Traumatic optic neuropathy - to treat or to observe?

The Management of Traumatic Optic Neuropathy: A Systematic Review and Meta-Analysis

Introduction

Traumatic optic neuropathy (TON) is a serious condition resulting from optic nerve injury, often due to head trauma. This study systematically reviews the existing literature to evaluate the effectiveness of various treatments in improving visual outcomes in TON patients.

Methods

A comprehensive literature search was conducted across databases including Medline (via PubMed), Web of Science, Cochrane Library, and EMBASE from January 1992 to October 2024. Studies were selected based on inclusion criteria that focused on TON patients treated with corticosteroids, conservative therapy, erythropoietin therapy, or surgical interventions. Quality assessment of the included studies was performed using the Joanna Briggs Institute (JBI) Risk of Bias Tool for each design. Data extraction and quality assessment were performed by two independent reviewers, with a meta-analysis conducted to evaluate the pooled visual acuity (VA) improvement rates.

Results

A total of 23 studies were included, encompassing 1,851 patients with TON. The meta-analysis revealed a pooled VA improvement rate of 50.6% across all treatment modalities. Specifically, corticosteroid-only treatment resulted in a 56.2% improvement rate, while combined corticosteroid and surgical decompression showed a 42.9% improvement rate. Conservative therapy had a 47.8% improvement rate. The heterogeneity among studies was significant (I2= 89.9%), and no significant publication bias was detected. Subgroup analyses indicated varied outcomes, with some studies reporting better results with early intervention.

Conclusion

The treatment of TON remains challenging, with no single modality showing clear superiority. The corticosteroids and surgical interventions provide potential benefits; however, conservative therapy might be appropriate for certain cases. Future research should focus on optimizing treatment protocols and exploring new therapeutic options, such as erythropoietin to improve visual outcomes in TON patients.

Salvaging Vision: A Study of Non-Traumatic Optic Neuropathies

Background and Objectives

Various ear, nose, and throat (ENT) conditions can result in vision loss. The purpose of this study is to identify the etiologies, presentations, and radiological findings associated with impaired vision in the context of ENT. Additionally, this article discusses management protocols, including optic nerve decompression and orbital decompression.

Methods

In a retrospective study, we examined the period from 2016 to 2022 at a tertiary care hospital in Mumbai, India. The analysis included 11 patients who presented with progressive diminution of vision. All patients received a regimen of broad-spectrum intravenous antibiotics and high-dose intravenous steroids. This was followed by either endoscopic optic nerve decompression or orbital decompression. Subsequent improvements in vision were documented, and any complications were evaluated.

Results

A total of 11 patients were treated with medical management followed by successful surgery, with 10 patients demonstrating significant vision improvement.

Conclusion

Identifying the etiology of vision loss and managing the condition can present challenges for otorhinolaryngologists. A thorough grasp of the underlying pathophysiology, combined with active surveillance of clinical and radiological indicators, can enable these clinicians to achieve effective and rewarding outcomes.

Endoscopic trans-ethmosphenoid optic canal decompression is an optimal choice to save vision for indirect traumatic optic neuropathy

Purpose

To evaluate and compare the effectiveness of endoscopic trans‐ethmosphenoid optic canal decompression (ETOCD) and steroid pulse therapy (SPT) for indirect traumatic optic neuropathy (ITON).

Design

Prospective interventional case series.

Methods

Total 140 monocular ITON patients from January 2017 to June 2019 were recruited, including 100 patients received ETOCD (56 patients received ETOCD only and 44 patients received ETOCD combined with SPT before surgery), and 40 patients received SPT only. Their visual acuity (VA) and visual evoked potential (VEP) were analysed before and after treatments. Initial VA, lag time, causes of injuries and age were analysed for evaluating prognosis of treatment.

