Aiello et al1 reported two cases of spontaneous improvement of progressive anterior ischemic optic neuropathy (AION). They argued that since the conditions of patients with AION may spontaneously improve, it is reasonable to conduct a randomized clinical trial comparing the natural history of AION with AION treated with optic nerve sheath decompression (ONSD). While a trial may answer these questions, we are concerned that some issues are obfuscated in their cases.
We have examined many 45- to 65-year-old patients with acute loss of visual acuity. Some of these patients have intranerve sheath fluid on standardized echography. It has been suggested that these patients have optic neuritis of the elderly. If this is true, we would expect final visual acuities to be similar to those reported in the optic neuritis treatment trial, in which median visual acuity was 20/20 after 6 months of follow-up. None of our patients with fluidassociated
McHenry JG, Spoor TC. Spontaneous Improvement of Progressive Anterior Ischemic Optic Neuropathy. Arch Ophthalmol. 1993;111(12):1602. doi:10.1001/archopht.1993.01090120016003