[Methotrexate in Atypical Non-Arteritic Ischemic Optic Neuropathy]

Area of Science:

• Ophthalmology
• Neurology
• Immunology

Background:

• Optic nerve diseases stem from diverse causes including vascular, inflammatory, and toxic pathologies, often making etiology difficult to ascertain.
• These conditions typically manifest as progressive visual field loss and impaired visual acuity.

Observation:

• A 74-year-old woman diagnosed with non-arteritic ischemic optic neuropathy (NAION) showed initial improvement with steroids, but her condition relapsed upon dose reduction.
• Atypical presentation, lacking typical NAION risk factors, prompted consideration of autoimmune involvement.
• Methotrexate (MTX) therapy was initiated, with dosage adjustments over two years.

Findings:

• MTX therapy led to reversible optic nerve head swelling and visual field defects, allowing for steroid cessation.
• The patient maintained stable visual acuity and visual fields for two years without adverse events.
• Absence of optic nerve head pallor suggested an underlying pathology beyond typical NAION, supporting an autoimmune component.

Implications:

• Atypical NAION cases may indicate an autoimmune etiology, warranting further investigation.
• Immunosuppressive therapy with MTX can be a valuable strategy to avoid long-term corticosteroid use.
• MTX offers a potential treatment to stabilize visual fields and prevent disease relapses in select patients.