Results

In contrast with patients received SPT only (15/40 = 38%), the effective rate of patients received ETOCD only and patients received ETOCD combined with SPT were both significantly better (46/56 = 82%, p < 0.001 and 30/44 = 68%, p = 0.005). Whether with SPT before ETOCD or not, after ETOCD, patients with VA improvement showed no significant difference. And 59/76 (77.6%) patients showed improvement within 24 hours. Patients who had residual visions achieved higher effective rate than those with no light perception (56/58 = 97% and 20/42 = 48%; p < 0.001) after ETOCD. For patients with long lag time of 21–90 days, 23/32 (72%) patients presented with vision improvement. Moreover, VEP was significantly improved after ETOCD. No severe complications were observed.

Conclusions

Endoscopic trans‐ethmosphenoid optic canal decompression (ETOCD) is an effective and safe therapy for ITON, which is more effective than SPT. Even for patients with failure in responding to SPT, the successfully physical decompression is the most effective way to rescue optical nerve from permanent damage.

Optic neuritis after ocular trauma in anti-aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder

OBJECTIVE

The aim of this study was to report the possible association between minor trauma to the eyes and the subsequent occurrence of optic neuritis in patients with serum anti-aquaporin-4 (AQP4) antibody-positive neuromyelitis optica spectrum disorder (NMOSD).

METHODS

Herein, we present three patients who developed acute optic neuritis with visual disturbances after accidental minor trauma to their eyes, without any fundus abnormality or orbital floor fractures present.

RESULTS

Two of the three patients had a preceding history of neurological disturbances compatible with NMOSD (e.g., myelitis, area postrema syndrome) before the occurrence of trauma. One patient was rapidly treated with steroid pulse therapy and plasmapheresis, and he fully recovered visual acuity. The other two, who were left untreated in the acute phase, had sequelae of severe visual disturbances in the affected eyes.

CONCLUSIONS

These cases suggest possible association between minor trauma to the eyes and the subsequent occurrence of optic neuritis in patients with serum anti-AQP4 antibodies. Avoiding ocular trauma and early administration of steroid pulse therapy in response to optic neuritis after trauma are desired in such cases.

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.

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.

Update on the application of optic nerve sheath fenestration

BACKGROUND

With the ongoing development of surgical procedures and instruments, the safety of optic nerve sheath fenestration (ONSF) has been improved.

OBJECTIVE

Through the past three decades, progress has been made in preventing visual loss from chronic optic nerve swelling in idiopathic intracranial hypertension (IIH), secondary intracranial hypertension and local optic nerve diseases. We now review the updated application of ONSF in those diseases.

METHODS

The application of ONSF in papilledema due to IIH, secondary intracranial hypertension to cerebral venous sinus occlusion, Cryptococcal meningitis, and intracranial mass or tumors is reviewed. Additionally, the potential benefits of ONSF in local optic neuropathy from optic nerve sheath meningioma, optic nerve drusen, traumatic optic neuropathy and optic nerve/sheath biopsy are also described.

RESULTS

Although ONSF has little or no effect on intracranial pressure, it is a safe, relative easy and effective surgical procedure to prevent or reverse visual loss in IIH. When other treatment modalities fail to timely protect vision, ONSF can be useful in protecting visual function or delay visual loss in secondary intracranial hypertension.

CONCLUSION

We recommend that ONSF should be considered as a meaningful alternative or an adjunct therapy to reduce or delay the visual morbidity of these diseases, although the use of ONSF for some of them remains controversial.

Eye-Directed Overpressure Airwave-Induced Trauma Causes Lasting Damage to the Anterior and Posterior Globe: A Model for Testing Cell-Based Therapies

PURPOSE

Characterization of the response of the Balb/c mouse to an eye-directed overpressure airwave, with the hypothesis that this mouse strain and model is useful for testing potential therapeutics for the treatment of traumatic eye injury.

METHODS

The left eyes of adult Balb/c mice were exposed to an eye-directed overpressure airwave. Intraocular pressure (IOP) was measured and eyes were inspected for gross pathology changes. Optical coherence tomography and histology were used to examine the structural integrity of the retina and optic nerve. Immunohistochemistry, in vivo molecular fluorophores, and a multiplex enzyme-linked immunosorbent assay were utilized to identify changes in cell death, neuroinflammation, and oxidative stress.

