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Kumar S, Joshi A, Tuli R, Chauhan N. Traumatic Optic Neuropathy Our Experience with Combined Therapy. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1739479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
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.
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Affiliation(s)
- Sudesh Kumar
- Department of Otolaryngology and Head Neck Surgery, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Amit Joshi
- Department of Neurosurgery, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Rajeev Tuli
- Department of Ophthalmology, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Narvir Chauhan
- Department of Radiodiagnosis, Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
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Abstract
A host of different types of direct and indirect, primary and secondary injuries can affect different portions of the optic nerve(s). Thus, in the setting of penetrating as well as nonpenetrating head or facial trauma, a high index of suspicion should be maintained for the possibility of the presence of traumatic optic neuropathy (TON). TON is a clinical diagnosis, with imaging frequently adding clarification to the full nature/extent of the lesion(s) in question. Each pattern of injury carries its own unique prognosis and theoretical best treatment; however, the optimum management of patients with TON remains unclear. Indeed, further research is desperately needed to better understand TON. Observation, steroids, surgical measures, or a combination of these are current cornerstones of management, but statistically significant evidence supporting any particular approach for TON is absent in the literature. Nevertheless, it is likely that novel management strategies will emerge as more is understood about the converging pathways of various secondary and tertiary mechanisms of cell injury and death at play in TON. In the meantime, given our current deficiencies in knowledge regarding how to best manage TON, "primum non nocere" (first do no harm) is of utmost importance.
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Affiliation(s)
- Neil R Miller
- Department of Ophthalmology, Neurology & Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Abstract
PURPOSE To study the distribution and mechanism of traumatic injuries to the nerves supplying the eye and muscles protecting the visual apparatus. METHODS Brain autopsy was carried out in 12 consecutive patients who died within three days after closed head injury. A segment of the brainstem with the entire intracranial portion of nerves II-VII was dissected out in each case and fixed in formalin. The specimens were stripped of the leptomeninges and inspected thoroughly under magnification. RESULTS Injuries to the nerves were seen in nine subjects. The oculomotor nerve was completely torn off from the midbrain unilaterally in three and bilaterally in two cases. In one patient only a portion of the superficial fibres on the medial aspect of the nerve was ripped out from the brainstem. In two patients the fourth nerve was ruptured. The root of the fifth cranial nerve was contused and the fibres between the brainstem and Gasserian ganglion crushed and separated in one case. Bilateral avulsion of the root of the sixth nerve from the brainstem was found in two cases. The initial segment of the facial nerve was crushed in two subjects. No visible injury to the optic nerves was found. CONCLUSIONS Cranial nerves related to the visual system are subject to serious injury in a large proportion of cases of severe head trauma resulting from automobile accidents. In the majority of cases damage results from ripping the roots of these nerves out of the brainstem.
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Affiliation(s)
- Z Mariak
- Department of Ophthalmology, University Medical School, Bialystok, Poland
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Abstract
SUMMARY Traumatic brain injury (TBI) is a major cause of morbidity and mortality. Concussion, a form of mild TBI, might be associated with long-term neurological symptoms. The effects of TBI and concussion are not restricted to cognition and balance. TBI can also affect multiple aspects of vision; mild TBI frequently leads to disruptions in visual functioning, while moderate or severe TBI often causes structural lesions. In patients with mild TBI, there might be abnormalities in saccades, pursuit, convergence, accommodation, and vestibulo-ocular reflex. Moderate and severe TBI might additionally lead to ocular motor palsies, optic neuropathies, and orbital pathologies. Vision-based testing is vital in the management of all forms of TBI and provides a sensitive approach for sideline or post-injury concussion screening. One sideline test, the King-Devick test, uses rapid number naming and has been tested in multiple athlete cohorts.
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Affiliation(s)
- Rachel E Ventura
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Laura J Balcer
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Steven L Galetta
- Department of Neurology, New York University School of Medicine, New York, NY, USA.
