Treatment of traumatic optic neuropathy with corticosteroids

Unveiling the Multifaceted Problems Associated with Dysrhythmia

Dysrhythmia is a term referring to the occurrence of spontaneous and repetitive changes in potentials with parameters deviating from those considered normal. The term refers to heart anomalies but has a broader meaning. Dysrhythmias may concern the heart, neurological system, digestive system, and sensory organs. Ion currents conducted through ion channels are a universal phenomenon. The occurrence of channel abnormalities will therefore result in disorders with clinical manifestations depending on the affected tissue, but phenomena from other tissues and organs may also manifest themselves. A similar problem concerns the implementation of pharmacotherapy, the mechanism of which is related to the impact on various ion currents. Treatment in this case may cause unfavorable effects on other tissues and organs. Drugs acting through the modulation of ion currents are characterized by relatively low tissue specificity. To assess a therapy's efficacy and safety, the risk of occurrences in other tissues with similar mechanisms of action must be considered. In the present review, the focus is shifted prominently onto a comparison of abnormal electrical activity within different tissues and organs. This review includes an overview of the types of dysrhythmias and the basic techniques of clinical examination of electrophysiological disorders. It also presents a concise overview of the available pharmacotherapy in particular diseases. In addition, the authors review the relevant ion channels and their research technique based on patch clumping.

Traumatic Optic Neuropathy: Update on Management

Traumatic optic neuropathy is one of the causes of visual loss caused by blunt or penetrating head trauma and is classified as both direct and indirect. Clinical history and examination findings usually allow for the diagnosis of traumatic optic neuropathy. There is still controversy surrounding the management of traumatic optic neuropathy; some physicians advocate observation alone, while others recommend steroid therapy, surgery, or both. In this entry, we tried to highlight traumatic optic neuropathy's main pathophysiologic mechanisms with the most available updated treatment. Recent research suggests future therapies that may be helpful in traumatic optic neuropathy cases.

Ophthalmic trauma: the top 100 cited articles in Ophthalmology journals

OBJECTIVES

To analyze the top 100 cited papers on ophthalmic trauma.

METHODS

A literature search of Ophthalmology journals within the ISI Web of Science database for the most cited papers related to ophthalmic trauma.

RESULTS

The most cited articles were published between 1943 and 2013, the greatest number being published in 2000. Ophthalmology (45), Archives of Ophthalmology (17), and the American Journal of Ophthalmology (15) published most of the articles. The institutions with the highest number of publications were Wilmer Eye Institute (10) and Massachusetts Eye and Ear Infirmary (7). Sixty-seven percent of the articles originated from the USA. The most common type of trauma studied was non-open-globe injuries and the most frequent topic studied were pathological conditions secondary to trauma (34), particularly endophthalmitis (8), and optic neuropathy (6). Articles presenting a standardized classification system for eye injury received the highest average of citations per publication. Types of research most frequently cited were observational clinical studies (62) and epidemiological studies (30); the least frequent were clinical trials (2).

CONCLUSION

This bibliographic study provides a historical perspective of the literature and identifies trends within the most highly influential papers on ophthalmic trauma. Many of these articles emerged within the past three decades and came from Ophthalmology journals that remain high impact to this day. Clinical trials have been difficult to conduct and are lacking, reflecting a critical need in ophthalmic trauma research, as most of our understanding of ophthalmic trauma comes from observational and epidemiological studies.

Traumatic Optic Neuropathy: Analysis of Demographic and Clinical Parameters Over Three Years in a Tertiary Care Hospital in India

Background Treatment options for traumatic optic neuropathy (TON) are limited and the role of steroids in the treatment of TON is still controversial. Hence this study was planned to highlight the role of steroids in the treatment of TON. Purpose The study aims to highlight the epidemiological and clinical characteristics, as well as the role of steroids, in TON cases seen during a three-year period at a tertiary care center in India. Methods This was a retrospective study that reviewed records of all cases of TON between January 2018 to January 2020. Results Twenty-three cases of TON were seen representing 1.26% cases of head injuries. The median age was 18 years. One patient (4.34%) had bilateral TON and 18 patients (78.26%) were referred from accident and trauma care. None of the patients presented directly to an ophthalmologist. The most common cause of injury was automobile accident (69.56%). Visual acuity at presentation was 20/80-20/100 in six (26.08%) cases. Fifteen (65.4%) patients had associated closed globe injury. Seven (30.43%) patients had ocular adnexal involvement and 10 (43.47%) patients had orbital fractures. Seventeen (73.91%) received steroid treatment and six of these patients showed visual improvement. Conclusions The study showed that there was no significant association between presenting visual acuity and treatment. The presence of significant ocular injury and orbital injury increased the likelihood of treatment. There was no difference between the treated and untreated groups with respect to final visual acuity.

Traumatic Optic Nerve Sheath Hematoma

The aim of this report is to present a patient with traumatic optic nerve sheath hematoma (ONSH), a rare diagnosis with high potential for visual sequelae. This case involves a 41-year-old male who presented promptly following blunt trauma to the right eye and orbit that resulted in acute vision loss. Following computed tomography and ophthalmic examination, a diagnosis of ONSH was made and medical therapy with methylprednisolone was initiated. He reported significant improvements in visual symptoms following intravenous corticosteroid therapy. Although the patient reported significant improvements and had normal Snellen visual acuities in follow-up, he continued to have an inferior visual field defect at 1 week in the affected eye. ONSH causing subsequent localized compression of the optic nerve is a rare mechanism of traumatic optic neuropathy in patients following head trauma. The localized compartment syndrome of the optic nerve and subjective visual symptoms were relieved following corticosteroid therapy with no initial need for surgical decompression. Although central visual acuity returned to baseline, the patient had a persistent visual field defect and relative afferent pupillary defect.

Surgical Decompression or Corticosteroid Treatment of Indirect Traumatic Optic Neuropathy: A Randomized Controlled Trial

BACKGROUND

Traumatic optic neuropathy (TON) is a rare cause of severe permanent visual impairment after injury. Traumatic optic neuropathy may occur due to sharp trauma (direct injury) that damages the optic nerve directly or due to damage from the transmitted forces after a concussive blow to the head or orbit (indirect injury). The management of indirect TON remains controversial. Either surgical decompression or mega dose corticosteroid is used for managing indirect TON. However, no consensus exists regarding the definitive treatment.