RESULTS

This model induced a transient increase in IOP, corneal injuries, infrequent large retinal detachments, retinal pigment epithelium (RPE) vacuolization, glial reactivity, and retinal cell death. Both the corneal damage and RPE vacuolization persisted with time. Optic nerve degeneration occurred as early as 7 days postinjury and persisted out to 60 days. Retinal cell death, increased levels of reactive oxygen species, and neuroinflammation were detected at 7 days postinjury.

CONCLUSIONS

The injury profile of the Balb/c mouse is consistent with commonly observed pathologies in blast-exposed patients. The damage is throughout the eye and persistent, making this mouse model useful for testing cell-based therapies.

Ocular Injuries in Association with Middle Third Facial Injuries in Developing Countries: A Prospective Study

Introduction

The middle third of the face is the most common site of injury and is frequently complicated by associated ocular injuries. It may be simple laceration, ecchymosis, circumorbital edema, or severe as globe injury or injury to the optic nerve and vision loss. Even severe injury like internal bleeding causes increased intraocular pressure and damages the optic nerve; if managed earlier, it could prevent further damage and dysfunction of the eye. Midfacial fractures associated with ocular injuries should have an early ophthalmological examination to detect ocular injuries. Little is known about the current epidemiology of midface fractures and associated ocular injuries in Tamil Nadu, the state of India. The aim was to study the etiology and pattern of middle third fracture and associated ocular injuries.

Materials and methods

This prospective study on midface fractures was carried out in the Department of Dentistry to analyze etiology, incidence, and patterns of midface fractures and associated ocular injuries. A total of 201 patients who reported with the history of midface injuries were included in the study. These patients were examined clinically and routine radiographs and computerized tomography magnetic resonance imaging (MRI) were taken to confirm the diagnosis. All the patients sustaining confirmed middle third fractures with or without eye signs were referred to an ophthalmology department for the evaluation and management of associated ophthalmic injury. Statistical Package for the Social Sciences software version 16.0 was used for data analysis. The outcome of the study was measured using percentages, mean, standard deviation, and test of proportion as appropriate.

Results

Traffic accident was the major cause of injury, mainly by motorized two wheelers (MTWs). Males in the 21 to 40 age group were common victims. Zygomatic complex fracture was the most common fracture type. Subconjunctival hemorrhage and infraorbital nerve injuries were common clinical findings.

Conclusion

Midthird facial injury cases should have an early ophthalmological examination for timely management to prevent dysfunction of the eye.

How to cite this article

Mohanavalli S, Suma E, Senthamarai G, Vijayabala GS. Ocular Injuries in Association with Middle Third Facial Injuries in Developing Countries: A Prospective Study. World J Dent 2016;7(3):135-140.

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.

Endoscopic optic nerve decompression for patients with traumatic optic neuropathy: is nerve sheath incision necessary?

OBJECTIVE

To evaluate the necessity of nerve sheath incision for the treatment of patients with traumatic optic neuropathy (TON) during endoscopic optic nerve decompression.

METHODS

Seventy-four TON patients were enrolled and subjected to endoscopic optic nerve decompression. In 31 TON patients (group A), osseous decompression and nerve sheath incision were performed, and in 43 TON patients (group B), osseous decompression alone was carried out. Visual acuity was evaluated postoperatively.

RESULTS

After surgery, visual acuity was improved in 47 of 74 patients, with a total effectiveness ratio of 63.5%. The total ratio of improvement in groups A and B was 61.2 and 65.1%, respectively, and no significant difference was observed (p > 0.05). As to the patients with residual vision preoperatively, the ratio of improvement in groups A and B was 64.2 and 71.4%, respectively (p > 0.05), not favoring nerve sheath incision during endoscopic optic nerve decompression.

CONCLUSION

Our preliminary results suggest that during endoscopic optic nerve decompression for the treatment of TON patients, nerve sheath incision is not obligatory for the improvement of visual acuity.