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Ehsaei MR, Heidari M, Karimiani EG, Ehsaei A. Ophthalmic complications among cases of head trauma in north-eastern Iran. Int Ophthalmol 2013; 34:825-9. [PMID: 24346425 DOI: 10.1007/s10792-013-9886-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 11/17/2013] [Indexed: 11/27/2022]
Abstract
The aim of this study was to investigate the prevalence and pattern of ocular complications in patients with head trauma admitted to the main trauma centre in north-eastern Iran. A total of 459 head-injured patients (36.56 ± 19.30 years of age) with at least one ocular manifestation were recruited. Each individual patient was examined by a neurosurgeon and an ophthalmologist to confirm the type of ocular complication. In addition, all patients were analysed for age, gender, and cause of head injury in addition to the ophthalmic and neurosurgical examinations. Of the 459 patients, 142 (31 %) were female and 317 (69 %) were male. The maximum rate of ocular complications was during the third decade of life and minimum during childhood and in the elderly (>71 years) population. The leading cause of head trauma was motor vehicle accidents, predominant in male adults aged 21-40 years. Ocular complications observed were classified into three major groups: soft-tissue injuries to the globe and adnexae (n = 434), orbital complications (n = 45) and neuro-ophthalmic complications (n = 152). In conclusion, our data provides a useful estimation of the rate and pattern of ocular complications among patients with head injuries seen in trauma centres in north-eastern Iran. Understanding the pattern of ocular complications helps us to design more appropriate preventive methods.
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Affiliation(s)
- Mohammad Reza Ehsaei
- Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Traumatic optic neuropathy: an evolving understanding. Am J Ophthalmol 2011; 151:928-933.e2. [PMID: 21529765 DOI: 10.1016/j.ajo.2011.02.007] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 02/03/2011] [Accepted: 02/04/2011] [Indexed: 11/21/2022]
Abstract
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.
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Chou PI, Sadun AA, Chen YC, Su WY, Lin SZ, Lee CC. Clinical experiences in the management of traumatic optic neuropathy. Neuroophthalmology 2009. [DOI: 10.3109/01658109609044636] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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FALBE-HANSEN I, GREGERSEN E. The prognosis for disturbances in ocular motility following trauma to the head: a follow-up examination of an acute neurosurgical patient material. Acta Ophthalmol 2009; 37:359-70. [PMID: 13821377 DOI: 10.1111/j.1755-3768.1959.tb03447.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Li HB, Shi JB, Cheng L, Yun O, Xu G. Salvage optic nerve decompression for traumatic blindness under nasal endoscopy: risk and benefit analysis. Clin Otolaryngol 2008; 32:447-51. [PMID: 18076430 DOI: 10.1111/j.1749-4486.2007.01560.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Transnasal endoscopic optic nerve decompression was recommended to treat traumatic optic neuropathy as an effectively adjunctive procedure. The aim of this study was to assess the risks and benefits of salvage surgical decompression for complete vision loss (no light detection) after failure of mega-dose steroid therapy. DESIGN Retrospective study. SETTING Two hospitals in Guangzhou and Nanjing, China. PARTICIPANTS Forty-two patients of traumatic optic neuropathy with complete vision loss and failed to improve after steroid therapy for at least 3 days. MAIN OUTCOME MEASURES All patients were treated by transnasal endoscopic optic nerve decompression and received follow-up for at least 6 month. Vision improvement and complications were evaluated. RESULTS Transnasal endoscopic optic nerve decompression was performed successfully in 40 patients and was incomplete in two patients due to bleeding. Vision improved in four of 42 patients (9.5%) of traumatic optic neuropathy with complete vision loss and failed steroid therapy. Complications and sequelae included severe bleeding (two cases), cerebrospinal fluid rhinorrhea (one case), nasal polyps (seven cases), chronic sinusitis (four cases) and nasal synechia (17 cases). CONCLUSION Transnasal endoscopic optic nerve decompression was recommended as a minimally invasive, safe procedure, but complications and sequelae of the surgery should not be neglected. Based on the risk and benefit analysis, we conclude that the very poor surgical outcomes of this series do not support endoscopic optic nerve decompression for traumatic blindness.
