Progressive, Sequential Non-arteritic Anterior Ischemic Optic Neuropathy in the Context of Metabolic Syndrome and a Crowded Disc - A Case Highlighting Synergistic Vascular Risk

Sep 29, 2026

Non-arteritic anterior ischaemic optic neuropathy (NAION) is an ischaemic disorder affecting the anterior optic nerve and commonly presents with acute, painless vision loss on waking. This case report describes a 44-year-old woman with multiple metabolic risk factors, obstructive sleep apnoea, and an anatomically crowded optic disc who developed progressive NAION followed by sequential involvement of the fellow eye, even after optimization of her risk factors.

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CategoryHealthcare

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Review began 11/08/2025 Review ended 12/03/2025 Published 12/05/2025 © Copyright 2025 Mohammad Razali et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98545 Open Access Case Report Progressive, Sequential Non-arteritic Anterior Ischemic Optic Neuropathy in the Context of Metabolic Syndrome and a Crowded Disc: A Case Highlighting Synergistic Vascular Risk Amirah Mohammad Razali 1, Muhammad Khairul Adha Fuaad 2 , Muhammad Mohd Isa 1 1. Department of Ophthalmology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, MYS 2. Department of Ophthalmology, Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, Serdang, MYS Corresponding author: Muhammad Mohd Isa, [mmi@upm.edu.my](mmi@upm.edu.my) Abstract Non-arteritic anterior ischaemic optic neuropathy (NAION) is an ischaemic disorder involving the anterior portion of the optic nerve. It typically presents with acute, painless vision loss upon awakening, accompanied by optic disc oedema and an inferior altitudinal visual field defect. We report a 44-year-old woman with multiple metabolic risk factors, obstructive sleep apnoea, and an anatomically crowded optic disc, who developed progressive NAION followed by sequential involvement of the fellow eye, despite optimization of her risk factors. Categories: Internal Medicine, Ophthalmology, Otolaryngology Keywords: anterior ischemic optic neuropathy (aion), non-arteritic, obstructive sleep apnoea, progressive, sequential Introduction Non-arteritic anterior ischaemic optic neuropathy (NAION) is one of the leading causes of irreversible vision loss in middle-aged and elderly individuals, with an incidence of 10-11 per 100000 [1,2] . NAION in individuals under the age of 50 is not rare, whereby Arnold et al. found that 108 (12 . 7%) of their cohort of patients were under 50 years with higher rates of eye involvement than in those 50 years and older [3] . Clinically, patients typically present with a sudden onset, painless, unilateral blurring of vision, a relative afferent pupillary defect, variable visual field defect, a hyperaemic swollen optic disc and the presence of one or more splinter haemorrhages [4] . The pathogenesis of this condition involves a few features, commonly involving infarction in the laminar and retrolaminar regions with flow impairment to the prelaminar optic disc during the acute phase and a small, crowded disc as a predisposing factor [5] . Multiple vascular risk factors have been identified, including diabetes and hypertension, on top of other systemic risk factors such as obstructive sleep apnoea and migraine [5-7]. Arnold et al. found that chronic renal failure and migraine were more common in those younger than 50 years old [3] . In most cases, the visual acuity will remain stable with 42% showing improvement in vision without intervention based on the Ischemic Optic Neuropathy Decompression Trial [8] . A small proportion of patients suffer from the progressive form defined by worsening visual acuity of at least three Snellen lines occurring within the first 30 days after initial visual loss [3] . Sequential NAION on the other hand is said to occur when the patient experiences fellow eye involvement in subsequent years. This occurs in 14. 7% of patients over a period of five years [9] . We report a distinctive case of progressive non-arteritic anterior ischaemic optic neuropathy with subsequent sequential involvement, emphasizing its unique clinical course and delineating the critical learning points for diagnostic evaluation, risk assessment, and management strategies. Case Presentation A 44-year-old lady with underlying poorly controlled hypertension, diabetes mellitus, dyslipidaemia, morbid obesity and obstructi

FAQs

What is non-arteritic anterior ischaemic optic neuropathy (NAION) and how does it usually present?

NAION is an ischaemic disorder of the anterior optic nerve. It typically causes acute, painless vision loss on waking, with optic disc oedema and an inferior altitudinal visual field defect.

What factors were present in the reported 44-year-old patient?

The patient had poorly controlled hypertension, diabetes mellitus, dyslipidaemia, morbid obesity, obstructive sleep apnoea, and an anatomically crowded optic disc. Multiple metabolic risk factors were also noted.

How did the disease course progress in this case?

The patient developed progressive NAION in the right eye, followed by sequential involvement of the fellow eye in subsequent progression. This occurred despite optimization of her risk factors.

Sep 29, 2026

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