Anterior ischaemic optic neuropathy (AION) is among the commonest causes of sudden, painless, monocular visual loss in people over 50, and it comes in two forms that share almost nothing beyond the presentation. The arteritic form, usually a manifestation of giant cell arteritis, is a medical and ophthalmological emergency in which the second eye is at immediate risk. The non-arteritic form is far more common and has no specific effective treatment.
The Spanish Society of Internal Medicine's vascular risk and systemic autoimmune disease groups, working with the Spanish Retina and Vitreous Society, have set out a joint position on how these patients should be handled. Their starting observation is that management is heterogeneous: aetiological assessment, follow-up and secondary prevention vary widely, and the boundary between the ophthalmologist's responsibility and the physician's is often left undefined. The document is the third in a series, after consensuses on retinal arterial and venous occlusion.
These are consensus recommendations, and the authors are explicit that the evidence underneath several sections is weak. Read it as a way of standardising a pathway rather than as new evidence about treatment. The practical value for a rheumatologist is in the handover: any patient over 50 with sudden monocular visual loss needs inflammatory markers the same day and a decision about high-dose glucocorticoid before a temporal artery biopsy or ultrasound can be arranged, and the non-arteritic cases need their vascular risk factors addressed rather than being discharged from the eye clinic without a physician's review.
- In sudden painless monocular visual loss over 50, send ESR and CRP the same day
- Ask directly about jaw claudication, scalp tenderness, new headache and polymyalgic symptoms
- Do not delay high-dose glucocorticoid for the biopsy if arteritic disease is suspected — the other eye is the thing at stake
- Treat a non-arteritic diagnosis as a prompt for full vascular risk assessment, not as an endpoint
- Agree locally who owns follow-up: these patients fall between ophthalmology and internal medicine
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