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Affiliation(s)
- H B Li
- Department of Otolaryngology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Papageorgiou KI, Mathew RG, Ghazi-Nouri SMS, Andreou PS, Sinha AJ. Optochiasmal avulsion secondary to minor occipital trauma. Orbit 2007; 26:71-4. [PMID: 17510878 DOI: 10.1080/01676830600675350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Optic nerve avulsion is an extremely rare occurrence and usually arises in the setting of severe fronto-orbital fractures or penetrating orbital injuries. However, a few cases have been associated with minor injury. OBJECTIVE To overview the pathophysiology of delayed optochiasmal avulsion following minor ocipital trauma and discuss management options. METHODS Report of a unique case of a 79-year-old woman who presented with delayed partial expulsion of the right globe and complete optic nerve avulsion following closed head injury to the occiput. CONCLUSION Antero-posterior distortion of the skull following such a deceleration injury can cause laceration and thrombosis of the pre-chiasmal and pial arteries supplying the optic chiasm. The ensuing ischaemic changes subsequently caused delayed softening of the chiasm and its avulsion. The concomitant retrobulbar haemorrhage and mass effect within the orbit consequently led to the partial expulsion of the globe.
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Affiliation(s)
- K I Papageorgiou
- Ophthalmology Department, Broomfield Hospital, Chelmsford, Essex, UK.
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Yang Y, Wang H, Shao Y, Wei Z, Zhu S, Wang J. Extradural anterior clinoidectomy as an alternative approach for optic nerve decompression: anatomic study and clinical experience. Neurosurgery 2007; 59:ONS253-62; discussion ONS262. [PMID: 17041495 DOI: 10.1227/01.neu.0000236122.28434.13] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We introduce pterional craniotomy extradural anterior clinoidectomy as a new alternative approach for optic nerve decompression in patients with traumatic optic neuropathy. METHODS Intracranial structures pertinent to pterional craniotomy extradural anterior clinoidectomy were carefully studied in 10 dry craniums and 10 cranial bases with dura mater. Important parameters of these structures were measured. Stepwise dissections simulating pterional craniotomy extradural anterior clinoidectomy were performed in 20 cadaver heads bilaterally. Pterional craniotomy extradural anterior clinoidectomy was then applied to 12 patients (13 eyes) with traumatic optic neuropathy and severe visual dysfunction. RESULTS The anatomic features and their variations of optic canal, ophthalmic artery, falciform ligament, and Zinn's ring (annular tendon) were studied and measured in detail. Extensive opening of the optic canal and optic nerve sheath was successfully achieved in all 12 patients without major surgical complications. Significant visual acuity improvement occurred in eight (nine eyes) out of our 12 patients after surgery. The surgical techniques and advantages of pterional craniotomy extradural anterior clinoidectomy for optic nerve decompression are presented and discussed in detail. CONCLUSION Pterional craniotomy extradural anterior clinoidectomy is a promising new alternative approach for optic nerve decompression in patients with traumatic optic neuropathy.
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Affiliation(s)
- Yang Yang
- Department of Neurosurgery, Qilu Hospital, Shandong University, Jinan, China.
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Dhaliwal A, West AL, Trobe JD, Musch DC. Third, fourth, and sixth cranial nerve palsies following closed head injury. J Neuroophthalmol 2006; 26:4-10. [PMID: 16518159 DOI: 10.1097/01.wno.0000204661.48806.1d] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The relationship between the circumstances and severity of closed head injury (CHI) and the clinical and imaging features of cranial nerve 3, 4, and 6 palsies has not been rigorously addressed in a large study. METHODS Retrospective chart review of 210 consecutive patients with CHI examined at a single tertiary care center from 1987 to 2002. Patients were located by searching the ophthalmology inpatient consultation and neuro-ophthalmology outpatient databases and hospital emergency room billing codes for a diagnosis of traumatic 3, 4, or 6 cranial nerve palsy (Cranial Nerve Injury Group) and a diagnosis of CHI without traumatic 3, 4, or 6 nerve palsy (Control Group). The Cranial Nerve Injury Group was then subdivided into two groups: those with injuries to an individual cranial nerve and those with multiple (including bilateral) cranial nerve injuries. Comparisons between groups were based on age, gender, type of accident, Glasgow Coma Scale (GCS), documented loss of consciousness (LOC), type of ocular injury, presence of systemic injury, need for rehabilitation, physical therapy and cognitive scores, and imaging features. RESULTS The Cranial Nerve Injury Group had a significantly higher severity of head injury, more CT abnormalities, and worse short-term neurologic outcomes as compared with the Control Group. These trends were also found when each cranial nerve injury subgroup was compared with the Control Group. Those with cranial nerve 3 palsy had the most severe head injury; those with cranial nerve 4 palsy had an intermediate level of head injury; and those with cranial nerve 6 palsy had the lowest level of head injury. There were no consistent associations between the location of the imaging abnormalities and which cranial nerve was damaged. CONCLUSIONS CHI with palsy of an ocular motor nerve was more severe than CHI without ocular motor nerve palsy, as measured by the GCS, intracranial and skull imaging abnormalities, and a greater frequency of inpatient rehabilitation. Palsy of cranial nerve 3 was associated with relatively more severe CHI than was palsy of cranial nerves 4 or 6. The location of the imaging abnormalities did not correlate with a particular cranial nerve injury.
