Salvage optic nerve decompression for traumatic blindness under nasal endoscopy: risk and benefit analysis

Reconstruction of Medial Orbital Wall Using Autologous Perpendicular Plate of Ethmoid

The aim of this study is to investigate the feasibility of perpendicular plate of ethmoid as material for the reconstruction of medial orbital wall. The main outcome measurement was preoperative and postoperative orbital volume. The authors performed a study including 17 patients who have isolated medial orbital wall fracture (blow-out fracture). All the patients were fixed the defect using autologous perpendicular plate of ethmoid under endonasal approach. The authors compared the preoperative and postoperative orbital volume difference (unaffected orbit, affected orbit) of all the patients, and observed the improvement of diplopia or ocular motility disorders after operation. All 17 medial orbital wall reconstruction surgeries were successful with no severe postoperative ophthalmic complications. Statistically significant differences were found between the preoperative and postoperative orbital tissue volumes for the affected orbit. There was no statistically significant difference found between the tissue volume of the contralateral unaffected orbit and the affected orbit after reconstruction. And postoperative computed tomography showed the implant is in place and there is no medial rectus incarceration. Autologous perpendicular plate of ethmoid proved to be safe and effective in the reconstruction of medial orbital wall under endonasal approach with cost-effectivence, low complication rate, high biocompatibility, and minimally invasion.

Traumatic Optic Neuropathy Our Experience with Combined Therapy

Objective Traumatic optic neuropathy (TON) is an important cause of severe vision impairment after sustaining a closed head injury. This study describes the safety and efficacy of combined therapy in the management of TON.

Methods A retrospective analysis of 23 consecutive cases of unilateral TON managed with combined therapy (steroid and surgery) were performed. Statistical analysis of patient characteristic, timing of vision loss, radiological and intraoperative findings, and pre- and post-treatment vision were compared to assess the prognostic factors.

Results Seventeen patients (85%) had vision improvement with combined therapy. Three patients (15%), who recorded no improvement, initially presented with no perception of light, and loss was sudden and immediate. With steroids, 9 patients improved, all of them presented with perception of light (PL) or better and vision improved to (6/6 in five, 6/9 in one, 6/18 in 3). Eleven patients (6 PL–ve and 5 PL + ve after failed steroid therapy) underwent endoscopic optic nerve decompression and eight had improvement in vision. The status of vision at presentation was only statically significant prognostic factor (p < 0.02). Others prognostic factors, for example, time of starting treatment, surgery, and presence of fracture in optic canal, were not found statistically significant (p > 0.05). There were no significant intra- and postoperative complications.

Conclusion Combined therapy is safe and effective in management of TON. Mild form injury with some preserved vision at presentation respond well to steroids, while endoscopic nerve decompression should be reserved in cases with failed steroid therapy.

Role of delayed wider endoscopic optic decompression for traumatic optic neuropathy: a single-center surgical experience

BACKGROUND

The aim of the present study was to discuss the efficacy of delayed wider endoscopic optic decompression in traumatic optic neuropathy (TON).

METHODS

A total of 479 patients were treated with corticosteroids and delayed wider endoscopic optic decompression, including the injury-to-surgery interval, within 2 weeks in patients with no light perception (NLP), and within 1 month in patients with residual eyesight. Based on the traditional decompression range, the superior wall of the optic canal was further decompressed. The preoperative and postoperative visual acuities (VAs) were reviewed, and the therapeutic efficacy was analyzed.

RESULTS

The final VA was 0.1 or better in 29 cases, finger count in 79 cases, hand motion in 99 cases, light perception (LP) in 25 cases, and NLP in 247 cases. A total of 136 patients (136/383, 35.5%) recovered after NLP treatment, and 78 patients (69/96, 71.9%) had improved residual eyesight. The improvement rate in patients with residual eyesight was significantly higher than that of patients with NLP (P<0.01). Moreover, the total VA after treatment was better than that before surgery (P<0.01).

