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Case 19

Arshia Eshtiaghi (CC3)

Patient Presentation: A 24-year-old woman was referred to a tertiary ophthalmology clinic after reporting 3 days of painless, blurred vision in the superior field of her left eye. Her past medical history was significant for congenital nephrotic syndrome; she was receiving hemodialysis every other day for the last 2 years. On examination, her best-corrected distance visual acuity is 20/20 OU. There was a left RAPD. Fundus examination was performed and shown below:


Question: What is the abnormality in the fundus photography above?

A Humphrey visual field (24-2) was subsequently performed and showed a superior altitudinal defect in the left eye.


Further review of the patient’s electronic medical record demonstrated 7 episodes of hypotension during dialysis treatments over the last 3 months, the most recent event being one week ago where her blood pressure fell to 70/40 for 5 minutes. 

Question: What is the most likely diagnosis for this patient?

OCTs of the retinal nerve fiber layer and ganglion cell analysis were acquired and shown below.


Question: How would you describe these OCTs in the left eye?

A second series of OCTs of the retinal nerve fiber layer and ganglion cell analysis were acquired and shown below. 


Question: Based on the above OCTs, when were these OCTs performed in relation to the patient’s clinical presentation?

Question: What can we expect on repeat RNFL and GCA analysis in a year from now?

Question: What treatment recommendation should be made to prevent subsequent NAION in the fellow eye?


  1. Cestari DM, Gaier ED, Bouzika P, et al. Demographic, Systemic, and Ocular Factors Associated with Nonarteritic Anterior Ischemic Optic Neuropathy. Ophthalmology. 2016. doi:10.1016/j.ophtha.2016.08.017

  2. Kerr NM, Chew SSSL, Danesh-Meyer H V. Non-arteritic anterior ischaemic optic neuropathy: A review and update. J Clin Neurosci. 2009. doi:10.1016/j.jocn.2009.04.002

  3. Fard MA, Ghahvehchian H, Subramanian PS. Optical coherence tomography in ischemic optic neuropathy. Ann Eye Sci. 2020. doi:10.21037/aes.2019.12.05

Learning Objectives:

  1. To identify the classic clinical, fundus and OCT signs of NAION.

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