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Affiliation(s)
- Avninder Dhaliwal
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical Center, Ann Arbor, Michigan 48105, USA
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Affiliation(s)
- N Sarkies
- Addenbrookes Hospital, Hills Road, Cambridge, UK.
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Kreidl KO, Kim DY, Mansour SE. Prevalence of significant intraocular sequelae in blunt orbital trauma. Am J Emerg Med 2003; 21:525-8. [PMID: 14655229 DOI: 10.1016/j.ajem.2003.08.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The purpose of this study was to describe the prevalence of significant intraocular sequelae (SIOS) and its correlation with the severity of blunt orbital trauma. Four hundred ten consecutive patients presenting to the ED who had sustained blunt orbital trauma were studied. The severity of orbital trauma was graded and SIOS was determined by the presence of an intraocular injury as listed in Table 2. The presence of SIOS was noted in 14 (41.2%) mild, 22 (59.5%) moderate, and 20 (29.4%) severe orbital trauma. In the severe group, the presence of SIOS was detected in 8 (23.5%) blowout fractures and in 12 (35.3%) non-blowout fractures. In view of the high rates of ocular complications among mild and moderate orbital injuries, such patients should have prompt ophthalmic follow up. The relatively low prevalence of SIOS in patients with severe orbital trauma could suggest a protective mechanism in this type of injury.
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Affiliation(s)
- Ken O Kreidl
- Department of Ophthalmology, Stanford University School of Medicine, 900 Blake Wilbur Drive, Palo Alto, CA 94304, USA.
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Yip CC, Chng NW, Au Eong KG, Heng WJ, Lim TH, Lim WK. Low-dose intravenous methylprednisolone or conservative treatment in the management of traumatic optic neuropathy. Eur J Ophthalmol 2002; 12:309-14. [PMID: 12220002 DOI: 10.1177/112067210201200410] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare the efficacy of low-dose intravenous methylprednisolone or conservative treatment in the management of traumatic optic neuropathy. METHODS A non-randomized retrospective study of 21 patients (21 eyes) with traumatic optic neuropathy treated between October 95 and November 97 in a tertiary ophthalmology unit. Traumatic optic neuropathy was defined as traumatic visual loss with afferent pupillary defect in the absence of direct injury to the globe or optic nerve. The median follow-up period was one year. Nine patients were treated with 125-250 mg methylprednisolone 6-hourly intravenously for a mean of 3.3 days (range 2-5 days) and 12 patients were treated conservatively. Visual acuity (VA) was measured with a Snellen chart before and after treatment at each follow-up visit. Visual recovery was defined as an improvement of 2 or more Snellen lines one week post-injury or later. RESULTS The patients' mean age was 37.1 years (range 12-65 years). There were more males (90.5%) than females (9.5%). Traumatic optic neuropathy was in 12 right eyes and 9 left eyes. The cause of injury included traffic accidents (52.4%), falls (28.6%), assault (14.2%) and others (4.8%). The mean interval between the injury and steroid therapy was 3.6 days (range 1-11 days). Visual recovery was observed in 44.4% of eyes treated with methylprednisolone and in 33.3% treated conservatively (p = 0.673, Fisher's exact test). CONCLUSIONS Intravenous methylprednisolone at the dosage and duration used in this retrospective study did not significantly improve the visual recovery of eyes with traumatic optic neuropathy compared to conservative treatment. However, this small sample may not be sensitive enough to detect a small difference in visual recovery rates, and further studies with larger samples may be warranted.