CONCLUSIONS

Delayed wider optic nerve decompression plus corticosteroids remains an effective and safe therapeutic strategy for patients with delayed treatment intervals of more than 1 week, especially for those with residual eyesight within 1 month.

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.

Transsphenoidal Optic Canal Decompression for Traumatic Optic Neuropathy Assisted by a Computed Tomography Image Postprocessing Technique

The endoscopic transethmoidal approach is favored for the lack of external scars, a wide field of view, and rapid recovery time. But the effect of iatrogenic trauma should not be ignored due to the removal of the uncinate process and anterior and posterior ethmoidal sinus. Anatomically, the optic nerve is close to the sphenoid sinus and Onodi cell. In order to preserve the uncinate process and ethmoidal sinus, we perform endoscopic transsphenoidal optic canal decompression (ETOCD), which is less invasive. However, the anatomy of sphenoid sinus is quite variable, and the anatomical landmarks are rare. Therefore, identifying the position of optic canal is particularly important during surgery. To solve this, we use a postprocessing technique to identify the position of the optic nerve and internal carotid artery on the sphenoid sinus wall. Our results find that VA in 13 patients improved, with a total improve rate of 59.1%. No serious complications were found. We also found that the length of optic canal is different and the medial wall of the optic canal was the longest (p < 0.05). The middle section of the optic canal is the narrowest, which was significantly different from cranial mouth and orbital mouth (p < 0.05). We assumed that decompression may not require removal of all medial wall. If we remove the length of the shortest wall on the medial wall of the optic canal, the compression may be relieved. Thus, ETOCD was a feasible, safe, effective, and less-invasive approach for patients with TON. The CT postprocessing imaging facilitated recognition of the optic canal during surgery. The decompression length of the medial wall may not need to be completely removed, especially near the cranial mouth.

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.

Outcome of the surgical decompression for traumatic optic neuropathy: a systematic review and meta-analysis

There exists a persisting controversy regarding the indications for optic nerve surgical decompression (ONSD) in traumatic optic neuropathy (TON). A meta-analysis is warranted to help guiding therapeutic decisions and address gaps in knowledge. The authors conducted a search of PubMed and MEDLINE electronic databases. Primary endpoint was the improvement in the visual function with ONSD in comparison with the conservative management. Secondary endpoint was visual function improvement when surgery was performed within the first 7 days. A random effects model meta-analysis was conducted. Data from each study were used to generate log odds ratio and 95% confidence intervals, to compare post-operative visual improvement. Nine studies met the inclusion criteria for analysis, comprising 766 patients. Visual improvement occurred in 55% (198/360) of patients treated with ONSD, and in 40% (164/406) of those who underwent conservative treatment. Forest plot revealed significant differences in the visual function improvement among these two groups, although further analysis revealed the studies were heterogeneous (log OR, 0.81; CI, 0.07-1.55; I², 62.8% p = 0.015). Overall, patients who underwent early surgery had better visual outcomes (log OR, 0.94; CI, 0.29-1.60; I², 0% p = 0.9). ONSD is an effective technique to improve the outcome in the visual function in patients with TON. A lack of randomized controlled trial-and inherent surgical selection and publication bias-limits direct comparison between surgical decompression and conservative management. Suitably designed prospective cohort studies may be useful in identifying patients more likely to receive benefit from ONSD.

An evolving perspective of endoscopic transnasal optic canal decompression for traumatic optic neuropathy in clinic

Traumatic optic neuropathy (TON) is a serious complication of craniofacial trauma, which damages the optic nerve indirectly and leads to dysfunction of visual acuity. The clinical intervention for a patient with TON includes optic canal decompression (with or without steroids), treatment with corticosteroids alone, or observation only. Currently, there is a controversy among clinicians as to which treatment is optimal. An increasing number of retrospective studies have unveiled that patients could experience significant improvement in visual acuity after optic canal decompression surgery, particularly endoscopic transnasal/transethmosphenoid optic canal decompression (ETOCD), either with or without corticosteroids. In this review, we discuss the evolving perspective on surgical treatment, specifically ETOCD, for the management of patients with TON and focus mainly on the therapeutic efficacy, safety, and resulting prognosis in the clinic.

