/Text The clinical course of patients with signs and symptoms suggestive of temporal arteritis but with negative temporal artery biopsy specimens was evaluated. Ninety-one patients undergoing a biopsy formed the basis of this study. Of these, 63 patients had no evidence of arteritis on biopsy, and 28 patients had biopsy specimens showing granulomatous inflammation. False-negative findings from biopsy specimens occurred in 5% of patients who had the disease. Cancer was the final diagnosis in 21% of patients with negative biopsy specimens v 3% of patients with temporal arteritis. Various chronic systemic inflammatory diseases were found in 16% of patients with negative biopsy specimens, while none of the patients with temporal arteritis had additional systemic inflammatory diseases. Patients with proven arteritis were notably older and had higher ESRs than patients without the disease. However, no laboratory test or frequently observed symptom or sign noted on initial examination, considered alone or in combination with other findings, had diagnostic sensitivity or specificity as high as temporal artery biopsy.

PMID 6882256
S Hall, S Persellin, J T Lie, P C O'Brien, L T Kurland, G G Hunder
The therapeutic impact of temporal artery biopsy.
Lancet. 1983 Nov 26;2(8361):1217-20.
Abstract/Text To evaluate the clinical usefulness of temporal artery biopsy in the diagnosis of giant-cell arteritis we followed up all 134 residents of Olmsted County, Minnesota, who had temporal artery biopsies between 1965 and 1980. Initial biopsies were positive for giant-cell arteritis in 46 cases and negative in 88. A history of jaw pain or claudication and the findings of a palpably abnormal temporal artery were significantly more common in the patients whose biopsy specimens showed giant-cell arteritis. Over a median follow-up period of 70 months (range 1-192) only 8 of the 88 biopsy-negative patients had clinical courses requiring long-term, high-dose corticosteroid therapy for giant-cell arteritis. In this population-based study temporal artery biopsy correctly predicted the subsequent need for corticosteroid therapy in 94% of cases: these findings indicate that biopsy should be done before patients are committed to long-term corticosteroid therapy.

PMID 6139569
P J McDonnell, G W Moore, N R Miller, G M Hutchins, W R Green
Temporal arteritis. A clinicopathologic study.
Ophthalmology. 1986 Apr;93(4):518-30.
Abstract/Text Clinical and laboratory findings of 237 consecutive patients who had 250 temporal artery biopsies performed at the Wilmer Institute during a 15-year period were reviewed. Biopsies were reviewed independently on three separate occasions by four observers who, unaware of the clinical history, made one of the following histopathologic diagnoses: active arteritis, healed arteritis, arteriosclerosis, atherosclerosis, normal, or other. Biopsies were reviewed a fourth time by the observers together to establish a consensus diagnosis. The frequency of intraobserver disagreement in biopsy interpretation ranged from 4.4 to 25.6% of cases. The frequency with which observers disagreed with the consensus diagnosis (interobserver variation) ranged from 4.3 to 13.5% of cases. Pre-biopsy steroid therapy for seven to eight weeks or longer was associated with loss of the histopathologic features of active arteritis. We recommend biopsies for all patients with known contraindications to steroid therapy. In addition, multivariant regression analysis suggests that certain patients can be selected who are likely to have positive biopsies. For some patients, the clinical diagnosis of temporal arteritis can be based on the clinical signs and symptoms and their response to a therapeutic trial of steroids.

PMID 3703528
R G Klein, R J Campbell, G G Hunder, J A Carney
Skip lesions in temporal arteritis.
Mayo Clin Proc. 1976 Aug;51(8):504-10.
Abstract/Text Although isolated foci of arteritis ("skip lesions") are presumed to occur in temporal arteritis, there is little documentation of their existence or significance. We have identified skip lesions in 17 of 60 patients (28%) with temporal arteritis, based on a retrospective and prospective examination of temporal artery biopsy specimens. By examining more than 6,000 serial sections of arteries from patients with skip lesions, we have found foci or arteritis as short as 330 mu in length in an otherwise normal biopsy specimen. Our study emphasizes the need to biopsy long segments of artery, to examine multiple histologic sections, and to perform a contralateral temporal artery biopsy when frozen-section examination of the first side is normal.