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Affiliation(s)
- C C Yip
- The Eye Institute, National Healthcare Group, Tan Tock Seng Hospital, Singapore, Singapore
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Wohlrab TM, Maas S, de Carpentier JP. Surgical decompression in traumatic optic neuropathy. ACTA OPHTHALMOLOGICA SCANDINAVICA 2002; 80:287-93. [PMID: 12059868 DOI: 10.1034/j.1600-0420.2002.800311.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The management of traumatic optic neuropathy remains controversial. This retrospective study presents the results of 19 cases of indirect optic neuropathy where surgical decompression represented the primary mode of treatment. METHODS Nineteen patients (20 optic nerves) with traumatic optic neuropathy underwent primary surgical decompression. The surgery was performed using the transethmoidal technique. RESULTS The extent of bony optic canal injury documented during surgery indicated that this had been underestimated in this series by CT findings. Vision improved in eight patients, five of whom had had no light perception preoperatively. CONCLUSION Primary surgical decompression of the optic nerve within 48 h of injury produces beneficial results. Testing of visual acuity 6 weeks after surgery does not serve as a reliable predictor of final outcome.
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Abstract
BACKGROUND In some cases of closed head injuries after minor blunt trauma, an amaurosis can occur. Our knowledge concerning the pathophysiological mechanisms of traumatic optic neuropathy is limited. The aim of this study is to analyze the morphology of the optic canal in order to understand the effect of mechanical forces in the optic canal and the consecutive injuries. METHODS Forty-one optic canals from body donors were analyzed by light microscopic, polarization microscopic, immunohistochemical and scanning electron microscopic techniques. RESULTS In the optic canal, collagen fibrils of the dural sheath are organized in a scissor-like pattern. Within this collagen network multiple vessels are integrated. The main component of the extracellular matrix is collagen type I. The dural sheath and pial sheath are connected by collagen bundles. Parallel to these bundles, small vessels form anastomoses between the dural and pial vessel systems. In the arachnoidea, no blood vessels can be detected by immunohistochemical techniques. CONCLUSIONS Based on morphological findings, the following pathophysiological mechanisms can be discussed in cases of blunt closed head injury with consecutive amaurosis: 1. Squeezing and rupture of nutritive vessels by transduction of shearing forces via the scissor-like collagen network. 2. Atrophy by pressure of the optic nerve after injury to the microvasculature followed by formation of microhematomas and reactive edema. 3. Direct injury of axons of the optic nerve by shearing forces within the optic canal. These mechanisms should be studied further in the future.
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Affiliation(s)
- Andreas Thale
- Department of Ophthalmology, Christian-Albrechts-University, Kiel, Germany.
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Eidlitz-Markus T, Shuper A. Delayed visual loss after blunt head trauma. Neuroophthalmology 2000. [DOI: 10.1076/0165-8107(200002)2311-dft015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Levin LA, Beck RW, Joseph MP, Seiff S, Kraker R. The treatment of traumatic optic neuropathy: the International Optic Nerve Trauma Study. Ophthalmology 1999; 106:1268-77. [PMID: 10406604 DOI: 10.1016/s0161-6420(99)00707-1] [Citation(s) in RCA: 295] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To compare the visual outcome of traumatic optic neuropathy treated with corticosteroids, treated with optic canal decompression surgery, or observed without treatment. DESIGN Comparative nonrandomized interventional study with concurrent treatment groups. PARTICIPANTS A total of 133 patients with traumatic optic neuropathy (127 unilateral and 6 bilateral) who had an initial visual assessment within 3 days of injury. At least 1 month of follow-up was required for inclusion in the primary analysis. INTERVENTIONS On the basis of treatment received within 7 days of injury, patients with unilateral injuries were categorized as being in one of three treatment groups: untreated (n = 9), corticosteroid (n = 85), or optic canal decompression surgery (n = 33). MAIN OUTCOME MEASURE Visual acuity. RESULTS Visual acuity increased by > or = 3 lines in 32% of the surgery group, 57% of the untreated group, and 52% of the steroid group (P = 0.22). The surgery group had more patients whose initial vision was no light perception. After adjustment for the baseline visual acuity, there were no significant differences between any of the treatment groups. There was no indication that the dosage or timing of corticosteroid treatment or the timing of surgery was associated with an increased probability of visual improvement. CONCLUSIONS No clear benefit was found for either corticosteroid therapy or optic canal decompression surgery. The number of patients studied was sufficient to rule out major effects in the treatment groups, although clinically relevant effects in specific subgroups could have been missed. These results and the existing literature provide sufficient evidence to conclude that neither corticosteroids nor optic canal surgery should be considered the standard of care for patients with traumatic optic neuropathy. It is therefore clinically reasonable to decide to treat or not treat on an individual patient basis.
