Optic nerve decompression in the comatose and conscious patients after trauma

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.

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.

Post-traumatic optic neuropathy: our surgical and medical protocol

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.

Traumatic optic neuropathy after maxillofacial trauma: a review of 8 cases

PURPOSE

To study the incidence and prognostic factors of traumatic optic neuropathy in maxillofacial trauma cases.

MATERIAL AND METHOD

Eight patients diagnosed with traumatic optic neuropathy among 354 cases of maxillofacial trauma treated from December 2008 through May 2011 were included in this retrospective study. Factors at the time of trauma, clinical findings, computed tomographic findings, and interventional modalities were studied for any improvement in vision.

RESULTS

Of 354 maxillofacial trauma cases, 8 cases (2.25%) were diagnosed with traumatic optic neuropathy. Patients' ages ranged from 21 to 60 years. The causes of trauma were road traffic accidents in 7 patients and surgery for zygomaticomaxillary complex (ZMC) fractures in 1 patient. All patients had ZMC fracture; 1 patient had Le Fort II, mandible condyle, and ramus fractures and 2 had associated cranial bone fracture. Six patients were administered steroid therapy; 1 patient showed improvement in visual acuity. Two patients underwent decompression by a lateral orbital approach; 1 patient showed an improvement in visual acuity. In 2 other patients, a spontaneous recovery was observed. Four of the 8 patients underwent open reduction and fixation of the maxillofacial fractures. Of the remaining patients, 1 patient had a nondisplaced ZMC fracture that was treated without surgical intervention and the other 3 patients refused any surgical intervention.

CONCLUSIONS

The present findings showed the occurrence of traumatic optic neuropathy in association with ZMC, Le Fort II, and cranial bone fractures. Additional risk factors such as a history of a loss of consciousness, injury to the superolateral orbital region, fracture of the optic canal, evidence of orbital hemorrhage, and evidence of blood within the posterior ethmoidal cells should be considered during the evaluation.

Traumatic optic neuropathy: an evolving understanding

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.

Study on the treatment of traumatic orbital apex syndrome by nasal endoscopic surgery

Orbital apex syndrome (OAS) is a complex disease caused by a variety of pathological factors, and trauma is one of the main factors/causes. Clinical data of 17 cases of traumatic OAS treated by nasal endoscopic surgery in our department from January 2002 to April 2009 were gathered and reviewed. Among them, the six patients presented with OAS after injury to the lateral wall of orbital apex. Seven other patients exhibited OAS after injury to the medial wall of orbital apex, two displayed OAS after zygomatic trauma, while OAS manifested in the other two patients with craniocerebral trauma 3 days after they had decompressive craniotomy--of them, one was blind in both eyes. In the 17 cases, 6 patients were without light sensation, 1 was blind in both eyes; the sight-chart index of eight patients was 0.1, that of three other patients was 0.1-0.2. Fifteen patients displayed eyeball movement disturbance (disorder) and cornea sensory disturbance (disorder), two were with the eyeball abducent disturbance. After the nasal endoscopic surgeries for OAS performed on the 17, the sight of the most patients was restored in varying degrees. The sight of nine patients was between 0.2 and 0.3, that of two patients was between 0.1 and 0.2, that of the other two patients was 0.1, and that of four patients remained unchanged. The eyeball movement and the cornea esthesia in 15 patients recovered from the surgeries, one patient recovered with good eyeball adducent movement and the cornea esthesia but with eyeball abducent disturbance, the other patient did not make a recovery from the eyeball immobility, cornea anesthesia and ptosis. A follow-up lasting 2 months to 2 years suggested that the 16 patients had stable recovery from the surgeries. Satisfactory results could be achieved in the treatment of traumatic OAS by nasal endoscopic surgery. From objective assessment of the therapeutic effects of traumatic OAS, it can be concluded that if a patient is diagnosed with fractures of the optic canal and the superior and medial walls of orbital apex, nasal endoscopic decompression of superior and medial walls of orbital apex and optic canal via the approach to the sphenoid and ethmoid sinuses is the most ideal operative therapy.

The early effect of nerve growth factor in the management of serious optic nerve contusion

OBJECTIVE

the aim was to investigate the early effect of nerve growth factor in the management of serious optic nerve contusion (ONC).

METHODS

nine patients with unilateral serious optic nerve contusion (seven males and two females) were enrolled in this study. Corticosteroid, energy mixture, red sage root, vitamins B1 and B12 were used for all patients within three weeks after trauma. Five of the nine patients were injected intramuscularly with 30 microg/time of nerve growth factor solution (once a day for a total of 14 days). Each patient was subjected to pattern visual evoked potential (VEP) examination and visual field test before and 14 days after treatment.

RESULTS

the visual acuity, latency of P100 in VEP and mean deviation in Humphrey Field Analyzer of all patients were improved after 14 days. The subtraction of latency of P100 in VEP between pre- and post-treatment showed a significant difference between the nerve growth factor treatment patients and the control patients (p = 0.015).