PMID 950804
A A Achkar, J T Lie, G G Hunder, W M O'Fallon, S E Gabriel
How does previous corticosteroid treatment affect the biopsy findings in giant cell (temporal) arteritis?
Ann Intern Med. 1994 Jun 15;120(12):987-92.
Abstract/Text OBJECTIVE: To determine the effect of previous corticosteroid treatment on the results of temporal artery biopsy.
DESIGN: Consecutive case series.
SETTING: Tertiary care center.
PATIENTS: A consecutive cohort of 535 patients who had temporal artery biopsies at Mayo Clinic, Rochester, Minnesota, between 1 January 1988 and 31 December 1991.
MEASUREMENTS AND RESULTS: The dose and duration of corticosteroid treatment received before temporal artery biopsy and detailed clinical and laboratory data were obtained from the patients' medical records. All temporal artery biopsy slides were re-evaluated by a pathologist blinded to clinical data, previous corticosteroid treatment information, and the original pathologic diagnosis. Biopsy specimens were classified as negative for arteritis, positive for typical temporal arteritis, or positive for atypical temporal arteritis. Biopsy results were positive for 31% of patients (89 of 286) who did not receive corticosteroids before biopsy and for 35% of those (86 of 249) who did receive corticosteroids before biopsy (P = 0.4; 95% confidence interval for the difference, -4.7% to 11.5%). Patients who received corticosteroids before biopsy tended to have clinical features more suggestive of arteritis. A multiple logistic regression analysis model, controlling for these differences in clinical and laboratory features, showed that the biopsy positivity rate was unrelated to previous corticosteroid treatment.
CONCLUSIONS: Although these results do not prove that histologic features are unaffected by corticosteroids, they show that, in this large, consecutive sample, the positivity rates of temporal artery biopsy were similar in untreated and corticosteroid-treated patients. Temporal artery biopsy may show arteritis even after more than 14 days of corticosteroid therapy in the presence of clinical indications of active disease.

PMID 8185147
M C Allison, P J Gallagher
Temporal artery biopsy and corticosteroid treatment.
Ann Rheum Dis. 1984 Jun;43(3):416-7.
Abstract/Text Eighty-four of 132 patients with clinically genuine cranial arteritis had histological evidence of inflammation at temporal artery biopsy. The highest incidence of a positive result (82%) was in patients biopsied before corticosteroid therapy. The figure fell to 60% if corticosteroids had been given for less than a week before biopsy and 10% thereafter.

PMID 6742903
P D Aiello, J C Trautmann, T J McPhee, A R Kunselman, G G Hunder
Visual prognosis in giant cell arteritis.
Ophthalmology. 1993 Apr;100(4):550-5.
Abstract/Text PURPOSE: The visual prognosis in giant cell arteritis (GCA) was evaluated over a 5-year period.
METHODS: The authors reviewed the records of all patients with a diagnosis of GCA established at the Mayo Clinic over a 5-year period regarding visual status. Follow-up data for these patients were obtained 5 years later.
RESULTS: Of the 245 patients studied, 34 (14%) permanently lost vision because of GCA. In 32 of these patients, the visual deficit developed before glucocorticoid therapy for GCA was begun; in the 2 other patients, the visual loss occurred after the diagnosis was made and therapy was started. Visual loss progressed in three patients after initiation of oral glucocorticoids, and in five other patients vision improved. After 5 years, the probability of loss of vision developing after initiating oral glucocorticoid treatment was determined to be 1% (Kaplan-Meier technique), and the probability of additional loss was 13% in patients with GCA who had a visual deficit at the time therapy was begun.
CONCLUSION: The development or progression of visual loss was rare after the initiation of glucocorticoid therapy.