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Affiliation(s)
- L A Levin
- Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, Madison, USA
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Abstract
Knowledge concerning the pathophysiologic mechanisms of traumatic optic neuropathy is limited. The optic nerve is a tract of the brain. Therefore, the cellular and biochemical pathophysiology of brain and spinal cord trauma and ischemia provide insight into mechanisms that may operate in traumatic optic neuropathy. The dosage of methylprednisolone (30 mg/kg/6 hours) which was successful in the National Acute Spinal Cord Injury Study 2 (NASCIS 2) evolved from the unique pharmacology of corticosteroids as antioxidants. The management of traumatic optic neuropathy rests on an accurate diagnosis which begins with a comprehensive clinical assessment and appropriate neuroimaging. The results of medical and surgical strategies for treating this injury have not been demonstrated to be better than those achieved without treatment. The spinal cord is a mixed grey and white matter tract of the brain in contrast to the optic nerve which is a pure white matter tract. The treatment success seen with methylprednisolone in the NASCIS 2 study may not generalize to the treatment of traumatic optic neuropathy. Conversely, if the treatment does generalize to the optic nerve, NASCIS 2 data suggests that treatment must be started within eight hours of injury, making traumatic optic neuropathy one of the true ophthalmic emergencies. Given the uncertainties in the treatment, ophthalmologists involved in the management of traumatic optic neuropathy are encouraged to participate in the collaborative study of traumatic optic neuropathy.
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Affiliation(s)
- K D Steinsapir
- Orbital and Ophthalmic Plastic Surgery Division, Jules Stein Eye Institute, UCLA School of Medicine
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Abstract
Ten patients with traumatic disruption of the optic chiasm are presented. The clinical sequence of fronto-facial trauma and CSF rhinorrhoea, followed days later by diabetes insipidus and discovery of a bi-temporal visual field loss constitute a characteristic syndrome which should be recognized by the attending medical staff. Magnetic resonance imaging, not previously reported, and post-mortem evidence point to a physical disruption of the chiasm and infundibulum as the cause of the visual and hypothalamic signs. The resulting field defect is permanent but the diabetes insipidus is transient in 50% of patients and can be adequately managed with manipulation of the patient's fluid intake.
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Affiliation(s)
- Z Domingo
- Department of Neurosurgery, Groote Schuur Hospital, University of Cape Town, South Africa
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Seiff SR. High Dose Corticosteroids for Treatment of Vision Loss Due to Indirect Injury to the Optic Nerve. Ophthalmic Surg Lasers Imaging Retina 1990. [DOI: 10.3928/1542-8877-19900601-04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Walls RD, Helmy ES, Timmis DP. Carotid-cavernous sinus fistula accompanying an isolated mandibular fracture. J Oral Maxillofac Surg 1989; 47:1215-21. [PMID: 2681613 DOI: 10.1016/0278-2391(89)90018-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A patient who developed carotid-cavernous sinus fistula associated with an isolated mandibular fracture is reported, and the etiology, diagnosis, and treatment of this condition and the associated abducens nerve palasy are discussed.
