[Interdisciplinary diagnosis and therapy of traumatic optic nerve damage]

[Optic nerve decompression-state of the art]

Rarely, but often with serious consequences for the patient, the optic nerve is affected during the course of head injuries. Traumatic optic nerve compression is always an emergency situation, which is why time is of the essence for both diagnosis and treatment. Precise knowledge of this accident sequelae but also of the resulting conditions, especially in terms of traumatic optic neuropathy, is indispensable for adequate patient care. The aim of this paper is to provide an overview of this clinical picture, particularly with regard to etiology, diagnosis, and treatment options, and to discuss this in the context of the current literature.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Efficacy of transcutaneous transseptal orbital decompression in treating acute retrobulbar hemorrhage and a literature review

Decreasing visual acuity secondary to orbital trauma may be caused by sudden space-occupying or expanding intraorbital lesions, including retrobulbar hemorrhage (RBH), herniation, or swelling. RBH must be diagnosed and treated immediately. This article addresses the efficacy of transcutaneous transseptal orbital decompression in a combination with a systematic review of the literature for a comparison of this method with existing treatment options. For this study the department's database was retrospectively screened for patients with acute RBH who were treated between 2009 and 2011 using the authors' approach. Patients presenting with RBH were classified into RBH classes I to III according to three different clinical and radiological manifestations of acute RBH. The efficacy of transcutaneous transseptal orbital decompression was assessed by postoperative visual acuities. The literature review was performed by using the MEDLINE database. The time period for the study was between 2009 and 2011 during which 10 patients were diagnosed with suspected RBH and 9 were treated with the authors' technique. Visual acuities were reconstituted or maintained in almost 86% of patients who were diagnosed and treated according to the authors approach and who survived initial trauma. It was concluded that transcutaneous transseptal orbital decompression provides an efficient and rapid approach for treating patients with acute RBH. By distinguishing three different manifestations of acute RBH, the authors present a diagnostic tool that may facilitate classification of RBH and determination of treatment options.

Optic nerve monitoring

Orbital and anterior skull base surgery is generally performed close to the prechiasmatic visual pathway, and clear strategies for detecting and handling visual pathway damage are essential. To overcome the common problem of a missed clinical examination because of an uncooperative or unresponsive patient, flash visual evoked potentials and electroretinograms should be used. These electrophysiologic examination techniques can provide evidence of intact, pathologic, or absent conductivity of the visual pathway when clinical assessment is not feasible. Visual evoked potentials and electroretinograms are thus essential diagnostic procedures not only for primary diagnosis but also for intraoperative evaluation. A decision for or against treatment of a visual pathway injury has to be made as fast as possible due to the enormous importance of the time elapsed with such injuries; this can be achieved additionally using multislice spiral computed tomography. The first-line conservative treatment of choice for such injuries is megadose methylprednisolone therapy. Surgery is used to decompress the orbital compartment by exposure of the intracanalicular part of the optic nerve in the case of optic canal compression. Modern craniomaxillofacial surgery requires detailed consideration of the diagnosis and treatment of traumatic visual pathway damage with the ultimate goal of preserving visual acuity.

Acute proptosis in trauma: retrobulbar hemorrhage or orbital compartment syndrome--does it really matter?

PURPOSE

To review the nature and outcomes of acute severe proptosis in patients after craniofacial trauma, over a 6-year period.

PATIENTS AND METHODS

These were identified prospectively. The mechanism of injury, nature of the proptosis, and visual outcomes in each case were reviewed. Review of the literature was undertaken.

RESULTS

In all cases proptosis, was secondary to retrobulbar edema and not hemorrhage.

CONCLUSIONS

Many cases of "retrobulbar hemorrhage" may, in fact, be secondary to edema. This has significant implications when managing the proptosed eye on an emergent basis. Possible reasons for poor outcomes are discussed. A number of unanswered questions arise from this review.

Emergency care in facial trauma--a maxillofacial and ophthalmic perspective

Facial trauma, with or without life- and sight-threatening complications, may arise following isolated injury, or it may be associated with significant injuries elsewhere. Assessment needs to be both systematic and repeated, with the establishment of clearly stated priorities in overall care. Although the American College of Surgeons Advanced Trauma Life Support (ATLS) system of care is generally accepted as the gold standard in trauma care, it has potential pitfalls when managing maxillofacial injuries, which are discussed. Management of facial trauma can arguably be regarded as "facial orthopaedics", as both specialities share common management principles. This review outlines a working approach to the identification and management of life- and sight-threatening conditions following significant facial trauma.

Blindness after Blunt Facial Trauma: Are There Any Clinical Clues to Early Recognition?

BACKGROUND

Vision-threatening injury is a relatively rare but devastating complication of maxillofacial trauma. Identification is not always straightforward. The purpose of this study was to look at our experience of blindness after blunt facial injuries to see whether any useful patterns or risk factors were identified to assist in early recognition.

METHODS

This was a retrospective, qualitative study undertaken at the University Hospital of North Staffordshire. All case notes, plain radiographs, and computed tomographic scans were reviewed and the relevant data collated.

RESULTS

Over a 10-year period, 17 patients were identified in which loss of vision occurred secondary to blunt injury to the face.

CONCLUSION

It is important to maintain a high index of suspicion when dealing with maxillofacial trauma, particularly if the patient is not cooperative. We provide a list of salient features to look for in the examination and history to aid the clinician.

Optic nerve decompression in the comatose and conscious patients after trauma

OBJECTIVE

To investigate the efficacy of early optic nerve decompression in comatose and conscious patients with indirect traumatic optic neuropathy.

STUDY DESIGN

Retrospective analysis of 65 optic nerve decompressions.

METHODS

The total collective of optic nerve decompressions comprised 65 patients treated within the period between February 1987 and December 1998. Thirteen of these 65 patients (average age, 32 y) were comatose and required critical care treatment, so visual acuity could not be measured. The indication for surgical decompression in all patients was based on the ophthalmological examination and the finding on computed tomography (CT) scan of a lesion inside the optic nerve canal or the orbit apex, respectively.

RESULTS

In the comatose patients the time interval between trauma and surgery was 16.1+/-12.1 hours (mean +/- standard deviation). During the subsequent postoperative examinations (on average, 12.3 mo postoperatively) five patients showed a normal visual acuity (20/20), two patients a visual acuity of 20/30 and 20/50, and one a visual acuity of 20/200. Three patients (three eyes) remained amaurotic. Two patients died of the general and severe consequences of injury. The beneficial visual acuity results achieved within the group of comatose patients were equivalent to those achieved within the group of patients who were conscious during the preoperative examination. The success rate, defined as an improvement of three lines with a final visual acuity of at least 20/1000, was 57.7% versus 61.5%.

CONCLUSION

The results confirm our concept of early decompression of the optic nerve, based on close interdisciplinary cooperation and the ophthalmological findings.