PMID 8479714
G T Liu, J S Glaser, N J Schatz, J L Smith
Visual morbidity in giant cell arteritis. Clinical characteristics and prognosis for vision.
Ophthalmology. 1994 Nov;101(11):1779-85.
Abstract/Text PURPOSE: To characterize visual morbidity in giant cell arteritis and to assess prognosis with respect to treatment.
METHODS: Record review of 185 patients with coded diagnosis of giant cell (cranial) arteritis examined at the Bascom Palmer Eye Institute from January 1, 1980, to January 31, 1993.
RESULTS: Forty-five patients with biopsy-proven giant cell arteritis had visual symptoms, and 41 individuals (63 eyes) lost vision. The visual loss was unilateral in 19 patients (46%), sequential in 15 (37%), and simultaneous in 7 (17%). Anterior ischemic optic neuropathy developed in 88% of eyes, visual acuity was 20/200 or worse in 70%, 21% had no light perception, and the majority of field defects in testable eyes, aside from central scotomas associated with loss, showed altitudinal or arcuate patterns. Six patients lost vision during corticosteroid therapy for systemic symptoms of giant cell arteritis, whereas in 39 patients visual symptoms prompted steroid treatment. For visual symptoms, 25 patients received intravenous methylprednisolone, whereas 20 received oral prednisone alone. In the 41 patients with visual loss, vision was unchanged in 20 (49%), it worsened in 7 (17%), and it improved in 14 (34%). Subsequent fellow eye involvement was observed only with oral therapy, and a greater percentage of patients (9/23 [39%] versus 5/18 [28%]) improved after intravenous treatment.
CONCLUSIONS: In the authors' series, patients with visual loss due to giant cell arteritis had a 34% chance for some improvement in visual function after corticosteroid treatment. Intravenous therapy may diminish the likelihood of fellow eye involvement and was associated with a slightly better prognosis for visual improvement.

PMID 7800356
Rod Foroozan, Vincent A Deramo, Lawrence M Buono, D Gerard R Jayamanne, Robert C Sergott, Helen Danesh-Meyer, Peter J Savino
Recovery of visual function in patients with biopsy-proven giant cell arteritis.
Ophthalmology. 2003 Mar;110(3):539-42. doi: 10.1016/S0161-6420(02)01775-X.
Abstract/Text OBJECTIVE: To assess the visual function of patients with giant cell arteritis (GCA) who had visual loss from either anterior ischemic optic neuropathy (AION) or central retinal artery occlusion and had a subsequent improvement in visual acuity after treatment with corticosteroids.
DESIGN: Retrospective, observational case series.
PARTICIPANTS: Thirty-two consecutive patients with biopsy-proven GCA treated at one institution between January 1992 and December 1997.
INTERVENTION: Treatment with intravenous methylprednisolone 250 mg every 6 hours for 3 days, followed by oral prednisone 1 mg/kg daily for at least 4 weeks duration.
MAIN OUTCOME MEASURES: The number of patients with an improvement in visual acuity after treatment with intravenous methylprednisolone; neuro-ophthalmic evaluation, including visual acuity, funduscopy, and visual field examination of these patients.
RESULTS: Improvement in visual acuity occurred in 5 of 39 eyes (13%) with visual loss from biopsy-proven GCA, and all 5 patients had AION. Despite the improvement of visual acuity in these 5 patients, perimetry revealed marked constriction of the visual field in each affected eye.
CONCLUSIONS: The prognosis for visual improvement in GCA is poor. Although an improvement in visual acuity occurred in 5 of our patients, marked constriction of the visual field was present in all of them.

