27-gauge microincision vitrectomy for acute nonarteritic anterior ischemic optic neuropathy with peripapillary wrinkles: a pilot study

To assess the functional stabilizing potential and structural safety of 27-gauge microincision vitrectomy surgery (MIVS) in a targeted subgroup of patients with acute nonarteritic anterior ischemic optic neuropathy (NAION) presenting with peripapillary wrinkles (PPWs). In this prospective, nonrandomized, patient-choice controlled pilot study, 39 patients presenting with acute unilateral NAION and PPWs (within 21 days of onset) were allocated into a surgical group (27-gauge MIVS) and a medical control group (tapered oral prednisone). All participants additionally received oral methylcobalamin. Main outcome measures included changes from baseline in best-corrected visual acuity (BCVA), mean deviation (MD), and visual field index (VFI); clinically meaningful response rates (≥ 15-letter BCVA gain/loss, ≥ 10% VFI, ≥ 3 dB MD change); and structural integrity of the foveal cone mosaic and peripapillary retinal nerve fiber layer (pRNFL) using AOSLO. Baseline characteristics were comparable. Changes from baseline in BCVA, MD, and VFI were significantly better in the PPWs+MIVS group across all follow-up intervals ( P < 0.05). The rates of MD improvement (≥ 3 dB) and VFI improvement (≥ 10%) were higher in the PPWs+MIVS group at 3 months (55.56% vs. 18.75%; P = 0.04). No eyes in the PPWs+MIVS group experienced clinically meaningful decline, compared to 25–33% for BCVA and 38–44% for visual field in the PPWs+Prednisone group (all P < 0.05). Exploratory AOSLO and pRNFL assessments in a single representative case revealed no postoperative structural damage to photoreceptors or RNFLs. 27-gauge MIVS may be associated with visual benefits for acute NAION patients with PPWs. The favorable short-term safety profile and exploratory structural observations, coupled with potential functional benefits, warrants further investigation in larger randomized trials to confirm the role of MIVS in this subgroup. ChiCTR2200066515, December 7, 2022, retrospectively registered.