The Outcome of Endoscopic Optic Nerve Decompression for Bilateral Traumatic Optic Neuropathy

OBJECTIVE

To investigate the outcomes of endoscopic optic nerve decompression (EOND) for bilateral traumatic optic neuropathy (TON).

METHODS

A retrospective analysis was conducted in 5 patients with bilateral TON, between January 2003 and December 2013. All the patients underwent preoperative ophthalmological evaluation, flash visual-evoked potentials, computed tomography scan, and systemic corticosteroid therapy. All the patients required an EOND surgery, due to poor response to medical therapy, and the remainder one was only treated with corticosteroid due to operative contraindication.

RESULTS

Of the 5 patients (10 eyes) undergoing EOND, visual acuity improved in 30% of eyes (n = 3) with a mean follow-up of 3 months. The remainder 7 eyes still had no light perception. All of the 5 patients undergoing EOND had no operative complications.

CONCLUSION

Treatment for bilateral TON should not be limited on the length of time to injury and visual-evoked potentials results. If surgical conditions permit and with no contraindications, patients should receive active surgical treatment as soon as possible.

The Outcome of Endoscopic Transethmosphenoid Optic Canal Decompression for Indirect Traumatic Optic Neuropathy with No-Light-Perception

Purpose. To present the safety and effect of endoscopic transethmosphenoid optic canal decompression (ETOCD) for indirect traumatic optic neuropathy (ITON) patients with no-light-perception (NLP). Methods. A retrospective study performed on 96 patients (96 eyes) with NLP after ITON between June 1, 2010, and June 1, 2015, who underwent ETOCD, was reviewed. Visual outcome before and after treatment was taken into comparison. Results. The overall visual acuity improvement rate after surgery was 46.9%. The improvement rates of visual acuity of patients who received treatment within 3 days of injury, 3-7 days after injury, and later than 7 days were 63.6%, 42.9%, and 35.7%, respectively. Statistically significant difference was detected between the effective rates of within-3-day group and later-than-7-day group (χ² = 5.772, P = 0.016). The effective rate of atrophy group and nonatrophy group was 25.0% and 51.3%, respectively. The effective rate was significantly higher in nonatrophy group (χ² = 4.417, P = 0.036). Conclusion. For patients suffering from ITON with NLP, time to medical treatment within 3 days is an influential factor for visual prognosis. Optic nerve atrophy is an important predictor for visual prognosis. Treatment should still be recommended even for cases of delayed presentation to hospital.

The Outcome of Endoscopic Transethmosphenoid Optic Canal Decompression for Indirect Traumatic Optic Neuropathy with No-Light-Perception

Purpose. To present the safety and effect of endoscopic transethmosphenoid optic canal decompression (ETOCD) for indirect traumatic optic neuropathy (ITON) patients with no-light-perception (NLP). Methods. A retrospective study performed on 96 patients (96 eyes) with NLP after ITON between June 1, 2010, and June 1, 2015, who underwent ETOCD, was reviewed. Visual outcome before and after treatment was taken into comparison. Results. The overall visual acuity improvement rate after surgery was 46.9%. The improvement rates of visual acuity of patients who received treatment within 3 days of injury, 3-7 days after injury, and later than 7 days were 63.6%, 42.9%, and 35.7%, respectively. Statistically significant difference was detected between the effective rates of within-3-day group and later-than-7-day group (χ² = 5.772, P = 0.016). The effective rate of atrophy group and nonatrophy group was 25.0% and 51.3%, respectively. The effective rate was significantly higher in nonatrophy group (χ² = 4.417, P = 0.036). Conclusion. For patients suffering from ITON with NLP, time to medical treatment within 3 days is an influential factor for visual prognosis. Optic nerve atrophy is an important predictor for visual prognosis. Treatment should still be recommended even for cases of delayed presentation to hospital.