CONCLUSION

the application of NGF within three weeks after trauma could promote the recovery of visual function in the patients with serious optic nerve contusion.

High-dose intravenous methylprednisolone in recent traumatic optic neuropathy; a randomized double-masked placebo-controlled clinical trial

BACKGROUND

To compare the effect of high-dose intravenous corticosteroid therapy with placebo in the treatment of recent traumatic optic neuropathy (TON).

METHODS

In a double-masked placebo-controlled clinical trial, 31 eyes of 31 patients were randomly assigned to two groups. Patients with history of trauma < or =7 days were included. Unconscious patients, eyes with penetrating trauma and candidates for decompression surgery were excluded. The treatment group (16 eyes) received 250 mg methylprednisolone intravenously every 6 h for 3 days, then 1 mg/kg prednisolone orally for 14 days; the placebo group (15 eyes) received 50 ml normal saline intravenously every 6 h for 3 days, then placebo for 14 days. Visual improvement was considered as a decrease of at least 0.4 logMAR in final visual acuity.

RESULTS

Mean final BCVA (best corrected visual acuity) in the treatment group was 1.11+/- 1.14 and the placebo group was 1.78 +/- 1.23. This difference was not significant (P = 0.13). Visual acuity was improved in 68.8% of the treatment group and 53.3% of the placebo group, but the difference was not statistically significant (P = 0.38). The difference between initial and final BCVA in both groups was determined to be statistically significant (P < 0.001 and 0.010 respectively).

CONCLUSIONS

Our study confirms earlier findings that there is no difference in visual acuity improvement between intravenous high-dose corticosteroids and placebo in treatment of recent TNO.

[Single and temporally displaced second nerve lesions in an animal model and their clinical significance]

BACKGROUND

Surgical optic decompression after trauma has been discussed controversially. The surgical trauma is supposed to produce an additional nerve lesion with the danger of complete loss of vision. Alternatively, conservative high dose cortisone therapy has been recommended.

METHODS

The functional and morphological consequences of a lesion after calibrated optic compression in one or two sessions were examined in an animal model using 29 Wistar rats.

RESULTS

Depending on the duration and intensity of the lesion, we observed a linear decline in the number of neurons in the RGC (retinal ganglion cell) layer as well as an increasing reactivity to GFAP (glial fibrillary acidic protein) as an indication of central gliosis of astrocytes; however, this was independent on whether optic compression was performed in one or two sessions.

CONCLUSIONS

To reduce secondary damage to the visual nerve and the central visual system that might increase with a persisting lesion, the indication for surgical relief of an eye affected by afference should be considered liberally, especially in view of the low morbidity of rhinosurgical intervention.

Blindness after Blunt Facial Trauma: Are There Any Clinical Clues to Early Recognition?

BACKGROUND

Vision-threatening injury is a relatively rare but devastating complication of maxillofacial trauma. Identification is not always straightforward. The purpose of this study was to look at our experience of blindness after blunt facial injuries to see whether any useful patterns or risk factors were identified to assist in early recognition.

METHODS

This was a retrospective, qualitative study undertaken at the University Hospital of North Staffordshire. All case notes, plain radiographs, and computed tomographic scans were reviewed and the relevant data collated.

RESULTS

Over a 10-year period, 17 patients were identified in which loss of vision occurred secondary to blunt injury to the face.

CONCLUSION

It is important to maintain a high index of suspicion when dealing with maxillofacial trauma, particularly if the patient is not cooperative. We provide a list of salient features to look for in the examination and history to aid the clinician.

Traumatic optic neuropathy in children and adolescents

PURPOSE

Retrospective review to describe the features and visual outcome of traumatic optic neuropathy (TON) in children and adolescents.

METHODS

Interventional and observational case series of children <18 years with TON.

RESULTS

Forty children, 24 boys and 16 girls, were identified with 43 affected eyes. The mean age was 11.6 years (range, 2 to 18). The most common causes were motor vehicle accidents (62%) and sports injuries (22%). The trauma was blunt in 78% of cases and penetrating in 22%. Visual acuity at presentation for 27 patients whose visual acuity could be assessed ranged from no light perception to 20/80. Interventions included corticosteroids (n = 18), decompression of the optic canal (n = 3), and optic sheath nerve fenestration (n = 1). Visual outcome for 22 children with at least 1 month of follow-up was no light perception in 10 (45%), < 20/200 in 7(32%), 20/200 to < 20/80 in 1(4%), and > or = 20/80 in 4 (18%). There was no difference in the rate or degree of improvement between treated and untreated patients.

CONCLUSION

TON in children is caused by mechanisms similar to those that cause TON in adults. The severity of visual loss as well as the rate and degree of improvement are also similar. Our data do not indicate that treatment improves visual outcome.