Case Report
Bilateral non-arteritic anterior ischemic optic neuropathy following second-trimester spontaneous abortion-related haemorrhage

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Abstract

Bilateral anterior ischemic optic neuropathy is a rare complication of massive haemorrhage and related hypotension and anaemia in young individuals. We report a 34-year-old woman with bilateral non-arteritic ischemic optic neuropathy (NAION) after a massive spontaneous abortion-related haemorrhage who presented with sudden painless visual loss in her left eye. Visual acuity was 20/20 in the right eye with only hand motion discernible in the left eye. There was a left relative afferent papillary defect (RAPD). Fundus examination revealed bilateral swollen, hyperaemic optic discs and nerve fiber layer haemorrhages. Brain MRI and magnetic resonance venography were normal. The diagnosis of bilateral NAION was made and intravenous pulse corticosteroid therapy (1000 mg/day) was administered for three days. On the sixth day, optic disc oedema regressed bilaterally and on the third week, the visual acuity improved to 20/80 in the left eye. The visual field showed only a small spared area in the nasal region, and persistent RAPD was present. After two months, fundus examination showed a small and crowded optic disc on the right and a pale optic disc on the left. Severe acute haemorrhage is an important risk factor for NAION in healthy young individuals. In addition to correction of hypotension and anaemia, intravenous high dose corticosteroid might be beneficial for treatment.

Introduction

Non-arteritic ischemic optic neuropathy (NAION) is an ischemic process of the anterior portion of the optic nerve characterized by sudden, painless visual loss. Typically, NAION affects the elderly and is associated with risk factors such as diabetes mellitus, systemic hypertension and optic disc morphology (small and crowded optic disc).[1], [2] However, in younger patients, NAION is usually related to massive blood loss with resultant hypotension, and it has been reported after several surgical procedures, including spinal and cardiac surgery but rarely after trauma or obstetric haemorrhage.[2], [3], [4], [5], [6] Here we report a patient with bilateral NAION after abortion that resulted in a unilateral visual impairment. To our knowledge, this is a unique case presented after spontaneous abortion.

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Case report

A 34-year-old woman was referred to our clinic three days after spontaneous abortion with visual loss in her left eye. She first complained about blurred vision two days after the abortion. Her medical history was unremarkable. She had four healthy children and no history of prior miscarriages. During her fifth pregnancy recurrent vaginal bleeding began during the fourth gestational week and complicated the pregnancy until a spontaneous abortion at the 20th week. Presumed uterine atony led to

Discussion

The pathophysiologic mechanisms causing NAION are unclear. The proposed mechanisms are decreased perfusion pressure in short posterior ciliary arteries (paraoptic branches) due to hypotension, impaired autoregulation with release of vasoactive amines, vasculopathy and venous insufficiency.[2], [7] The presence of a crowded disc (small cup-to-disc ratio) is considered an important anatomical risk factor that results in a compartment syndrome after axonal oedema.[1], [2] Additional risk factors,

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