PMID 12623817
Sohan Singh Hayreh, Bridget Zimmerman, Randy H Kardon
Visual improvement with corticosteroid therapy in giant cell arteritis. Report of a large study and review of literature.
Acta Ophthalmol Scand. 2002 Aug;80(4):355-67.
Abstract/Text OBJECTIVES: (1) To report the incidence and extent of visual improvement achieved by high-dose systemic corticosteroid treatment in eyes with visual loss due to giant-cell arteritis (GCA). (2) To understand the cause of the discrepancies between visual improvement revealed by routine visual acuity (VA) and by the central visual field in kinetic perimetry. (3) To review critically the contradictory literature on the effectiveness of corticosteroid therapy on visual recovery in GCA and to attempt to reconcile differences in the reported results.
METHODS: Clinical data were collected systematically on 84 consecutive patients (114 eyes) with visual loss, all of whom had GCA confirmed by temporal artery biopsy and treated by us with high-dose systemic corticosteroid therapy. The patients were treated between 1974 and 1999 and data were compiled retrospectively. All patients underwent a detailed visual and ophthalmic evaluation at the initial visit and at every follow-up. This included visual field testing (with a Goldmann perimeter). All were treated with systemic corticosteroid therapy (intravenous followed by oral in 41 patients and oral only in 43 patients).
RESULTS: Visual loss was due to anterior ischaemic optic neuropathy (91%), central retinal artery occlusion (10.5%), cilioretinal artery occlusion (10%), and/or posterior ischaemic optic neuropathy (4%), either alone or in different combinations. Improvement in both VA (>or= 2 lines) and central visual field was found in only five (4%) eyes of five patients (three treated with intravenous and two with oral steroid therapy). Improvement in VA >or= 2 lines but not in the central visual field was found in seven eyes (in six patients). Visual improvement was seen in 7% of 41 patients treated initially with intravenous steroids versus 5% (p = 0.672) of 43 patients treated with oral steroids only. Comparison of patients with visual improvement in both VA and fields versus those with no improvement suggested a shorter interval (p = 0.065) between onset of visual loss and start of therapy in the improved patients.
CONCLUSIONS: In our study, only 4% of eyes with visual loss due to GCA improved, as judged by improvement in both VA and central visual field (by kinetic perimetry and Amsler grid). The data also suggest that there is a better (p = 0.065) chance of visual improvement with early diagnosis and immediate start of steroid therapy. Improvement in VA without associated improvement in the central visual field or Amsler grid may simply represent a learned ability to fixate eccentrically with more effective use of remaining vision: this factor could help explain a number of reported cases in the literature of improved VA after steroid treatment for GCA. To prevent further visual loss in either eye and for management of systemic manifestations of GCA, all patients must be treated on a long-term basis with adequate amounts of systemic corticosteroids.

PMID 12190776
Gideon Nesher, Yaakov Berkun, Michal Mates, Mario Baras, Alan Rubinow, Moshe Sonnenblick
Low-dose aspirin and prevention of cranial ischemic complications in giant cell arteritis.
Arthritis Rheum. 2004 Apr;50(4):1332-7. doi: 10.1002/art.20171.
Abstract/Text OBJECTIVE: Cranial ischemic complications such as cerebrovascular accidents (CVAs) and acute visual loss are among the leading causes of giant cell arteritis (GCA)-related morbidity. In this retrospective study, we evaluated the effect of treatment with low-dose aspirin on the incidence of cranial ischemic complications in GCA.
METHODS: Charts of 175 consecutive patients in whom GCA was diagnosed between 1980 and 2000 were reviewed for medical data. Data for 166 patients who were followed up for at least 3 months were also available.
RESULTS: At the time of the diagnosis of GCA, 36 patients (21%) had already been receiving low-dose aspirin (100 mg/day). In all cases, the indication for this treatment was ischemic heart disease. There were no significant differences between the aspirin-treated and non-aspirin-treated groups regarding the mean age of patients, the male-to-female ratio, duration of GCA-related symptoms, rates of headaches, systemic symptoms, and jaw claudication, and the mean erythrocyte sedimentation rate, hemoglobin count, and platelet count. Cerebrovascular risk factors (hypertension, hyperlipidemia, or diabetes mellitus) were more common in the aspirin-treated group (38.9% versus 20%; P= 0.03). Cranial ischemic complications were diagnosed in 43 patients at presentation: 30 patients had acute visual loss, 11 had CVAs, and 2 had both conditions simultaneously. Only 3 of the aspirin-treated patients (8%) presented with cranial ischemic complications, compared with 40 (29%) of the non-aspirin-treated patients (P = 0.01). Despite the use of steroid therapy, cranial ischemic complications developed in 14 of the 166 patients followed up for 3 months or longer. However, cranial ischemic complications developed in only 3% of the aspirin-treated patients, compared with 13% of the patients treated with prednisone only (P = 0.02).
CONCLUSION: These data suggest that low-dose aspirin decreases the rate of visual loss and CVAs in patients with GCA.

