CAN LIGHTNING STRIKE THE SAME PLACE TWICE? NON-ARTERITIC ANTERIOR ISCHEMIC OPTIC NEUROPATHY FOLLOWING CATARACT SURGERY

Non-arteritic anterior ischemic optic neuropathy (NA-AION) is a leading cause of severe visual loss in the elderly. It typically presents with acute, unilateral, painless vision loss, optic disc edema, and a relative afferent pupillary defect (RAPD). The presumed mechanism is compromised optic nerve perfusion, but the exact pathogenesis and treatment remain unclear.
We report a rare case of recurrent NA-AION occurring twice shortly after successful phacoemulsification, resulting in permanent visual loss.

A 72-year-old male with diabetes, hypertension, and benign prostatic hyperplasia was diagnosed with dense cataracts and scheduled for phacoemulsification on December 9, 2024. He chose to have surgery elsewhere and returned to our clinic on March 25, 2025, with sudden decreased vision and visual field loss.

A 72-year-old male patient presented with difficulty seeing in dim light. His medical history included diabetes mellitus, hypertension, and benign prostatic hyperplasia. Ocular examination revealed a visual acuity of 1/10 in both eyes and grade 3 nuclear cataracts. Fundus examination showed drusen deposits without macular edema, confirmed by OCT. RNFL thickness measured 90 µm in the right eye (OD) and 89 µm in the left (OS), with no apparent defects. The patient was informed about the cataracts and placed on the surgical waiting list.

He later underwent cataract surgery at another clinic. One month postoperatively, he returned with sudden inferior visual field loss. Best-corrected visual acuity was 7/10, with optic disc edema, decreased color vision, and a relative afferent pupillary defect in the affected eye. The 30-2 visual field test demonstrated an inferior altitudinal scotoma. Laboratory results, including CRP, infection markers, and biochemistry, were within normal limits except for elevated blood glucose (HbA1c: 8.8%). He was referred for systemic evaluation and management.

Two weeks later, symptoms worsened, and visual acuity declined to hand motion perception. OCT showed RNFL swelling (211 µm) compared with 89 µm in the fellow eye, and visual field testing revealed near-total scotoma. Vision remained at hand motion level without subsequent improvement.

Although several reports suggest a link between cataract surgery and NA-AION, the mechanism remains uncertain. Intraoperative or postoperative IOP fluctuations are considered possible triggers. NA-AION is an uncommon but devastating complication that can follow otherwise successful cataract surgery, with a reported risk up to fourfold higher within the first postoperative year. Recurrent, bilateral cases are exceptionally rare.
Surgeons should be cautious when operating on high-risk patients, especially those with a prior postoperative NA-AION in the fellow eye, and must inform patients about this potential complication.