Post-traumatic optic neuropathy: our surgical and medical protocol

Abstract

Post-traumatic optic neuropathy (TON) is a rare, but very much feared event. It is a traumatic injury of the optic nerve at any level along its course (often inside the optic canal), with partial or total loss of visual acuity, temporarily or permanently. Until now, an univocal treatment strategy does not exist. The clinical records of 26 patients, treated from 2002 to 2013, were reviewed. The most frequent cause of injury was road traffic accident (63%), followed by iatrogenic damage, work injuries, sport or home accidents. All patients underwent pre-operative ophthalmological evaluation, neuro-imaging (angio-CT or angio-MRI scans) and systemic corticosteroid therapy. All patients required a surgical treatment, due to poor response to medical therapy; it consisted of an endonasal endoscopic decompression of the intracanalicular segment of the optic nerve, performed by removing the bony wall of the optical canal and releasing the perineural sheath. Improvement of visual acuity was reached in 65% of cases. No minor or major complication occurred intra- or post-operative, with a maximum follow-up time of 41 months. An improvement in visual acuity was achieved, although very limited in some cases, when surgery was performed as close as possible to the traumatic event. In the literature, there is no evidence-based data evaluating both of the two main treatment options (medical therapy versus surgical decompression), to state which is the gold standard in the treatment for TON. We discuss the pro and cons of our protocol: medical endovenous steroid treatment, within 8 h of injury, and endoscopic surgical decompression within 12-24 since the beginning of medical therapy, represent the best solution in terms of risk-benefit ratio for the patients.

Complex Anterior Skullbase Fracture Caused by a Bottle Cap: A Case Report and Review of the Literature

“…14)15) After clinical diagnosis of TON, high-dose steroid therapy within 8 hours of injury is advocated as an initial treatment because of the neuroprotective mechanism of steroids. 14) In the present case, there was no significant optic canal wall injury or compression on computed tomography scans. However, the usefulness of imaging in TON remains debatable because there is no definite correlation between the severity of visual acuity loss, optic canal fracture, and prognosis for improvement of visual acuity.…”

“…Traumatic optic neuropathy (TON) is a traumatic injury of the optic nerve or secondary neuronal apoptosis of the optic nerve due to trauma. 14) Even though there is no definite injury of the optic canal wall based on preoperative radiologic evaluation, subsequent partial or total visual loss can occur. 14)15) After clinical diagnosis of TON, high-dose steroid therapy within 8 hours of injury is advocated as an initial treatment because of the neuroprotective mechanism of steroids.…”

Endoscopic decompression of the optic canal for traumatic optic neuropathy

“…There is no orbital retraction during the procedure. The endoscopes could provide an optimal visual field 9 . Based on our experience, we believe that endoscopic decompression of the optic canal is a safe and effective therapy for TON.…”

Treatment Outcomes following Traumatic Optic Neuropathy

“…The ideal timing of adult fracture reduction is recommended to occur in a time frame of 5 to 10 days, [35][36][37] but the associated urgency of optic nerve decompression must be planned within 24 hours of injury. 38 Subjecting patients to the stress of multiple operations that could be avoided with simultaneous surgery or deferral of optic nerve decompression may put the various members of the team at odds regarding the sequence of surgical intervention. Our institutional experience 12 has obviated this conflict, as optic nerve decompression has fallen out of favor, and we have shown than an earlier impetus toward facial fracture reduction can minimize unnecessary secondary procedures.…”