PMID 15077317
Michael S Lee, Scott D Smith, Anat Galor, Gary S Hoffman
Antiplatelet and anticoagulant therapy in patients with giant cell arteritis.
Arthritis Rheum. 2006 Oct;54(10):3306-9. doi: 10.1002/art.22141.
Abstract/Text OBJECTIVE: Vision loss and cerebrovascular accidents often complicate giant cell arteritis (GCA). Antiplatelet and anticoagulant therapy reduce the risk of stroke in other populations. We sought to determine whether antiplatelet or anticoagulant therapy reduces ischemic complications in patients with GCA.
METHODS: A retrospective chart review for patients with GCA was conducted. Included patients fulfilled modified 1990 American College of Rheumatology criteria for GCA. Collected information included demographic data, dates of antiplatelet or anticoagulant use, vision loss or stroke, and presence of bleeding complications and cerebrovascular risk factors.
RESULTS: A total of 143 patients were included with a mean followup period of 4 years. The cohort included 109 women (76%) and 34 men (24%) with a mean age of 71.8 years. A total of 104 patients (73%) had a biopsy-proven diagnosis. Eighty-six patients (60.1%) had received long-term antiplatelet or anticoagulant therapy, including 18 (12.6%) who did not start therapy until after an ischemic event had occurred. Antiplatelet agents or anticoagulants were not used in 57 patients (39.9%). Overall, 11 of 68 patients (16.2%) had an ischemic event while receiving antiplatelet or anticoagulant therapy, compared with 36 of 75 patients (48.0%) not receiving such therapy (P < 0.0005). Univariate analysis failed to show a statistical difference between groups in regard to cerebrovascular risk factors, age, sex, or biopsy-proven diagnosis. Bleeding complications occurred in 2 patients receiving aspirin, 1 patient receiving warfarin, and 5 patients who did not receive anticoagulant or antiplatelet therapy.
CONCLUSION: Antiplatelet or anticoagulant therapy may reduce the risk of ischemic events in patients with GCA. An increased risk of bleeding complications was not observed.

PMID 17009265
Janet C Rucker, Valérie Biousse, Nancy J Newman
Ischemic optic neuropathies.
Curr Opin Neurol. 2004 Feb;17(1):27-35.
Abstract/Text PURPOSE OF REVIEW: To review recent clinical data on ischemic optic neuropathies, which are some of the most frequently encountered optic neuropathies. These disorders include nonarteritic anterior ischemic optic neuropathy, arteritic anterior ischemic optic neuropathy, and posterior ischemic optic neuropathy.
RECENT FINDINGS: Recent studies have facilitated our understanding of the natural history of visual loss, recovery, and recurrence in these disorders. Additionally, the value of various diagnostic techniques and treatment options, particularly for arteritic anterior ischemic neuropathy, has been clarified.
SUMMARY: Application of the studies described in this paper should allow the clinician to more accurately diagnose ischemic optic neuropathies and counsel the patient with regard to appropriate management, prognosis for visual recovery and future risk of recurrence.