MATERIALS AND METHODS

We designed a randomized controlled trial study to investigate this issue. Only patients with indirect TON and normal vision before the injury were enrolled. The patients' data were recorded, and fine cut facial computed tomography scan was performed to exclude those with retrobulbar hematoma. All the study subjects were randomly allocated to either the mega dose steroid (30 mg/kg stat and 15 mg/kg every 6 hours for 3 days) group or the surgical decompression group. The patients were followed up at 1 week, 1 month, 3 months, 6 months, and 9 months. During each follow-up, the Snellen visual acuity (VA), visual field, color change, fundus findings, and intraocular pressure were evaluated. These data were compared and analyzed using the Mann-Whitney U test and odds ratio. The short form questionnaire was used to analyze the lift quality difference between the two groups.

RESULTS

Thirty patients were enrolled, 12 in the surgical group and 18 in the steroid treatment group. There were no significant differences in the improvement rate, improvement degree, and life quality between the groups. However, the odds ratios are 5, 10, 2.5, and nonavailable in the cutoff points of no light perception (NLP), light perception (LP), hand movement, and counting finger in surgery group. In steroid group, they are 1, 1, 1, 1.83 in each cutoff points. Patients with better VA than NLP had better life quality than those with NLP VA (P = 0.005). Other cutoff point groups had no significant difference.

CONCLUSIONS

Patients with worse initial VA (eg, NLP and LP) had a higher chance of benefiting from surgical treatment and experiencing improvements in the life quality.

A Systematic Literature Review on Traumatic Optic Neuropathy

Traumatic optic neuropathy (TON) is an uncommon vision-threatening disorder that can be caused by ocular or head trauma and is categorized into direct and indirect TON. The overall incidence of TON is 0.7-2.5%, and indirect TON has a higher prevalence than direct TON. Detection of an afferent pupillary defect in the presence of an intact globe in a patient with ocular or head trauma with decreased visual acuity strongly suggests TON. However, afferent pupillary defects may be difficult to detect in patients who have received narcotics that cause pupillary constriction and in those with bilateral TON. Mechanical shearing of the optic nerve axons and contusion necrosis due to immediate ischemia from damage to the optic nerve microcirculation and apoptosis of neurons is a probable mechanism. The proper management of TON is controversial. High-dose corticosteroid therapy and decompression of the optic nerve provide no additional benefit over observation alone. Intravenous erythropoietin may be a safe and efficient treatment for patients with TON.

Facial Fracture-Associated Blindness

INTRODUCTION

Yet uncommon, blindness is a potential associated injury of facial fractures.

METHODS

Epidemiology, mechanisms, fracture types, and outcome of facial fractures-associated blindness in a 10-year period are retrospectively reviewed.

RESULTS

Out of 907 facial fractures patients, 10 had blindness, giving a frequency of 1.1%. There were 9 men and 1 woman whom age range was 6 to 59 years (mean: 31.2 years). Intentional injury patients were significantly the most at risk of blindness (P = 0.02). In all the patients, the fracture involved at least 1 of the orbit walls. Risk of blindness was significantly higher in naso-fronto-orbito-ethmoidal complex fractures (P = 0.03). The vision loss was recorded in 13 eyes (unilateral in 7 patients and bilateral in 3). Its predominant mechanism was a globe rupture or perforation, recorded in 8 eyes. A treatment with intention to improve the vision was attempted in 1 patient only. None of the patients had vision recovery.

DISCUSSION

The findings of this study commend comprehensive ophthalmologic evaluation in any patient with an orbit wall fracture.

Traumatic Optic Neuropathy

Traumatic optic neuropathy (TON) refers to optic nerve injury resulting from direct and indirect head and facial trauma. The pathogenesis of indirect TON has not been fully elucidated, and the management of TON remains controversial. In this review article, I review the recent literature regarding TON and discuss how to manage indirect TON.

Clinical Evaluation and Treatment Outcome of Traumatic Optic Neuropathy in Nepal: A Retrospective Case Series

This study aims to report the clinical features and role of different treatment modalities in final visual outcome in traumatic optic neuropathy (TON). The authors retrospectively reviewed the records of patients with TON over 4 years. There were 37 patients of unilateral TON. Mean age was 28.70 ± 15.20 years (range: 8-90) and 89% (n = 33) were males. Road traffic accident was the common cause (43.2%), followed by fall injury (35.1%). There was improvement of visual acuity in 51.4% (n = 19) cases. Out of different treatment modalities, high-dose intravenous methylprednisolone (1 g/day) led to significant improvement in final visual acuity (p = 0.013). There was no significant improvement in final visual outcome in patients with poor initial visual acuity and those with intracranial injuries.

Trauma to the cranial nerves

Cranial nerve injury is often an overlooked aspect of neurotrauma, which is diagnosed later in the course of recovery. Most of these injuries do not require active intervention in the acute stage. Cranial nerve injuries are important cause of morbidity, which requires long-term management, repeated surgical procedures or reconstructive measures. Management of optic nerve injury remains controversial, and injury to lower cranial nerves may influence the ultimate outcome due to paralysis of aerodigestive passage. Cranial nerve injury in the setting of head injury should be diagnosed early, so that appropriate treatment can be planned early.

Risk Factors Analysis for the Outcome of Indirect Traumatic Optic Neuropathy With Steroid Pulse Therapy

BACKGROUND

Although recent evidence suggests a controversy effect of steroids in the management of indirect traumatic optic neuropathy (TON), steroid pulse therapy remains one of the reasonable treatments for patients with indirect TON. It is thought that microcirculatory spasms, edema, and nerve cell necrosis can be prevented or reduced by large doses of steroids. The aim of this study is to analyze the predisposing factors for the recovery of patients with indirect TON who were treated with steroid pulse therapy.

MATERIALS AND METHODS

In tracing the 2008 to 2014 data from the Trauma Center of Chang Gung Memorial Hospital, 20 consecutive cases of indirect TON were identified retrospectively. Twenty cases showed no light perception (NLP) under initial ophthalmologic examination. They all received steroid pulse therapy with methylprednisolone in IV form after examination by ophthalmologists, and they did not receive optic nerve decompression. The general data, fracture pattern from images, hospital courses, trauma-related data from ER record, and the initial and final visual data from ophthalmologic records are reviewed. The odds ratio (OR) and 95% confidence intervals (CI) are calculated. Fisher exact test is used for 2 variables to test differences between proportions. Nonparametric statistics are applied to compare the mean values of the data.

RESULTS

The results show that for female patients (OR, 3.400; 95% CI, 1.628-7.101; P = 0.049), the administration of methylprednisolone in less than 24 hours from the injury (OR, 3.429; 0.297-39.637), lateral force fracture pattern (OR, 3.500; 0.313-39.153), age of 40 years or younger (OR, 2.333; 0.197-27.567), and pure facial trauma (OR, 3.667; 0.273-49.288) are the predisposing factors for improvement of visual acuity. Patients with orbital blowout fractures (OR, 9.800; 95% CI, 0.899-106.845; P = 0.070), initial free extraocular movement (EOM) (OR, 6.667; 0.809-54.597; P = 0.145), initial intraoptic pressure (IOP) greater than 25 mmHg (OR, 8.000; 0.598-106.936), and higher triage grade (OR, 3.000; 0.447-20.153) are at risk of showing no improvement.

CONCLUSIONS

From this study, we might suggest to apply steroid pulse therapy on those patients without contraindication, with an incurring injury less than 24 hours previously. Factors such as sex, age, lateral force fracture pattern, and pure facial trauma revealed a better outcome for improvement of visual acuity. Orbital blowout fractures, initial free EOM, initial IOP greater than 25 mmHg, and higher triage grade suggested poor improvement of visual acuity.

Traumatic optic neuropathy-Clinical features and management issues

Traumatic optic neuropathy (TON) is an uncommon cause of visual loss following blunt or penetrating head trauma, but the consequences can be devastating, especially in cases with bilateral optic nerve involvement. Although the majority of patients are young adult males, about 20% of cases occur during childhood. A diagnosis of TON is usually straightforward based on the clinical history and examination findings indicative of an optic neuropathy. However, the assessment can be difficult when the patient's mental status is impaired owing to severe trauma. TON frequently results in profound loss of central vision, and the final visual outcome is largely dictated by the patient's baseline visual acuities. Other poor prognostic factors include loss of consciousness, no improvement in vision after 48 hours, the absence of visual evoked responses, and evidence of optic canal fractures on neuroimaging. The management of TON remains controversial. Some clinicians favor observation alone, whereas others opt to intervene with systemic steroids, surgical decompression of the optic canal, or both. The evidence base for these various treatment options is weak, and the routine use of high-dose steroids or surgery in TON is not without any attendant risks. There is a relatively high rate of spontaneous visual recovery among patients managed conservatively, and the possible adverse effects of intervention therefore need to be even more carefully considered in the balance.

Evidence-based medicine: Orbital floor fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the epidemiology, anatomy, and pathophysiology of orbital floor fractures. 2. Select the optimal timing of--and understand the indications for-operative repair of orbital floor fractures. 3. List advantages and disadvantages of the surgical approaches and materials available for orbital floor reconstruction. 4. Identify special considerations in treating pediatric patients presenting with orbital floor fractures.

SUMMARY

This maintenance of certification module reviews the anatomy, pathophysiology, diagnosis, and management of orbital floor fractures in addition to special considerations for pediatric patients. The shows the evidence rating scale used for the literature review in creating this maintenance of certification article.

Traumatic optic neuropathy: facial CT findings affecting visual acuity

The purpose of this study was to determine the relationship between admission visual acuity (VA) and facial computed tomographic (CT) findings of traumatic optic neuropathy (TON). We retrospectively evaluated CT findings in 44 patients with TON. Mid-facial fractures, extraconal and intraconal hematomas, hematomas along the optic nerve and the posterior globe, optic canal fracture, nerve impingement by optic canal fracture fragment, and extraconal and intraconal emphysema were evaluated. CT variables of patients with and without available VA were compared. VA was converted into logarithm of the minimum angle of resolution (logMAR) to provide a numeric scale for the purpose of statistical analysis. The risk factors related to poor VA on univariate analysis were as follows: intraconal hematoma [median logMAR -4.7 versus -1.15, p = 0.016] and hematoma along the optic nerve [median -4.7 versus -1.3, p = 0.029]. Intraconal hematoma was the best predictor of poor VA (coefficient, 1.01; SE, 0.34; and p = 0.008). Receiver operating characteristic (ROC) curve analysis showed that the presence of intraconal hematoma and hematoma along the optic nerve predicted poor VA (logMAR of -3.7 or lower) with an area under the curve of 0.8 and 0.85, respectively. TON patients at higher risk of severe visual impairment may be identified based on admission facial CT.

Traumatic optic neuropathy: a review

The aim of this article is to evaluate current literature on investigation and management of traumatic optic neuropathy (TON), propose recommendations for diagnosis and management, and explore novel future treatments. TON, though uncommon, causes substantial visual loss. Without clear guidelines, there is much ambiguity regarding its diagnosis and management. Investigation and treatment (conservative, medical, surgical, and combined) vary widely between centers. Electronic databases PubMed, MEDLINE, PROSPERO, CENTRAL, and EMBASE were searched for content that matched "Traumatic optic neuropathy." Articles with abstracts and full text available, published in the past 10 years, written English and limited to human adults, were selected. All study designs were acceptable except case reports and case series with fewer 10 patients. All abstracts were then evaluated for relevance. References of these studies were evaluated and if also relevant, included. A total of 2,686 articles were retrieved and 43 examined for relevance. Of these, 23 articles were included. TON is a clinical diagnosis. Visual-evoked potential is useful in diagnosis and prognosis. Computed tomography demonstrates canal fractures and concomitant injuries. Magnetic resonance images should be reserved for select and stable patients. Conservative treatment is appropriate in mild TON. Steroids are of questionable benefit and may be harmful. Surgery should be reserved for patients with radiological evidence of compression and individualized.

Controversies in neuro-ophthalmology: steroid therapy for traumatic optic neuropathy

BACKGROUND

There is an increase in the incidence of traumatic optic neuropathy (TON) due to increasing urbanization and rapid spurt in the number of motor vehicles on the road. Despite early presentation and ease of diagnosis the visual outcomes in TON are still limited. There is also significant confusion about the timing, dose and efficacy of steroid treatment in its management.

PURPOSE

To provide a clinical update of the pros and cons of steroid therapy for TON.

DESIGN

The paper is a retrospective review of the currently available literature in the English language indexed in PubMed.

METHODS

A PubMed search was conducted by the authors using the following terms: Traumatic optic neuropathy, megadose, steroids, methylprednisolone. Relevant original articles, review articles, and case reports related to the topic of discussion were evaluated and discussed in the paper.

RESULTS

There is no prospective randomized control trial evaluating the effect of steroids in TON. There are varying reports on the effect of steroid therapy from significant improvement to no difference compared to observation.

CONCLUSION

The decision to give steroids to patients with TON has to be on an individual case to case basis and must involve informed consent from the patient. There are documented advantages and disadvantages of steroid therapy and a prospective, randomized, controlled trial is necessary comparing steroids, surgery and observation before definitive management can be evolved.

Surgery for traumatic optic neuropathy

BACKGROUND

Traumatic optic neuropathy (TON) is an important cause of severe visual loss following blunt or penetrating head trauma. Following the initial insult optic nerve swelling within the optic nerve canal or compression by bone fragments are thought to result in secondary retinal ganglion cell loss. Optic nerve decompression with steroids or surgical interventions or both have therefore been advocated to improve visual prognosis in TON.

OBJECTIVES

To examine the effects and safety of surgical interventions in the management of TON.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to May 2013), EMBASE (January 1980 to May 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to May 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (http://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 28 May 2013. We also searched the reference lists of other reviews and book chapters on TON. We also contacted researchers in the field.

SELECTION CRITERIA

We planned to include only randomised controlled trials (RCTs) of TON in which any form of surgical intervention either on its own or in combination with steroids was compared to steroids alone or no treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the titles and abstracts identified from the search strategy. No studies were found that met our inclusion criteria and therefore none were included for analysis.

MAIN RESULTS

No studies were found that met our inclusion criteria.

AUTHORS' CONCLUSIONS

The current body of evidence consists mostly of small, retrospective case series. Given the wide range of surgical interventions used in TON it is very difficult to compare these studies, even qualitatively. However, there is a relatively high rate of spontaneous visual recovery and no evidence that surgical decompression of the optic nerve provides any additional benefit. On the other hand, surgery carries a definite risk of complications such as postoperative cerebrospinal fluid leak and meningitis. The decision to proceed with surgery in TON therefore remains controversial and each case needs to be assessed on its own merits. Although there is an urgent need for an adequately powered, RCT of surgical intervention in TON, this will prove a difficult endeavour.

Steroids for traumatic optic neuropathy

BACKGROUND

Traumatic optic neuropathy (TON) is an important cause of severe visual loss following blunt or penetrating head trauma. Following the initial injury, optic nerve swelling within the optic nerve canal can result in secondary retinal ganglion cell loss. Optic nerve decompression with steroids or surgical interventions or both has therefore been advocated as a means of improving visual prognosis in TON.

OBJECTIVES

The aim of this review was to examine the effectiveness and safety of using steroids in TON.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to May 2013), EMBASE (January 1980 to May 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to May 2013), Web of Science Conference Proceedings Citation Index- Science (CPCI-S) (January 1990 to May 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (http://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 21 May 2013. We also searched the reference lists of included studies, other reviews and book chapters on TON to find references to additional trials. The Science Citation Index was used to look for papers that cited the studies included in this review. We did not manually search any journals or conference proceedings. We contacted trial investigators and experts in the field to identify additional published and unpublished studies.

SELECTION CRITERIA

We planned to include only randomised controlled trials (RCTs) of TON in which any steroid regime, either on its own or in combination with surgical optic nerve decompression, was compared to surgery alone or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts identified from the electronic searches.

MAIN RESULTS

We included one study that met our selection criteria; a double-masked, placebo-controlled, randomised trial of high dose intravenous steroids in patients with indirect TON diagnosed within seven days of the initial injury. A total of 31 eligible participants were randomised to receive either high dose intravenous steroids (n = 16) or placebo (n = 15), and they were all followed-up for three months. Mean final best corrected visual acuity (BCVA) was 1.78±1.23 Logarithm of the Minimum Angle of Resolution (LogMAR) in the placebo group, and 1.11±1.14 LogMAR in the steroid group. The mean difference in BCVA between the placebo and steroid groups was 0.67 LogMAR (95% confidence interval -1.54 to 0.20), and this difference was not statistically significant (P = 0.13). At three months follow-up, an improvement in BCVA of 0.40 LogMAR occurred in eight eyes (8/15, 53.3%) in the placebo group, and in 11 eyes (11/16, 68.8%) in the treatment group. This difference was not statistically significant (P = 0.38).

AUTHORS' CONCLUSIONS

There is a relatively high rate of spontaneous visual recovery in TON and there is no convincing data that steroids provide any additional visual benefit over observation alone. Recent evidence also suggests a possible detrimental effect of steroids in TON and further studies are urgently needed to clarify this important issue. Each case therefore needs to be assessed on an individual basis and proper informed consent is paramount.

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.

Mechanisms and management of vision loss following orbital and facial trauma

PURPOSE OF REVIEW

To examine the proposed mechanisms of vision-threatening injuries occurring secondary to orbital and facial trauma: traumatic optic neuropathy (TON), retrobulbar haemorrhage (RBH) and penetrating eye injury. To evaluate the evidence supporting different management options for traumatic vision-threatening injury.

RECENT FINDINGS

Despite considerable debate over the roles of surgical decompression and systemic steroid therapy for TON, these interventions have not been proved to be more effective than conservative management and there is limited evidence that the use of steroids may be associated with an adverse outcome. Lateral canthotomy and inferior cantholysis have been proven to be effective treatments for RBH. Orbital exploration and surgical evacuation of haematoma remains a second line intervention. Open globe injuries require immediate primary surgical exploration and repair. Irretrievable devastating globe injuries require either enucleation or evisceration. There is no consensus as to which is the best treatment with recent surveys indicating that enucleation is preferred in the USA and evisceration in the United Kingdom.

SUMMARY

Conservative management is the first line treatment for TON. The evidence strongly supports lateral canthotomy and inferior cantholysis as best treatment for RBH. There is no consensus as to whether enucleation or evisceration is the best treatment for irretrievable devastating globe injury. The choice of management is currently determined by surgeon preference.

Wide optic nerve canal decompression for the treatment of blindness resulting from an indirect optic nerve injury

OBJECTIVE

The objective of this study was to investigate the efficacy of wide decompression of the optic canal for treating blindness resulting from an indirect optic nerve injury.

METHODS

Forty-three patients with blindness resulting from an indirect optic nerve injury were retrospectively reviewed for preoperative vision, preoperative image, operative video, postoperative visual acuity, complications, and follow-up results.

RESULTS

The 43 patients included 37 men and 6 women with an age range from 15 to 41 years (average, 31.8 years). On preoperative examination, all patients presented blindness in the involved eye. Six patients had an optic canal fracture. During the operation, a compression of the optic canal from a bony fragment was found in 1 patient, and an optic nerve sheath hematoma was found in another patient. After the operation, 6 patients developed cerebrospinal fluid rhinorrhea but recovered with conservative therapy. At the 6-month follow-up, visual acuity was improved to 3/60 in 3 patients, 5 patients could count fingers, 3 patients could see hand motions, and 3 patients retained light perception in the afflicted eye. The vision in other patients remained nonperceptive to light.

CONCLUSIONS

Although the prognosis for blindness resulting from an indirect optic injury is poor, some patients have a chance to recover with enough decompression on the traumatized optic nerve. Poor results of this procedure may be related to the severity of the primary optic nerve injury.

Role of the maxillofacial surgeon in the management of severe ocular injuries after maxillofacial fractures

Aim:

This study was designed to evaluate the incidence of severe ocular injuries associated to maxillofacial fractures and report their management in the Emergency Department.

Patients and Methods:

Among the 1779 patients admitted for maxillofacial fractures, those with partial or total loss of vision at the time of emergency consultation were included in the study. Data collected from the patients’ medical records included age, gender, mechanism of injury, location and type of facial fractures, type of ocular injuries and cause of blindness, methods of treatment, and days of hospitalization.

Results:

Forty patients (2.2%), 32 men and 8 women, ranging from 17 to 85 years of age, presented with severely reduced vision or blindness associated to fractures of the facial middle third with involvement of one or more orbital walls, mainly caused by motor vehicle and work accidents. In 18 patients, severe ocular injuries were determined by direct lesion of the globe, in 14 by direct or indirect traumatic optic neuropathy and in 8 by a retrobulbar hematoma. Direct lesion of the eyeball was treated by prompt repair or enucleation of the globe, though no or little recovery of vision was obtained. Ophthalmologic and/or maxillofacial treatment of the anterior compartment lesions of the eye allowed a partial or total recovery of the vision. A partial or total recovery of the vision was observed in almost all the patients with indirect traumatic optic neuropathy after administration of steroids according to NASCIS II protocol. Likewise, an evident improvement of the vision was obtained by immediate drainage of retrobulbar hematoma.

Conclusions:

Early diagnosis of the nature of the ophthalmic injury and treatment are important, and involvement of the ophthalmologist is mandatory.

Traumatic optic neuropathy: an evolving understanding

PURPOSE

To critically review the treatment of traumatic optic neuropathy.

DESIGN

A perspective of clinical and basic science studies related to traumatic optic neuropathy and its treatment.

METHODS

Published clinical and basic science studies on traumatic optic neuropathy were critically reviewed and interpreted.

RESULTS

Clinical progress in the treatment of traumatic optic neuropathy is limited by small clinical studies lacking appropriate control groups. The Corticosteroid Randomization for Acute Head Trauma (CRASH) trial found an increased rate of death among patients with acute head trauma treated with high-dose corticosteroids compared to placebo-treated patients (21% vs 18%, P = .0001). Recent animal studies also suggest that high-dose corticosteroids are toxic to the injured optic nerve.

CONCLUSIONS

The Corticosteroid Randomization for Acute Head Trauma study is immediately relevant to the treatment of traumatic optic neuropathy as individuals with traumatic optic neuropathy often have concomitant head trauma. High-dose corticosteroids for traumatic optic neuropathy will result in a measurable loss of life in patients who also have a brain injury. Death has never been an endpoint for traumatic optic neuropathy studies. Given human and animal data suggesting that treatment is harmful and the lack of demonstrated clinical efficacy, corticosteroids should not be used to treat traumatic optic neuropathy. The benefit of optic canal decompression is also unclear. There is a need to identify traumatic optic neuropathy soon after injury to further define the natural history of this injury. This information will provide a basis for assessing potential future treatments for traumatic optic neuropathy.

Steroids for traumatic optic neuropathy

BACKGROUND

Traumatic optic neuropathy (TON) is an important cause of severe visual loss following blunt or penetrating head trauma. Following the initial injury, optic nerve swelling within the optic nerve canal can result in secondary retinal ganglion cell loss. Optic nerve decompression with steroids or surgical interventions or both has therefore been advocated as a means of improving visual prognosis in TON.

OBJECTIVES

The aim of this review was to examine the effectiveness and safety of using steroids in TON.

SEARCH STRATEGY

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 11), MEDLINE (January 1950 to November 2010), EMBASE (January 1980 to November 2010), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to November 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (http://clinicaltrials.gov) and Web of Science Conference Proceedings Citation Index- Science (CPCI-S). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 23 November 2010. We also searched the reference lists of included studies, other reviews and book chapters on TON to find references to additional trials. The Science Citation Index was used to look for papers that cited the studies included in this review. We did not manually search any journals or conference proceedings. We contacted trial investigators and experts in the field to identify additional published and unpublished studies.

SELECTION CRITERIA

We planned to include only randomised controlled trials (RCTs) of TON in which any steroid regime, either on its own or in combination with surgical optic nerve decompression, was compared to surgery alone or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts identified from the electronic searches.

MAIN RESULTS

We included one study that met our selection criteria; a double-masked, placebo-controlled, randomised trial of high dose intravenous steroids in patients with indirect TON diagnosed within seven days of the initial injury. A total of 31 eligible participants were randomised to receive either high dose intravenous steroids (n = 16) or placebo (n = 15), and they were all followed-up for three months. Mean final best corrected visual acuity (BCVA) was 1.78±1.23 Logarithm of the Minimum Angle of Resolution (LogMAR) in the placebo group, and 1.11±1.14 LogMAR in the steroid group. The mean difference in BCVA between the placebo and steroid groups was 0.67 LogMAR (95% confidence interval -1.54 to 0.20), and this difference was not statistically significant (P = 0.13). At three months follow-up, an improvement in BCVA of 0.40 LogMAR occurred in eight eyes (8/15, 53.3%) in the placebo group, and in 11 eyes (11/16, 68.8%) in the treatment group. This difference was not statistically significant (P = 0.38).

AUTHORS' CONCLUSIONS

There is a relatively high rate of spontaneous visual recovery in TON and there is no convincing data that steroids provide any additional visual benefit over observation alone. Recent evidence also suggests a possible detrimental effect of steroids in TON and further studies are urgently needed to clarify this important issue. Each case therefore needs to be assessed on an individual basis and proper informed consent is paramount.

Blindness following facial fracture: treatment modalities and outcomes

Blindness is an uncommon, yet documented complication of facial trauma. Numerous case studies, series, and retrospective analyses have been published, with a reported incidence around 3%. Hippocrates first noted the association between maxillofacial trauma and blindness; millennia later, this was expounded upon by Berlin, who discovered such trauma may directly lead to fracturing of the optic canal. As diagnostic modalities such as computed tomographic scanning evolved, particularly over the past few decades, more specific, in-depth reports analyzing maxillofacial trauma and subsequent sequelae have emerged. It is the goal of this article to examine the current literature for those publications that have addressed the issue of blindness following facial trauma (including operative interventions) and create a concise review for maxillofacial surgeons.

Treatment of traumatic optic neuropathy: our experience of endoscopic optic nerve decompression

OBJECTIVE

Traumatic optic neuropathy can be treated by various methods including steroids and surgical decompression. Endoscopic optic nerve decompression has been suggested to be effective in treating this condition. The aim of this study was to assess the outcome of treating traumatic optic neuropathy with steroids and endoscopic surgical decompression.

METHODS

Two hundred and thirty-seven patients with traumatic optic neuropathy were treated with steroids; 176 also consented to endoscopic optic nerve decompression.

RESULTS

The total vision improvement rate was 55 per cent in the 176 patients treated with both steroids and endoscopic optic nerve decompression, compared with 51 per cent in the 61 patients treated with steroids alone; this difference was not statistically significant (p > 0.05). Treatment with steroids plus endoscopic optic nerve decompression resulted in a significantly greater vision improvement in patients with gradual vision loss, compared with those with immediate blindness (68 vs 42 per cent, respectively). Early surgery (within one week) was an important prognostic factor for vision recovery, compared with more delayed surgical treatment (associated vision improvement rates were 60 and 31 per cent, respectively).

CONCLUSIONS

Endoscopic optic nerve decompression is a minimally invasive, safe and efficient treatment for traumatic optic neuropathy. Used in combination with steroids, it provides effective rescue for some patients suffering visual loss. It should be undertaken as soon as possible.

Comparative evaluation of megadose methylprednisolone with dexamethasone for treatment of primary typical optic neuritis

AIM

To compare the efficacy of intravenous methylprednisolone and intravenous dexamethasone on visual recovery and evaluate their side-effects for the treatment of optic neuritis.

MATERIALS AND METHODS

Prospective, randomized case-controlled study including 21 patients of acute optic neuritis presenting within eight days of onset and with visual acuity less then 20/60 in the affected eye who were randomly divided into two groups. Group I received intravenous dexamethasone 200 mg once daily for three days and Group II received intravenous methylprednisolone 250 mg/six-hourly for three days followed by oral prednisolone for 11 days. Parameters tested were pupillary reactions, visual acuity, fundus findings, color vision, contrast sensitivity, Goldmann visual fields and biochemical investigations for all patients at presentation and follow-up.

RESULTS

Both groups were age and sex-matched. LOGMAR visual acuity at presentation was 1.10 +/- 0.52 in Group I and 1.52 +/- 0.43 in Group II. On day 90 of steroid therapy, visual acuity improved to 0.28 +/- 0.33 in Group I and 0.36 +/- 0.41 in Group II ( P =0.59). At three months there was no statistically significant difference in the color vision, contrast sensitivity, stereoacuity, Goldman fields and the amplitude and latency of visually evoked response between the two groups. The concentration of vitamin C, glucose, sodium, potassium, urea and creatinine were within the reported normal limits.

CONCLUSION

Intravenous dexamethasone is an effective treatment for optic neuritis. However, larger studies are required to establish it as a safe, inexpensive and effective modality for the treatment of optic neuritis.

Steroids for traumatic optic neuropathy

BACKGROUND

Traumatic optic neuropathy (TON) is an important cause of severe visual loss following blunt or penetrating head trauma. Following the initial injury, optic nerve swelling within the optic nerve canal can result in secondary retinal ganglion cell loss. Optic nerve decompression with steroids or surgical interventions or both has therefore been advocated as a means of improving visual prognosis in TON.

OBJECTIVES

The aim of this review was to examine the effectiveness and safety of using steroids in TON.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 1, 2007), MEDLINE (1966 to February 2007), EMBASE (1980 to February 2007), LILACS (March 2007) and NRR (Issue 1, 2007). We also searched the reference lists of included studies, other reviews and book chapters on TON to find references to additional trials. The Science Citation Index was used to look for papers that cited the studies included in this review. We did not manually search any journals or conference proceedings. Trial investigators and experts in the field were contacted to identify additional published and unpublished studies. There were no date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We planned to include only randomised controlled trials (RCTs) of TON in which any steroid regime, either on its own or in combination with surgical optic nerve decompression, was compared to surgery alone or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts identified from the electronic searches.

MAIN RESULTS

No studies were found that met our selection criteria and therefore none were included for analysis.

AUTHORS' CONCLUSIONS

There is a relatively high rate of spontaneous visual recovery in TON and no convincing data that steroids provide any additional benefit over observation alone. Recent evidence also suggests a possible detrimental effect of steroids in TON and further studies are urgently needed to clarify this important issue. Based on the current literature, TON cases presenting more than eight hours after the initial injury should not be treated with steroids. The decision to initiate treatment for patients seen within the eight-hour window remains controversial and the supporting evidence is weak. Each case therefore needs to be assessed on an individual basis and proper informed consent is paramount. An adequately powered RCT of steroids in TON poses difficult challenges and is probably not feasible.

Endoscopically assisted transconjunctival decompression of traumatic optic neuropathy

Traumatic optic neuropathy (TON) is a severe sequel after maxillofacial trauma. Recent clinical experience has suggested that optic canal decompression is beneficial in the treatment of TON. With the advent of endoscopy in orbital reconstruction, we extended this technique to decompress the optical canal and reported its outcome. This technique was applied to 30 patients with TON who did not improve after corticosteroids treatment. The average age of the patients at the time of injury was 26 years. Nine patients presented preoperative vision of light perception (LP) or better and 21 patients had no light perception (NLP). Surgery was performed within 1 week of injury in 10 patients, between 1 and 2 weeks in another 10 patients, and between 2 and 4 weeks in the last 10 patients. Thirteen patients were found to have optic canal fractures during surgery. The average follow-up time was 9.5 months. Vision improved in 12 patients including 6 patients (28.6%) with NLP and in 6 patients (66.7%) with LP or better. The improvement degree of visual acuity was 50% in average. Only patient age reflected differences in improvement of visual acuity when analyzing the effect of optic canal fracture, timing of surgery and initial visual acuity. Two patients experienced postoperative cerebrospinal fluid leakage due to associated skull base fractures. The endoscope-assisted transconjunctival technique successfully decompresses the optic canal and improves visual acuity with minimal morbidity. Younger patients had a significantly better visual outcome.

Traumatic bitemporal hemianopia

A 45-year-old male pedestrian was struck by a motor vehicle moving at high speed. Upon initial assessment, the patient scored a 3T on the Glasgow Coma Scale. The patient suffered multiple facial and sinus fractures, a right orbital wall fracture, and a depressed open frontal skull fracture with visible brain parenchyma. Due to the nature of the brain injury, the patient was taken to the operating room emergently for a right frontal craniectomy. The patient required prolonged hospitalization followed by transfer to a rehabilitation facility. Six weeks after the accident, the patient underwent an extensive neuro-ophthalmologic evaluation. At that time, visual acuity was 20/200 in both eyes. On visual field testing, a bitemporal hemianopia was noted. Ophthalmoscopic examination revealed bilateral temporal disc pallor, right greater than left. Neuroimaging demonstrated damage to the optic chiasm. Although rare, head trauma may cause a bitemporal hemianopia secondary to optic chiasmal injury.

Neuromodulatory Therapy to Improve Erectile Function Recovery Outcomes After Pelvic Surgery

PURPOSE

Erectile dysfunction is a recognized, common adverse consequence of radical prostatectomy as well as various other pelvic surgeries. While a host of management options have been considered to decrease this complication, neuromodulatory therapy has recently been advanced as an intervention that may be applied for this purpose. We evaluated concepts regarding the neuropathic basis for erectile dysfunction following pelvic surgery, principles for establishing neuromodulatory therapy in this clinical context, evidence from preclinical studies supporting neuromodulatory approaches as a therapeutic strategy and the progress of early clinical developments in this field.

MATERIALS AND METHODS

The exercise principally consisted of a current literature search using the National Library of Medicine PubMed Services, a survey of recent abstract proceedings from national meetings relevant to the topic and an Internet online search for current information on federally and privately supported clinical trials specific to this topic. References were made to such key words as neuroprotection, nerve regeneration, nerve growth factors, neurotrophic factors, cavernous nerves, nerve guides and penile erection.

RESULTS

Basic science research and clinical studies support the concept that erectile loss after pelvic surgery is frequently related to neuropathic effects, resulting in penile vascular impairment. An assortment of neurobiological studies using rodent models of cavernous nerve injury have shown nerve reconstitutive actions for a host of neurotrophic substances, including classic neurotrophins, growth hormone, cytokines and atypical neurotrophic mediators. Clinical trials of several proposed neuroprotective and neurotrophic applications have been done or are in progress.

CONCLUSIONS

Erectile dysfunction is a well recognized and yet ineffectively averted complication of pelvic surgery. Neuromodulatory therapy offers a therapeutic approach for addressing the neuropathic changes of the penis that occurs in this context with the goal of maximally preserving erectile function postoperatively. While several specific neuromodulatory applications have gained interest for their potential benefit with pelvic surgery, determining their actual roles awaits the completion of controlled clinical trials.

Cortisol promotes survival and regeneration of axotomised retinal ganglion cells and enhances effects of aurintricarboxylic acid

BACKGROUND

Neuroprotection is essential for repair processes after a traumatic insult in the central nervous system. We have demonstrated previously significant neuroprotective properties of the anti-apoptotic drug aurintricarboxylic acid in the model of axotomised retinal ganglion cells. Glucocorticoids are widely used to treat injuries of the nervous system. Due to the anti-inflammatory and microglia-inhibiting properties of glucocorticoids, we studied the neuroprotective effects of intravitreally administered cortisol after an optic nerve cut.

METHODS

Ninety-eight adult Sprague-Dawley rats were used in this study. The optic nerve was cut intra-orbitally. Either vehicle or compound solution was injected intravitreally. Fluorescent dye was put onto the optic nerve stump to label retinal ganglion cells retrogradely. Retinal whole mounts were prepared 2 weeks after axotomy, and surviving retinal ganglion cells were counted.

RESULTS

Two weeks after axotomy, up to 50+/-7% of all retinal ganglion cells survived if cortisol was injected into the eye compared with 17+/-5% survival if only vehicle solution was injected. The neuroprotective effects of aurintricarboxylic acid (43+/-5% survival) could be further enhanced if combined with cortisol (up to 61+/-5% survival). Regeneration of cut retinal ganglion cell axons into a peripheral nerve graft could also be enhanced by an intravitreal injection of cortisol (169+/-42 regenerating retinal ganglion cells per mm2 vs. 73+/-12 cells per mm2 after vehicle injection). The increase was not as high as with aurintricarboxylic acid (192+/-40 cells per mm2), although more retinal ganglion cells survived with cortisol. This indicates that neuronal survival alone is not sufficient for subsequent axonal regeneration. Nevertheless, regeneration could be markedly increased if aurintricarboxylic acid and cortisol were combined (308+/-72 cells per mm2).

CONCLUSIONS

Whereas aurintricarboxylic acid seems to act directly on lesioned retinal ganglion cells, cortisol seems to act on the glial environment, as indicated by microglial cell morphology and enhanced glial fibrillary acidic protein expression. The results show that both neuroprotection and regeneration can be enhanced by the combination of two simple compounds acting on different sites.

[Single and temporally displaced second nerve lesions in an animal model and their clinical significance]

BACKGROUND

Surgical optic decompression after trauma has been discussed controversially. The surgical trauma is supposed to produce an additional nerve lesion with the danger of complete loss of vision. Alternatively, conservative high dose cortisone therapy has been recommended.

METHODS

The functional and morphological consequences of a lesion after calibrated optic compression in one or two sessions were examined in an animal model using 29 Wistar rats.

RESULTS

Depending on the duration and intensity of the lesion, we observed a linear decline in the number of neurons in the RGC (retinal ganglion cell) layer as well as an increasing reactivity to GFAP (glial fibrillary acidic protein) as an indication of central gliosis of astrocytes; however, this was independent on whether optic compression was performed in one or two sessions.

CONCLUSIONS

To reduce secondary damage to the visual nerve and the central visual system that might increase with a persisting lesion, the indication for surgical relief of an eye affected by afference should be considered liberally, especially in view of the low morbidity of rhinosurgical intervention.

Surgery for traumatic optic neuropathy

BACKGROUND

Traumatic optic neuropathy (TON) is an important cause of severe visual loss following blunt or penetrating head trauma. Following the initial insult optic nerve swelling within the optic nerve canal or compression by bone fragments are thought to result in secondary retinal ganglion cell loss. Optic nerve decompression with steroids or surgical interventions or both have therefore been advocated to improve visual prognosis in TON.

OBJECTIVES

The aim of this review was to examine the effects and safety of surgical interventions in the management of TON.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (Issue 3, 2005), MEDLINE (1966 to August 2005), EMBASE (1980 to 2005 wk 31), NRR 2005 Issue 3, LILACS (September 2004) and the reference lists of other reviews and book chapters on TON. We also contacted researchers in the field. There were no date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We planned to include only randomised controlled trials of TON in which any form of surgical intervention either on its own or in combination with steroids was compared to steroids alone or no treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the titles and abstracts identified from the search strategy. No studies were found that met our inclusion criteria and therefore none were included for analysis.

MAIN RESULTS

No studies were found that met our inclusion criteria.

AUTHORS' CONCLUSIONS

The current body of evidence consists mostly of small, retrospective case series. Given the wide range of surgical interventions used in TON it is very difficult to compare these studies, even qualitatively. However, there is a relatively high rate of spontaneous visual recovery and no evidence that surgical decompression of the optic nerve provides any additional benefit. On the other hand surgery carries a definite risk of complications such as postoperative cerebrospinal fluid leak and meningitis. The decision to proceed with surgery in TON therefore remains controversial and each case needs to be assessed on its own merits. Although there is an urgent need for an adequately powered, randomised controlled trial of surgical intervention in TON, this will prove a difficult endeavour.

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.

Treatment of ischemic optic neuropathy

Ischemic damage of the optic nerve has no proven effective treatment. While ischemia related to vasculitis (arteritic) is treated with systemic corticosteroids, the primary goal is to prevent further damage, either in the affected or fellow eye. Thrombolytic or anticoagulation supplementive therapy may be considerations for the future. In the more common idiopathic (nonarteritic) form (NAION), multiple attempts at therapy, including systemic corticosteroids, anticoagulants and antiplatelet agents, diphenylhydantoin, hyperbaric oxygen, and optic nerve sheath decompression have been unsuccessful. The use of levodopa has been proposed but is unproven. Megadose intravenous corticosteroid therapy has not been studied in a systematic way. Neuroprotective strategies are under intense investigation for optic neuropathies including NAION, and clinical trials in humans are in progress. Optic nerve regeneration studies are ongoing in animals. Prophylaxis in NAION is unproven.

Mega dose corticosteroid treatment for traumatic superior orbital fissure and orbital apex syndromes

The superior orbital fissure syndrome and orbital apex syndrome are rare complications of craniomaxillofacial traumas. The neurologic symptoms are generally due to reversible neuropathy caused by edema, contusion, and compression of the nerves. Much has been written but no firm conclusions have been reached on the best mode of treatment. Whereas some authors advocate emergency optic nerve decompression, others recommend mega dose corticosteroids alone. We have treated 11 patients with traumatic superior orbital fissure or orbital apex syndromes with mega dose corticosteroids in the last 10 years. No complications attributable to the very high dose of corticosteroids were observed. The long-term follow-up of the patients showed complete recovery. These satisfactory results have led to our recommendation of the mega dose corticosteroid treatment in the management of these patients.

Indirect Traumatic Optic Neuropathy Complicated With Periorbital Facial Bone Fracture

This study evaluated the outcome for 45 consecutive, nonrandomized patients whose indirect type traumatic optic neuropathy and periorbital facial bone fracture were treated at the Chang Gung Memorial Hospital in Kaohsiung between June of 1996 and June of 2001. There were a total of 48 eye injuries in 45 patients (3 patients sustained bilateral eye injuries). Data related to megadose steroid treatment, timing of open reduction and internal fixation for periorbital facial fractures, and pretreatment and post-treatment of visual acuities were collected from the medical records. Measurements of visual improvement in terms of degree and percentage were calculated after the visual acuities were converted into the log of the minimum angle of resolution units. Visual acuities were significantly improved according to mechanism of injury, gender, or associated periorbital skin laceration wound. However, no light perception for eight patients at initial presentation and gradually deteriorating vision in four injured eyes of three patients were identified as poor prognostic factors. Therefore, repeated visual measurements are recommended to detect any gradually deteriorating vision, which although uncommon, has a poor prognosis. No significantly improved vision was found after treatment with megadose steroids. However, if improvement in vision did occur, treatment with megadose steroids resulted in a much greater visual improvement in terms of degree (p = 0.001) and percentage (p = 0.02). Thus treatment with megadose steroid is recommended. No significant differences were found in the visual improvement between those who received and those who did not receive periorbital open reduction and internal fixation operations, and between those who received early repair within 48 hours and those who received late repair after more than 48 hours. However, it seems medicolegally prudent to delay the procedure because some patients may experience gradually deteriorating vision, which has a poor prognosis, and because postoperative visual loss after facial fracture repair did happen.