Non-arteritic anterior ischemic optic neuropathy: ACTH gel as an option for steroid sensitive and resistant disease

Abstract

Non-arteritic anterior ischemic optic neuropathy (NAION) is characterized by sudden onset of painless visual loss with ipsilateral optic nerve edema. It is estimated to affect 6000 Americans each year. The exact pathogenesis of this condition is not known but it is currently thought that ischemia of the optic disc may precipitate a compartment syndrome of the optic nerve head (ONH) leading to the clinical features of NAION. There have been several medication trials, which have been largely unsuccessful. Corticosteroids have been considered a mainstay for the treatment of optic neuritis and have therefore been used in the acute phase of NAION though some studies have shown improvement in visual acuity and visual fields and others that have shown no improvement. ACTH gel, which is a long acting formulation of ACTH peptides is considered an alternative to steroid treatment in optic neuritis and acute exacerbations of MS. ACTH gel may exert direct anti-inflammatory and immune modulating effects within the CNS and peripheral tissues mediated through melanocortin receptors, which may lead to reduction of symptoms. Here, we present the results of a small series of four cases that did not respond to steroid therapy and were then given ACTH 80 units/ml daily for 10 days as treatment. Improvement was documented on optical coherence tomography (OCT) and no side effects were reported.