Outcome of Endoscopic Optic Nerve Decompression for Traumatic Optic Neuropathy

Endoscopically-assisted extraction of broken roots or fragments within the mandibular canal: a retrospective case series study

PURPOSE

To assess the impact of endoscope-assisted fractured roots or fragments extraction within the mandibular canal, along with quantitative sensory testing (QST) alterations in the inferior alveolar nerve (IAN).

METHODS

Six patients with lower lip numbness following mandibular third molar extraction were selected. All patients had broken roots or fragments within the mandibular canal that were extracted under real-time endoscopic assistance. Follow-up assessments were conducted on postoperative days 1, 7, and 35, including a standardized QST of the lower lip skin.

RESULTS

The average surgical duration was 32.5 min, with the IAN exposed in all cases. Two of the patient exhibited complete recovery of lower lip numbness, three experienced symptom improvement, and one patient remained unaffected 35 days after the surgery. Preoperative QST results showed that the mechanical detection and pain thresholds on the affected side were significantly higher than those on the healthy side, but improved significantly by postoperative day 7 in five patients, and returned to baseline in two patients on day 35. There were no significant differences in the remaining QST parameters.

CONCLUSIONS

All endoscopic surgical procedures were successfully completed without any additional postoperative complications. There were no cases of deterioration of IAN injury, and lower lip numbness recovered in the majority of cases. Endoscopy allowed direct visualization and examination of the affected nerve, facilitating a comprehensive analysis of the IAN.

Surgical Outcome in Patients with Traumatic and Atraumatic Optic Neuropathy Following Endoscopic Optic Nerve Decompression

Endoscopic optic nerve decompression is a highly effective and reliable approach for patients with select cases of optic neuropathy. It reduces the hydrostatic pressure and helps in relieving the compressive forces within the intracanalicular portion of the optic nerve consequently preserving and arresting the deterioration of vision. The advantages of the endoscopic approach over other procedures include preservation of olfaction, quick recovery, lack of external scars and less morbidity. The objective of the study is to assess the surgical outcome of endoscopic optic nerve decompression in patients with traumatic and atraumatic optic neuropathy. The case records of consequent patients attending ENT department with defective vision due to traumatic and atraumatic causes were reviewed. The outcome was measured in terms of improvement in visual acuity by log MAR scale. Among the 14 patients studied, 57% were females and the median age of presentation was 33 years. As compared to preoperative baseline visual acuity, the overall improvement was achieved in 11 patients, with an effective rate of 78.5% postoperatively. Patients presenting with no light perception and residual vision had significant improvement in visual acuity after surgery. Trans-nasal endoscopic surgery helps in decompressing the optic nerve with proper exposure of the orbital apex and optic canal without any intracranial or intra-orbital complications. Further, being a minimally invasive procedure has great advantage in cases of optic neuropathy.

Effects of light perception on visual function recovery in patients with traumatic optic neuropathy

This study aimed to assess the impact of light perception presence or absence on visual function recovery in patients with traumatic optic neuropathy (TON). A retrospective analysis was conducted on the clinical data of 206 TON patients. Based on the presence or absence of light perception after injury, patients were categorized into a light perception group and a non-light perception group. A comparison was made between the two groups regarding visual acuity recovery before and after treatment. The non-light perception group comprised 63 patients, with a treatment effectiveness rate of 39.68%. The light perception group consisted of 143 patients, with a treatment effectiveness rate of 74.83%. The difference between the two groups was statistically significant (χ2 = 23.464, P < 0.01). Subgroup analysis indicated that surgical treatment appeared to be more effective than steroid hormone therapy for patients with light perception. Conversely, for patients without light perception, there was no significant difference in the effectiveness of the two methods. The total effectiveness rate of the light perception group was significantly higher than that of the non-light perception group, suggesting that patients with light perception before treatment experience better outcomes compared to those without light perception. Treatment choices should be individualized to ensure optimal results.

Anatomical Study and Clinical Application of Optic Canal Decompression Via Transethmoid-sphenoid Approach Under Endoscope