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Affiliation(s)
- R D Walls
- Department of Oral and Maxillofacial Surgery, Emory University School of Post Graduate Dentistry, Atlanta, Georgia 30322
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Nagaseki Y, Shimizu T, Kakizawa T, Fukamachi A, Nukui H. Primary internal ophthalmoplegia due to head injury. Acta Neurochir (Wien) 1989; 97:117-22. [PMID: 2718803 DOI: 10.1007/bf01772821] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Six cases of internal ophthalmoplegia due to direct head injury are presented. All six patients had a dilated, nonreactive pupil. Four had no extraocular palsies or ptosis and two had partial extraocular palsies or ptosis. Disturbance of consciousness was absent or very mild, and all patients fully recovered within 1 to 7 days after the traumatic event. No patient had a history that suggested a cause for oculomotor nerve palsy, and emergency CTscans showed no mass lesions. The internal ophthalmoplegia was recognized immediately after trauma. Although minimal oculomotor nerve palsies due to unruptured intracranial aneurysms have been described, none of our patients complained of periorbital or retroorbital pain either before or after the trauma, which rules out intracranial aneurysms as the cause of the internal ophthalmoplegia. Therefore, we concluded that the internal ophthalmoplegia was due to direct head injury. The pathophysiological mechanism of the internal ophthalmoplegia appeared to be slight injury of the pupillomotor fibres on the ventromedial surface of the third nerve at the posterior petroclinoid ligament, which acted as the fulcrum due to the downward displacement of the brainstem at the time of impact.
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Affiliation(s)
- Y Nagaseki
- Department of Neurosurgery, Yamanashi Medical College, Japan
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Asari S, Yamamoto Y, Satoh T. Direct CT demonstration suggesting oculomotor nerve avulsion following minor head trauma: case report. COMPUTERIZED RADIOLOGY : OFFICIAL JOURNAL OF THE COMPUTERIZED TOMOGRAPHY SOCIETY 1987; 11:131-4. [PMID: 3608458 DOI: 10.1016/0730-4862(87)90037-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The interesting case of the left oculomotor nerve paralysis with right hemiparesis following minor head trauma was reported in this paper. Computerized tomography showed clearly the intracranial lesions suggesting the oculomotor nerve avulsion.
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Brooks AM, Cairns JD. Contusion injuries of the optic nerve. AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY 1986; 14:269-73. [PMID: 3768183 DOI: 10.1111/j.1442-9071.1986.tb00048.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Indirect trauma to the optic nerve with secondary optic atrophy may result from minor trauma and has traditionally been associated with a poor visual prognosis. The case of a 32-year-old man who suffered a blow to his left supraorbital region and eyebrow in an automatic closing door is reported to draw attention to the uncommon but trivial nature of this injury which may result in profound visual loss. He suffered an initial inferonasal visual field loss which was related to vascular changes in the optic nerve head. Over the ensuing year there was deterioration in his central vision and visual field due to arachnoiditis. Current trends in the management of optic nerve contusion injuries are discussed. There is currently a move towards primary medical management with high-dose corticosteroids as in this case; surgery is reserved for those patients who fail to respond to steroids or deteriorate as the steroid dose is reduced.
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Babajews A, Williams JL. Blindness after trauma insufficient to cause bony injury: case report and review. Br J Oral Maxillofac Surg 1986; 24:7-11. [PMID: 2936389 DOI: 10.1016/0266-4356(86)90032-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Over the years, blindness following maxillofacial trauma has been reported by many workers. Although various mechanisms and suggested treatments have been proposed, blindness in the absence of any bony or direct penetrating injury is rare.
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Abstract
Two cases of blindness following fracture of a zygomatic bone, with disruption of the optic canal are reported. The importance of excluding optic canal disruption where blindness results subsequent to fracture or surgery to the orbit in the presence of certain features of retrobulbar haemorrhage is emphasised.
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Guyer DR, Miller NR, Long DM, Allen GS. Visual function following optic canal decompression via craniotomy. J Neurosurg 1985; 62:631-8. [PMID: 3989585 DOI: 10.3171/jns.1985.62.5.0631] [Citation(s) in RCA: 34] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Visual function was assessed in 15 eyes of 11 patients who underwent unilateral (seven patients) or bilateral (four patients) optic canal decompression for presumed compressive optic neuropathies. Both immediate and long-term postoperative vision was evaluated in all eyes. Over 90% of the eyes that had undergone nerve decompression had either the same or improved visual acuity and visual field immediately following surgery. In this group of patients there were no deaths and there was only one postoperative complication, a transient dysphasia caused by an epidural hematoma that was evacuated. Long-term follow-up evaluations revealed that most of the eyes retained their immediate postoperative visual function or showed gradual visual improvement with time. The results of this series as well as a review of the available literature indicate that optic canal decompression via craniotomy can be a safe procedure and that it appears to have lasting visual benefit in many patients.