Timing of endoscopic surgical decompression in traumatic optic neuropathy: a systematic review of the literature

BACKGROUND

Traumatic optic neuropathy (TON) represents a rare but devastating complication of closed head injuries. No accepted guidelines are available for medical and surgical management algorithms. A systematic review of the literature was performed to determine the optimal timing and candidacy for endoscopic surgical intervention.

METHODS

A systematic review of multiple databases was performed including Medline-Ovid, EMBASE, and PubMed. Data was extracted and patients stratified based on surgical delay from trauma (≤3 days, >3 days, ≤7 days, or >7 days) as well as preoperative and postoperative vision testing (no light perception [NLP]; light perception [LP]; hand motion [HM]; or finger counting [FC] or better).

RESULTS

The literature review identified 24 studies meeting inclusion criteria. In the group of patients receiving surgery ≤3 days after the antecedent event, 57% (105/183) had visual improvement, whereas in the >7-days group 51% (145/283) of patients improved. In those with NLP preoperatively, 41% (172/411) saw improvement, whereas those with LP (89%), HM (93%), or FC (85%) fared better.

CONCLUSION

The literature suggests that surgical intervention for TON is indicated despite delayed presentation, and is a better choice than no intervention at all. Patients with complete blindness on presentation (NLP) tend to have a poorer surgical outcome.

Endoscopic endonasal optic nerve and orbital apex decompression for nontraumatic optic neuropathy: surgical nuances and review of the literature

OBJECT

While several approaches have been described for optic nerve decompression, the endoscopic endonasal route is gaining favor because it provides excellent exposure of the optic canal and the orbital apex in a minimally invasive manner. Very few studies have detailed the experience with nontraumatic optic nerve decompressions, whereas traumatic cases have been widely documented. Herein, the authors describe their preliminary experience with endoscopic endonasal decompression for nontraumatic optic neuropathies (NONs) to determine the procedure's efficacy and delineate its potential indications and limits.

METHODS

The medical reports of patients who had undergone endoscopic endonasal optic nerve and orbital apex decompression for NONs at the Lyon University Neurosurgical Hospital in the period from January 2012 to March 2014 were reviewed. For all cases, clinical and imaging data on the underlying pathology and the patient, including demographics, preoperative and 6-month postoperative ophthalmological assessment results, symptom duration, operative details with video debriefing, as well as the immediate and delayed postoperative course, were collected from the medical records.

RESULTS

Eleven patients underwent endoscopic endonasal decompression for NON in the multidisciplinary skull base surgery unit of the Lyon University Neurosurgical Hospital during the 27-month study period. The mean patient age was 53.4 years, and there was a clear female predominance (8 females and 3 males). Among the underlying pathologies were 4 sphenoorbital meningiomas (36%), 3 optic nerve meningiomas (27%), and 1 each of trigeminal neuroma (9%), orbital apex meningioma (9%), ossifying fibroma (9%), and inflammatory pseudotumor of the orbit (9%). Fifty-four percent of the patients had improved visual acuity at the 6-month follow-up. Only 1 patient whose sphenoorbital meningioma had been treated at the optic nerve atrophy stage continued to worsen despite surgical decompression. The 2 patients presenting with preoperative papilledema totally recovered. One case of postoperative epistaxis was successfully treated using balloon inflation, and 1 case of air swelling of the orbit spontaneously resolved.

CONCLUSIONS

Endoscopic endonasal optic nerve decompression is a safe, effective, and minimally invasive technique affording the restoration of visual function in patients with nontraumatic compressive processes of the orbital apex and optic nerve. The timing of decompression remains crucial, and patients should undergo such a procedure early in the disease course before optic atrophy.

