Synopsis
Recognise optic-nerve ischaemia, urgently exclude an arteritic cause, and distinguish evidence-based vascular and medicine review from treatments that have not reliably restored vision in non-arteritic disease.
- Anterior ischaemic optic neuropathy affects the optic nerve head and commonly produces acute disc swelling with a monocular field deficit.
- Non-arteritic disease often presents as sudden painless loss, sometimes noticed on waking, with an altitudinal or other field defect.
- Arteritic disease, usually related to giant-cell arteritis in this setting, needs immediate treatment to protect remaining vision.
Key red flags
New visual loss with jaw or tongue claudication, scalp tenderness, constitutional symptoms or polymyalgic symptoms requires immediate consideration of giant-cell arteritis.
Investigation priorities
Localise visual dysfunction and assess the extent of injury.
Management branches
Acute ischaemic-looking visual loss is accompanied by clinical concern for giant-cell arteritis.
- Contact ophthalmology and the urgent GCA service on the same day, communicating the visual findings and systemic history.
- Take blood samples promptly if this does not delay treatment, and start the specialist-agreed high-dose glucocorticoid pathway.
Key medicines
Glucocorticoids for suspected arteritic visual lossBSR guidance conditionally supports intravenous methylprednisolone 500 mg to 1 g daily for up to three consecutive days in acute or intermittent visual loss, followed by oral treatment. If intravenous treatment is not immediately possible, oral prednisolone 60–100 mg daily for up to three days is a bridge and must not be delayed while intravenous access is arranged.