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Abstract
Injuries to the nasal frontal complex involve a moderately high degree of optic nerve trauma. This paper reviews opinions from notable experts in the field of maxillofacial trauma on appropriate management for acute facial fractures involving injury to the optic nerve and causing blindness in one eye. The opinions are mixed, but the overall attitude is one of conservatism. It is concluded that the weight of opinion supports a conservative approach consisting of external fixation without mobilization of the fractures, and a delayed cosmetic repair.
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Dutton JJ, Tse DT, Anderson RL. Compressive Optic Neuropathy Following Use of Intracranial Oxidized Cellulose Hemostat. Ophthalmic Surg Lasers Imaging Retina 1983. [DOI: 10.3928/1542-8877-19830601-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Blindness following facial trauma may occur with what appears to be a minor insult to the periorbital area. This report deals with our experience in treating five patients who had sudden blindness following frontal head trauma. Unselected optic nerve decompression was in general unrewarding in reversing blindness. However, the early administration of pharmacologic doses of corticosteroids does appear effective in reversing blindness in this select patient population and may indicate which patient is a good candidate for decompression. Examination of holographic experiments performed on dried skulls, in addition to clinical findings, appears to suggest that the cause of blindness associated with frontal head trauma may be related to stretching of the optic nerve and not necessarily to compression.
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Abstract
We evaluated the clinical records of 16 patients with blepharoptosis secondary to direct traumatic third-nerve palsies. Most patients were involved in auto accidents, and had associated skull fractures. Of 12 patients who were followed up for at least one year, ten recovered completely. Over half of the patients had evidence of aberrant regeneration, which could be seen clinically as early as nine weeks after the trauma. Orbital localization of the third-nerve dysfunction carries an excellent prognosis for prompt, spontaneous recovery without aberrant regeneration. Surgical intervention in these cases should be delayed at least one year after the traumatic event, and longer if continued slow but progressive recovery is demonstrated.
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Abstract
A case of unilateral blindness following blunt injury to the skull is presented. The patient died 4 days after the initial injury, presenting the rare opportunity of a detailed histopathological study of the acute features of the condition. The findings are discussed in the context of current theories of the pathogenesis of optic nerve injury in fractures of the optic canal.
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Abstract
In most cases of isolated oculomotor nerve palsy in 30 patients under age 20 years the palsy was congenital, and aberrant regeneration was present. The most common causes of acquired oculomotor nerve palsy were blunt trauma and infectious processes, both local and systemic. Neoplasms, aneurysms, and ophthalmoplegic migraine caused the other cases. The causes of isolated oculomotor nerve palsy in childhood differ from those in adults both in nature and in frequency of occurrence.
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Abstract
We examined 21 patients with closed-head trauma and resulting paralysis of the lateral rectus muscle. Clinical findings included laterally directed gaze palsy, some unconsciousness, and pseudo-duane's phenomenon suggesting a supranuclear lesion at the level of the upper pontine tegmentum, and pontine paramedial reticular formation. The surgical procedure of choice was a "midline operation," that is, the appropriate number of millimeters of recession and resection to achieve 0 to 5 degrees of exotropia in the primary position of gaze. Frequently, the medial rectus muscle must be recessed 10 nm or more and the lateral rectus muscle resected 10 nm or more to achieve this result. None of the 21 patients had diplopia after the midline procedure.
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Abstract
✓ Twelve cases with direct injury of the oculomotor nerve are presented. The clinical symptoms resemble those of an oculomotor nerve lesion associated with an expanding supratentorial mass lesion with uncal herniation. The clinical signs and mechanism of injury are discussed. The importance of early differentiation of the third nerve injury due to direct trauma from that of an expanding supratentorial mass lesion is emphasized, since conservative treatment of cases due to direct injury is preferable to operation.
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