A modified surgical procedure for endoscopic optic nerve decompression for the treatment of traumatic optic neuropathy

Background:

Although the endoscopic anterior-to-posterior technique offers many advantages, the long-term effects of the iatrogenic trauma (removal of the uncinate process and anterior ethmoidal sinus) resulting from the complete ethmoidectomy procedure used to gain full access to the optic nerve canal is unknown, and sequelae such as nasal synechia and sinusitis should not be ignored.

Aims:

The aim of our study is to develop a less invasive procedure for endoscopic optic nerve decompression.

Materials and Methods:

We proposed a modified trans-sphenoidal surgical procedure for endoscopic optic nerve decompression in five patients with traumatic optic neuropathy (TON), all with high sphenoidal pneumatisation and without Onodi cellulae.

Results:

After performing a direct sphenoidotomy through the natural ostium of the sphenoid sinus rather than a complete ethmo-sphnoidectomy, we found that the modified approach provided adequate access to the optic nerve canal and the apex using a 45° angled endoscope. Successful decompression of the canal optic nerve was performed trans-sphenoidally in all five TON patients using an angled endoscope. No surgical complications occurred, and none of the patients suffered from anterior ethmoidal sinus or skull base damage.

Conclusions:

The modified trans-sphenoidal approach is a feasible, safe, effective, and minimally invasive approach for TON patients with high sphenoidal pneumatisation and without supersphenoid-ethmoid cellulae.

Analysis of prognostic factors of endoscopic optic nerve decompression in traumatic blindness

CONCLUSIONS

Hemorrhage within the ethmoid and/or sphenoid sinus and an interval between the time of injury and the time of operation exceeding 3 days are the risk factors for the visual prognosis of traumatic blindness.

OBJECTIVES

To investigate the therapeutic efficacy of endoscopic optic nerve decompression in the treatment of traumatic blindness and to evaluate the relevant prognostic factors.

METHODS

Eighty-five cases of traumatic blindness were analyzed retrospectively. Univariate analysis and multiple logistic regression were performed to evaluate potential prognostic factors.

RESULTS

The overall rate of vision acuity improvement was 44.7% (38 of 85). Univariate analysis indicated that hemorrhage within the ethmoid and/or sphenoid sinus was significantly associated with unrecovered visual acuity. However, multiple logistic regression analysis identified that an interval between the time of injury and the time of operation exceeding 3 days, and hemorrhage within the ethmoid and/or sphenoid sinus were significantly correlated with the efficacy of treatment of traumatic blindness.

The therapeutic efficacy of endoscopic optic nerve decompression and its effects on the prognoses of 96 cases of traumatic optic neuropathy

BACKGROUND

Traumatic optic neuropathy (TON) is an important cause of severe loss of vision due to blunt or penetrating head trauma. The pathogenesis of TON remains unclear, and there are several potential causes for the observed loss in vision. Endoscopic optic nerve decompression (EOND) has been reported to improve the visual prognosis in TON cases, but its efficacy remains controversial. It is important to investigate the therapeutic efficacy of EOND in the treatment of TON and to evaluate the relevant prognostic factors.

METHODS

A retrospective study was conducted to analyze the clinical characteristics and prognoses of 96 TON cases. The χ(2) test and multiple logistic regression analyses were used to evaluate potential prognostic factors.

RESULTS

: The overall rate of EOND effectiveness was 40.6% (39 of 96). A significantly higher effective rate (83.3%) was observed for patients with light perception compared with those without light perception (26.4%, p < 0.05). Univariate and multiple logistic regression analyses identified three variables (no light perception, undergoing EOND 3 days after trauma, and hemorrhage within the ethmoid and/or sphenoid sinus) that were significantly associated with unrecovered visual acuity. Age, loss of consciousness, optic canal fracture, preoperative steroid megadose treatment, and optic nerve sheath incision were all factors that showed no significant correlation with therapeutic efficacy. However, patients with fractures in a single medial wall of the optic canal appeared to have better prognoses than patients with multiple fractures or those with a single fracture in a lateral wall.