This study aimed to evaluate the safety and accuracy of the endoscopic transethmoid-sphenoid approach for optic canal decompression. Twelve sides of 6 adult cadaveric heads fixed in formalin were selected to simulate optic canal decompression using the endoscopic transethmoid-sphenoid approach. Furthermore, this approach was used for optic canal decompression in 10 patients (11 eyes) with optic nerve canal injury. Related anatomical structures were observed using a 0-degree endoscope, and the anatomical characteristics as well as the surgical data were collected. The maximum effective widths of the cranial opening, orbital opening, and middle segment of the canal that could be drilled open endoscopically were 7.82±2.63, 8.05±2.77, and 6.92±2.01 mm, respectively. The angle between the line linking the center point of the tubercular recess with the midpoint of the cranial opening of the optic canal and the horizontal coordinate was 17.23±1.34 degrees. At the orbital opening of the optic canal, the ophthalmic artery was located directly inferior to the optic nerve in 2 cases (16.7%) and laterally inferior to the optic nerve in 10 cases (83.3%). Six of the operational eyes were effective while the remaining 5 were ineffective. No postoperative complications such as bleeding, infection, or cerebrospinal fluid leakage were observed during the follow-up period (6-12 mo). In conclusion, optic canal decompression positively impacts the prognosis of partial traumatic optic neuropathy. Furthermore, the endoscopic transethmoid-sphenoid approach for optic canal decompression is a minimally invasive procedure that provides direct access and adequate decompression. This technique is easy to master and suitable for clinical applications.

Traumatic Optic Neuropathy: Update on Management

Traumatic optic neuropathy is one of the causes of visual loss caused by blunt or penetrating head trauma and is classified as both direct and indirect. Clinical history and examination findings usually allow for the diagnosis of traumatic optic neuropathy. There is still controversy surrounding the management of traumatic optic neuropathy; some physicians advocate observation alone, while others recommend steroid therapy, surgery, or both. In this entry, we tried to highlight traumatic optic neuropathy's main pathophysiologic mechanisms with the most available updated treatment. Recent research suggests future therapies that may be helpful in traumatic optic neuropathy cases.

Endoscopic endonasal surgical anatomy of the optic canal: key anatomical relationships between the optic nerve and ophthalmic artery

PURPOSE

A detailed understanding of the neurovascular relationships between the optic nerve (ON) and the ophthalmic artery (OA) in the optic canal (OC) is paramount for safe surgery. We focused on the neurovascular anatomy of this area from both an endoscopic endonasal and transcranial trajectories to compare the surgical exposures and perspectives offered by these different views and provide recommendations to increase the intraoperative safety.

METHODS

Twenty sides of ten formalin-fixed, latex-injected head specimens were utilized. The surgical anatomy and anatomical relationships of the OA in relationship to the ON along their intracranial and intracanalicular segments was studied from endoscopic endonasal and transcranial perspectives.

RESULTS

Three types of OA-ON relationships at the origin of the OA were identified: inferomedial (type 1, 35%), inferior (type 2, 55%), and inferolateral (type 3, 10%). The endoscopic endonasal trajectory offers an inferomedial perspective of the ON-OA neurovascular complex, in which the OA, especially when located inferomedially, is first encountered. When comparing with the transcranial view, all OA were covered by the nerve, type 1 was located below the medial third, type 2 below the middle third, and type 3 below the lateral third of the OC. The mean extension of the intracanalicular portion of both OA and ON was 8.9 mm, while the intracranial portion of the OA and ON were 9.3 mm and 12.4 mm, respectively. The OA, endoscopically, is located within the inferior half of the OC, and occupies 39%, 43%, and 42% of the OC height at its origin, mid, and end points, respectively. The mean distance between the superior margin of the OC at its origin and superior margin of the OA is 1.4 mm.

CONCLUSIONS

Detailed anatomical understanding of the OC, and the ON and OA at their intracranial and intracanalicular segments is paramount to safe surgery. When opening the OC dura endoscopically, our results suggest that a medial incision along the superior third of the OC with a proximal to distal direction is recommended to avoid injury of the OA.

Endoscopic endonasal optic nerve decompression: treatment of fibrous dysplasia in a pediatric population

OBJECTIVE

Patients with fibrous dysplasia (FD) of the anterior skull base can experience progressive visual loss and impairment. The authors reviewed their experience with endonasal decompression of the optic nerve (ON) in this patient population. Endoscopic ON decompression (EOND) is a feasible surgical approach for children with FD and visual deficit due to structural ON compression.

METHODS

Electronic medical records of children between 1 and 17 years of age with unilateral FD of the anterior skull base and concomitant ON compression, who required EOND between 2017 and 2022 (n = 4), were reviewed for demographic data, both pre- and postoperative imaging, and evaluations by an otolaryngologist, neurosurgeon, and ophthalmologist in a multidisciplinary fashion.

RESULTS

EOND was found to be a safe and effective surgery for children with FD. Visual acuity was stable in 80% of the eyes postoperatively. Visual fields improved in 40% of the eyes and remained stable in the rest.

CONCLUSIONS

EOND is beneficial for progressive optic neuropathy that is unresponsive to steroid therapy and can prevent permanent disability if performed prior to irreversible damage to the nerve. EOND can decompress the edematous ON with proper exposure of the optic canal and orbital apex, without any major complications.

