Norepinephrine therapy of ischemic optic neuropathy

Two monocular normotensive patients with nonarteritic ischemic optic neuropathy and retinal ischemia unresponsive to steroid therapy were treated with intravenous norepinephrine. In both patients, improvement in vision began within minutes after moderate hypertension was produced. A third patient showed no response to this therapy in one eye with established ischemic optic neuropathy, but had prompt recovery of vision in the second eye early in the course of ischemic optic neuropathy. This patient returned with recurrent ischemic optic neuropathy more than 1 year later. At that time she was found to have essential hypertension. One patient could not be weaned from the norepinephrine infusion without recurrent visual loss. In the second patient, controlled hypertensive therapy restored visual acuity to 20/30 during two separate recurrences of ischemic optic neuropathy. Therapy of a later episode of ischemic optic neuropathy was delayed for 2 days, and vision did not improve with norepinephrine infusion. This eye subsequently became painful and required enucleation. Histopathological evaluation showed combined arterial and venous occlusions within the optic nerve and evidence of previous peripapillary choroidal vascular occlusion. Selected normotensive patients with ischemic optic neuropathy and retinal ischemia may benefit from controlled hypertensive therapy induced by norepinephrine infusion.