CONCLUSIONS

The overall therapeutic efficacy of EOND for the treatment of TON is far from satisfactory, especially for patients without light perception. The factors that impact TON prognoses are complex and may be interrelated. The indication for EOND must be individualized.

LEVEL OF EVIDENCE

III, epidemiological study.

[Traumatic optic nerve neuropathy. Longterm results following microsurgical optic nerve decompression]

BACKGROUND

Traumatic optic nerve neuropathy (TON) is defined as injury to the optic nerve with subsequent vision loss due to head or craniocerebral trauma. The treatment of this disease is the subject of controversial discussions. The purpose of the present study was to investigate pre- and immediate postoperative visual acuity in patients with unilateral TON and to compare the results with the time interval between trauma and surgical intervention.

PATIENTS AND METHODS

A total of 20 patients with unilateral TON and considerable vision loss were examined. All were treated with high dose corticoids and underwent microsurgical optic nerve decompression. Visual acuity was determined pre- and postoperatively. In long-term follow-up visual acuity was determined 3 months postoperatively.

RESULTS

Postoperatively, nine patients (45%) achieved an improvement in visual acuity of more than 0.4, and another three patients (15%) an improvement of ≥0.2. At 3 months postoperatively another four patients achieved a further improvement of their visual acuity of >0.2. A decrease in visual acuity was not observed in any case, nor were major surgical complications.

CONCLUSIONS

Factors which predict good prognosis for vision recovery include a short time interval between trauma and intervention, edema, and/or hematoma of the optic nerve sheath. Factors which predict a worse prognosis are a fracture line directly through the nerve canal, a time period between trauma and intervention of more than 24 h, and initial complete amaurosis.

Transsphenoidal optic nerve decompression: an endoscopic anatomic study

The objective was to study the relationships among the optic nerve, posterior paranasal sinuses, and ophthalmic artery. The identification of reliable anatomic landmarks would provide an endoscopic anatomic basis for optic nerve localization and effective prevention of ophthalmic artery injury during transsphenoidal optic nerve decompression surgery. The Messerklinger technique was performed to open the posterior ethmoid sinus and sphenoid sinus in 8 adult-head specimens. The opticocarotid recess and optic canal were identified under endoscopy, and the relationships between the optic nerve and posterior paranasal sinuses were observed. The relationship between the optic nerve and ophthalmic artery was examined. In all specimens, the opticocarotid recess could be identified; however, the optic nerve protuberance was present in only 10 sides (62%). Three types of relationships were found to exist among the optic nerve, sphenoid sinus, and posterior ethmoid sinus. The posterior ethmoid sinus was anterior and the sphenoid sinus was posterior in 8 sides (50%), the sphenoid sinus was both anterior and posterior in 5 sides (31%), and the ethmoid sinus was both anterior and posterior in 3 sides (19%). At the intracranial opening of the optic canal, the ophthalmic artery was inferomedial to the optic nerve in 9 sides (56%), inferior to the optic nerve in 4 sides (25%), and inferolateral to the optic nerve in 3 sides (19%). The ophthalmic artery coursed laterally from inferior to the optic nerve, and at the intraorbital opening of the optic canal, the ophthalmic artery was inferolateral to the optic nerve in 13 sides (81%) and inferior to the optic nerve in 3 sides (19%). The opticocarotid recess is always present; the imaging characteristics of endoscopy allow this recess to be more reliably identified than the optic nerve protuberance. It can be used as the anatomic landmark of choice in endoscopic optic nerve decompression. The origin of the ophthalmic artery is inferomedial to the optic nerve, and thereafter, it courses inferolaterally. An intersecting relationship exists along its course, a factor that must be taken into account during surgery to avoid injuring the ophthalmic artery.