Vision improvement in indirect traumatic optic neuropathy treated by endoscopic transnasal optic canal decompression

BACKGROUND

Indirect Traumatic optic neuropathy (ITON) is a severe disease characterized by a sudden decline of visual function after craniofacial injury. However, the best treatment for ITON is unknown. Endoscopic transnasal optic canal decompression (ETOCD) has gradually been used for ITON treatment worldwide in recent years.

OBJECTIVE

To assess the effect of ETOCD on visual acuity in patients with ITON and identify factors that affect prognosis.

METHODS

In this study, clinical characteristics of 44 ITON patients who underwent ETOCD in Qilu Hospital of Shandong University were retrospectively analyzed. Factors affecting prognosis were also evaluated.

RESULTS

ETOCD treatment improved the vision of 20 (45.5%) patients with no patient suffering from vision deterioration. The mean value of visual acuity (VA) scores improved from 1.57 to 2.39 (P < 0.001). Patients with residual vision had a better VA improvement percent than those without light perception (66.67% versus 34.48%, χ² = 4.13, P = 0.042). Although shorter duration before ETOCD was associated with better improvement score in ITON patients (r = -0.30, P = 0.044), optic canal fracture (OCF) and optic nerve sheath incision did not affect the prognosis of these patients. Five ITON patients with cerebrospinal fluid rhinorrhea were treated with free nasal mucosal flap during the surgery, and no other severe surgical complication occurred.

CONCLUSIONS

ETOCD can effectively and safely improve the vision of ITON patients, patients with residual vision and those treated earlier may benefit more from this surgery.

No Light Perception Vision in Neuro-Ophthalmology Practice

BACKGROUND

To determine differential diagnosis and visual outcomes of patients with no light perception (NLP) vision related to neuro-ophthalmic conditions.

METHODS

Retrospective case series of patients seen at tertiary neuro-ophthalmology practices. Patients were included if they had NLP vision any time during their clinical course. Outcome measures were final diagnosis, treatment, and visual outcome.

RESULTS

Seventy-two eyes of 65 patients were included. The average age was 57.6 (range 18-93) years, and 58% were women. The Most common diagnosis (21 patients) was compressive optic neuropathy (CON) with meningioma being the most common culprit (12). Other diagnoses included optic neuritis (ON) (11 patients), infiltrative optic neuropathies (8), posterior ischemic optic neuropathy (7), nonarteritic anterior ischemic optic neuropathy (4), arteritic anterior ischemic optic neuropathy (3), ophthalmic artery occlusion (3), nonorganic vision loss (3), radiation-induced optic neuropathy (2), cortical vision loss (1), retinitis pigmentosa with optic disc drusen (1), and infectious optic neuropathy (1). Ten patients recovered vision: 7 ON, 2 infiltrative optic neuropathy, and 1 CON. Corticosteroids accelerated vision recovery in 7 of the 11 patients with ON to mean 20/60 (0.48 logMAR) over 9.0 ± 8.6 follow-up months. Eleven patients deteriorated to NLP after presenting with at least LP; their diagnoses included CON (3), ophthalmic artery occlusion (2), infiltration (2), ON (1), posterior ischemic optic neuropathy (1), arteritic anterior ischemic optic neuropathy (1), and radiation-induced optic neuropathy (1).

CONCLUSIONS

NLP vision may occur because of various diagnoses. Vision recovery was mainly seen in patients with ON. Serious systemic conditions may present or relapse with NLP vision, which clinicians should consider as an alarming sign in patients with known malignancies.

Traumatic optic neuropathy: a review of current studies

Traumatic optic neuropathy (TON) is a serious complication of craniofacial trauma that directly or indirectly damages the optic nerve and can cause severe vision loss. The incidence of TON has been gradually increasing in recent years. Research on the protection and regeneration of the optic nerve after the onset of TON is still at the level of laboratory studies and which is insufficient to support clinical treatment of TON. And, due to without clear guidelines, there is much ambiguity regarding its diagnosis and management. Clinical interventions for TON include observation only, treatment with corticosteroids alone, or optic canal (OC) decompression (with or without steroids). There is controversy in clinical practice concerning which treatment is the best. A review of available studies shows that the visual acuity of patients with TON can be significantly improved after OC decompression surgery (especially endoscopic transnasal/transseptal optic canal decompression (ETOCD)) with or without the use of corticosteroids. And new findings of laboratory studies such as mitochondrial therapy, lipid change studies, and other studies in favor of TON therapy have also been identified. In this review, we discuss the evolving perspective of surgical treatment and experimental study.