PMID 15090874
G G Hunder, S G Sheps, G L Allen, J W Joyce
Daily and alternate-day corticosteroid regimens in treatment of giant cell arteritis: comparison in a prospective study.
Ann Intern Med. 1975 May;82(5):613-8.
Abstract/Text Alternate-day corticosteroid therapy was compared with two daily corticosteroid regimens for the treatment of giant cell arteritis. In a prospective study 60 patients with this disease were randomly assigned to three treatment groups: group A, 15 mg of prednisone every 8 hours; group B, 45 mg of prednisone every morning; and group C, 90 mgof prednisone every other morning. After 1 month of treatment, the arteritis seemed to be completely suppressed in 18 patients in group A and 16 in group B but in only 6 in group C. In the 14 other patients in group C, the continuing symptoms were cyclic and developed during the day steroids were not given. By changing to a daily regimen, the arteritis was controlled in most patients in group C. Adverse reactions to prednisone were noted frequently in groups A and B but rarely in group C.

PMID 1137255
M J Kupersmith, L Frohman, M Sanderson, J Jacobs, J Hirschfeld, C Ku, F A Warren
Aspirin reduces the incidence of second eye NAION: a retrospective study.
J Neuroophthalmol. 1997 Dec;17(4):250-3.
Abstract/Text The objective of this study was to determine if aspirin reduces the incidence of second eye involvement after nonarteritic anterior ischemic optic neuropathy (NAION) in one eye. Records were reviewed of 131 patients who sustained unilateral NAION. Of these, the 33 patients who sustained second eye NAION were compared to those followed for a minimum of 2 years without sustaining a second eye NAION (67). Thirty-one of the 131 patients were excluded because of inadequate follow-up. Except for diabetes (relative risk [RR] 1.43, p = 0.05), the incidence of second eye NAION was independent of gender, age, cup/disk, hypertension, anemia, and migraine. The degree of visual acuity or field dysfunction in the first eye correlated poorly with the acuity (r = 0.28) and field (r = 0.33) loss in the second eye. Aspirin (65-1,300 mg) taken two or more times per week decreased the incidence (17.5% vs. 53.5%) and relative risk (RR = 0.44, p = 0.0002) of second eye AION regardless of the usual risk factors. Even after eliminating those patients who had bilateral disease when first referred, ASA still reduced the incidence of second eye involvement (35% vs. 13%, RR = 0.74, p = 0.01). Aspirin may be an effective means of reducing second eye NAION.

PMID 9427177
O Salomon, R Huna-Baron, D M Steinberg, S Kurtz, U Seligsohn
Role of aspirin in reducing the frequency of second eye involvement in patients with non-arteritic anterior ischaemic optic neuropathy.
Eye (Lond). 1999 Jun;13 ( Pt 3a):357-9. doi: 10.1038/eye.1999.90.
Abstract/Text PURPOSE: To retrospectively evaluate in patients with non-arteritic ischaemic optic neuropathy (NAION) whether aspirin reduces the frequency of second eye involvement.
METHODS: In 52 patients who presented with NAION between 1984 and 1997 adequate information was available regarding use of aspirin, presence of risk factors and second eye involvement.
RESULTS: Second eye involvement was noted in 8 of 16 patients (50%) who did not receive aspirin, in 3 of 8 patients (38%) who received 100 mg/day aspirin and in only 5 of 28 patients (18%) who received aspirin 325 mg/day. Moreover, mean time to second eye involvement was 63 months in patients who did not receive aspirin versus 156 months in patients who received aspirin 325 mg/day.
CONCLUSION: Our results strongly suggest that aspirin at 325 mg/day may be effective in reducing the frequency of second eye involvement with NAION.

PMID 10624433
Abstract/Text
PMID 10755123

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから