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

Prognostic factors of traumatic optic neuropathy based on multimodal analysis-Especially the influence of postoperative dressing change and optic nerve blood supply on prognosis

Objective

To investigate the critical prognostic factors of patients with traumatic optic neuropathy (TON) treated with endoscopic transnasal optic canal decompression (ETOCD) and to perform multimodal analysis based on imaging examinations of optical coherence tomography angiography (OCTA) and CT scan. Subsequently, a new prediction model was established.

Methods

The clinical data of 76 patients with TON who underwent decompression surgery with the endoscope-navigation system in the Department of Ophthalmology, Shanghai Ninth People's Hospital from January 2018 to December 2021 were retrospectively analyzed. The clinical data included demographic characteristics, reasons for injury, interval between injury and surgery, multimode imaging information of CT scan and OCTA, including orbital fracture, optical canal fractures, vessel density of optic disc and macula, and the times of postoperative dressing change. Binary logistic regression was used to establish a model for best corrected visual acuity (BCVA) after treatment as a predictor of TON outcome.

Results

Postoperative BCVA improved in 60.5% (46/76) patients and did not improve in 39.5% (30/76) patients. The times of postoperative dressing change had a significant impact on the prognosis. Other factors affecting the prognosis were microvessel density of the central optic disc, the cause of injury, and the microvessel density above the macula. The area under the raw current curves of the predictive model was 0.7596.

Conclusions

The times of dressing changes after the operation, i.e., continuous treatment, is the key factor affecting prognosis. The microvessel density in the center of the optic disc and superior macula, quantitatively analyzed by OCTA, is the prognostic factor of TON and may be used as a prognostic marker of TON.

Vision improvement in indirect traumatic optic neuropathy treated by endoscopic transnasal optic canal decompression

BACKGROUND

Indirect Traumatic optic neuropathy (ITON) is a severe disease characterized by a sudden decline of visual function after craniofacial injury. However, the best treatment for ITON is unknown. Endoscopic transnasal optic canal decompression (ETOCD) has gradually been used for ITON treatment worldwide in recent years.

OBJECTIVE

To assess the effect of ETOCD on visual acuity in patients with ITON and identify factors that affect prognosis.

METHODS

In this study, clinical characteristics of 44 ITON patients who underwent ETOCD in Qilu Hospital of Shandong University were retrospectively analyzed. Factors affecting prognosis were also evaluated.

RESULTS

ETOCD treatment improved the vision of 20 (45.5%) patients with no patient suffering from vision deterioration. The mean value of visual acuity (VA) scores improved from 1.57 to 2.39 (P < 0.001). Patients with residual vision had a better VA improvement percent than those without light perception (66.67% versus 34.48%, χ² = 4.13, P = 0.042). Although shorter duration before ETOCD was associated with better improvement score in ITON patients (r = -0.30, P = 0.044), optic canal fracture (OCF) and optic nerve sheath incision did not affect the prognosis of these patients. Five ITON patients with cerebrospinal fluid rhinorrhea were treated with free nasal mucosal flap during the surgery, and no other severe surgical complication occurred.

CONCLUSIONS

ETOCD can effectively and safely improve the vision of ITON patients, patients with residual vision and those treated earlier may benefit more from this surgery.

Interventions for Indirect Traumatic Optic Neuropathy: A Report by the American Academy of Ophthalmology

PURPOSE

To review the literature on the efficacy and safety of medical and surgical interventions for indirect traumatic optic neuropathy (TON), defined as injury to the nerve that occurs distal to the optic nerve head.

METHODS

A literature search was conducted on October 22, 2019, and updated on April 8, 2020, in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis.

RESULTS

No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation. Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage.

CONCLUSIONS

Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON.

Combination analysis on the impact of the initial vision and surgical time for the prognosis of indirect traumatic optic neuropathy after endoscopic transnasal optic canal decompression

To analyze the impact of the initial vision and surgical time for endoscopic transnasal/transethmosphenoid optic canal decompression (ETOCD) in the treatment of indirect traumatic optic neuropathy (TON). This retrospective case series analysis included 72 patients with indirect TON who underwent ETOCD from August 2017 to May 2019. Visual acuity (VA) was compared before and after surgery to estimate the improvement rate. The overall VA improvement rate of ETOCD was 54.2%. There were 83.3% and 33.3% improvement rate of patients with residual vision and blindness, respectively. VA was improved in 60.9% of patients treated within 3 days, 61.5% treated within 7 days, and 35.0% treated later than 7 days. Of the blindness patients, 50.0%, 37.5%, and 0.0% were treated within 3 days, 3-7 days, and later than 7 days, respectively. Of patients with residual vision, 85.7%, 92.3%, and 70.0% were treated within 3 days, 3-7 days, and later than 7 days, respectively. A statistically significant difference was found between patients with residual vision and those with blindness (P < 0.01), as well as between patients who received ETOCD within 7 days and those who received ETOCD later than 7 days (P = 0.043). The improvement rate of blindness patients managed within 3 days (P = 0.008) and 3-7 days (P = 0.035) was significantly higher than that for patients managed beyond 7 days. Indirect TON patients can directly benefit from ETOCD, and patients with residual vision have better improvement rates. ETOCD should be performed as soon as possible to salvage the patient's VA, especially within the first 7 days. For blindness patients, it is necessary to carry out the surgery within 7 days with increased benefit seen before 3 days.

Intraoperative Corticosteroids for Voice Outcomes among Patients Undergoing Thyroidectomy: A Systematic Review and Meta-analysis

Objective

To determine if a preoperative dose of intravenous corticosteroids reduces the risk of postoperative recurrent laryngeal nerve palsy and improves subjective voice outcomes among patients undergoing thyroidectomy.

Data Sources

PubMed, Cochrane database, and EMBASE.

Review Methods

Randomized controlled trials comparing corticosteroids with placebo on voice outcomes in thyroid surgery were extracted with standardized search criteria. Systematic review and meta-analysis were performed. With random effects models, trial data were pooled to determine the overall rate of recurrent laryngeal nerve palsy as well as secondary outcomes of adverse events, including wound infection and hyperglycemia.

Results

Four studies with a total of 517 patients met inclusion criteria. The overall rate of recurrent laryngeal nerve palsy was 5.78%. There was no difference in the rate of palsy between the corticosteroid and placebo groups (risk ratio, 0.70; 95% CI, 0.34-1.44). There was also no difference between the groups in regard to wound infection, healing, or hyperglycemia.

Conclusions

Preoperative corticosteroids do not appear to reduce the risk of recurrent laryngeal nerve palsy following thyroid surgery. There is insufficient evidence to assess its effect on subjective voice outcomes. More robust randomized controlled trials are needed to assess the effectiveness of perioperative steroids in improving voice outcomes after thyroidectomy.

Steroid Treatment of Optic Neuropathies

The etiologies of optic neuropathy include inflammation, ischemia, toxic and metabolic injury, genetic disease, and trauma. There is little controversy over the practice of using steroids in the treatment of optic neuritis--it is well established that intravenous steroid treatment can speed visual recovery but does not alter final visual function. However, there is controversy surrounding the acceptable routes of administration, dosage, and course of treatment. Additionally, the typical patient with optic neuritis is young and otherwise healthy, and thus is likely to tolerate steroids well. In ischemic and traumatic causes of optic neuropathies, the initial injury is not inflammatory, but damage may be compounded by secondary injury due to resultant inflammation and swelling in the confined space of the optic canal. Steroids have been considered as a means of minimizing inflammation and swelling, and thus minimizing the secondary injury that results. However, the use of steroids in traumatic and ischemic optic neuropathies is highly controversial-the evidence for the efficacy of treatment with steroids is insufficient to show that there is significant benefit. Additionally, patients with these conditions are more likely to have comorbidities that make them vulnerable to significant adverse events with the use of steroids. In this article, we attempt to analyze the current state of the literature regarding the use of steroids in the treatment of optic neuropathies, specifically optic neuritis, nonarteritic anterior ischemic optic neuropathy, and traumatic optic neuropathy.

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.

Risk Factor Analysis for the Outcomes of Indirect Traumatic Optic Neuropathy with No Light Perception at Initial Visual Acuity Testing

BACKGROUND

The optimal management of indirect traumatic optic neuropathy (TON) is controversial. We aimed to compare the differences in visual improvement by treatment option in patients presenting with TON and no light perception (NLP). We also wanted to identify any patient-related factors that might favor the use of steroid pulse therapy or optic nerve decompression (OND).

METHODS

We retrospectively identified 46 consecutive patients with indirect TON treated at Chang Gung Memorial Hospital between 2007 and 2015. The outcome was the improvement in visual acuity by improvement rate and degree of improvement.

RESULTS

Females had a better improvement rate than did males. Compared with delayed treatment, patients receiving steroid pulse therapy within 14 hours or receiving OND within 26 hours had a better improvement rate/degree. In patients with an initial intraocular pressure (IOP) of 17-23 mm Hg, the improvement rate/degree was significantly better than for patients with an IOP outside this range. For patients treated by OND, an initially normal IOP (11-21 mm Hg) suggested a significantly better prognosis in the improvement rate/degree.

CONCLUSIONS

For patients with indirect TON, initial NLP implies a poor prognosis, but steroid pulse therapy or OND are both feasible treatment options. These results emphasize the importance of timely treatment for patients with indirect TON and NLP. Females and patients with an initial IOP of 17-23 mm Hg were more likely to recover. The results of our study indicate that normal initial IOP (11-21 mm Hg) is good prognostic factor for patients with indirect TON treated with OND.

Risk factors affecting the visual outcome in patients with indirect traumatic optic neuropathy

PURPOSE

To evaluate the etiology and possible prognostic factors affecting the visual outcome in patients with indirect traumatic optic neuropathy (TON).

METHODS

The records of patients with indirect TON were reviewed and compared the results of treatment with high doses of corticosteroids (Group 1) and simple observation without treatment (Group 2).

RESULTS

The mean age at the time of injury was 34.7 ± 11.4 (18-58) years in Group 1 and 37.5 ± 17.7 (8-73) years in Group 2 (p = 0.513). The mean value for the first referral of the patient to the ophthalmology clinic following trauma was 2.4 ± 2.4 (1-10) days in Group 1 and 16.7 ± 13.9 (1-30) days in Group 2 (p = 0.004). The most common causes of trauma were road traffic collision (57.1 and 68%) in the Group 1 and 2, respectively (p = 0.606). The mean initial visual acuity was 0.03 ± 0.07 (0.00-0.30) in Group 1 and 0.17 ± 0.21 (0.00-0.80) decimal in Group 2 patients (p = 0.001). The mean visual acuity at the final follow-up was 0.21 ± 0.35 (0.00-1.00) and 0.46 ± 0.42 (0.00-1.00) in Group 1 and Group 2, respectively, indicating better initial and final visual acuity values in Group 2 (p = 0.022), and also a statistically significant recovery of visual acuity between initial and final values in both groups (p < 0.05). The most important determinant of the final visual acuity was initial visual acuity (p < 0.001; 95.0% CI: 0.792-2.096).

CONCLUSIONS

Our study demonstrated that road traffic collision is the leading cause of indirect traumatic optic neuropathy, and the best predictor of final visual acuity outcome is the initial visual acuity.

Midface Fractures I

Facial fractures are a common source of emergency department consultations for the plastic surgeon. A working understanding of evaluation, assessment, management, and prevention of further injury when dealing with these fractures is vital. This two-part series detailing the management of midface fractures serves as a guide for the appropriate workup and management of the wide variety of fracture patterns that are commonly encountered.