Navigation-guided transcaruncular orbital optic canal decompression in indirect traumatic optic neuropathy: long-term outcomes

PURPOSE

To determine the surgical outcomes using navigation-guided transcaruncular orbital optic canal decompression (NGTcOCD) and investigate the relationship between visual prognosis. visual evoked potential (VEP), association with DeLano type of optic canal and Onodi cells in patients with indirect traumatic optic neuropathy (TON).

DESIGN

Prospective observational.

METHODS

Fifty-two consecutive patients with indirect TON unresponsive to steroid therapy were divided into three groups where Group I comprised of cases with optic canal fracture who underwent NGTcOCD, Group II without optic canal fracture who underwent NGTcOCD and Group III, no-decompression group who chose not to undergo NGTcOCD. An improvement in visual acuity (VA) at 1 week, 3 months and 1 year and amplitude and latency of VEP at 1 year were considered as primary and secondary outcomes, respectively.

RESULTS

The mean VA improved from 2.55±0.67 and 2.62±0.56 LogMAR at presentation to 2.03±0.96 and 2.33±0.72 LogMAR at final follow-up among Group I and Group II patients, respectively (p<0.001 and p=0.01). Statistically significant improvement observed among both the Groups in VEP amplitude (p=<0.01) and among Group II in VEP latency (p<0.01). Both Group I and Group II patients have better outcomes than patients in no-decompression group. VA at presentation and Type 1 DeLano optic canal were observed as significant prognostic factors.

CONCLUSIONS

NGTcOCD serves as a minimally invasive transcaruncular route to the optic canal which enables ophthalmologists to perform decompression from the anterior-most orbital end under direct visualisation. Patients with indirect TON with or without optic canal fracture and unresponsive to steroid therapy when managed with NGTcOCD have shown comparable and superior outcomes.

Optic Nerve Avulsion from Optochiasmal Region Secondary to an Animal Attack: A Case Report

ABSTRACT

Optic nerve avulsion without bone fracture was observed in four cases in the literature. This case is unique with its cranial effects and complications. A 50-year-old Caucasian female patient attacked by an animal on her left eye was admitted. Traumatic subarachnoid hemorrhage in the suprasellar cistern and epidural hematoma was observed upon brain computed tomography (CT). Enucleation and duraplasty were performed on the patient whose epidural hemorrhage did not increase. Two weeks after being discharged, the patient presented to the emergency room again with numbness on the right side of her face and sensory aphasia. The patient was followed up by medical treatment with left temporoparietal infarction and had completely recovered. Optic nerve avulsion secondary to trauma is a topic that needs to be carefully investigated due to potentially fatal complications. This article was written to share our experience with this rare condition and its case management.

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.

[Efficacy and prognostic factors of endoscopic optic canal decompression in children with traumatic optic neuropathy]

Objective: To explore the efficacy and prognostic factors of endoscopic optic canal decompression in children with traumatic optic neuropathy (TON). Methods: The clinical data of 47 children with TON treated with endoscopic optic nerve decompression in the Department of Neurosurgery of Beijing Tongren Hospital from November 2010 to October 2021 were retrospectively analyzed, and the visual acuity before and after treatment was compared. The clinical factors were taken as independent variables, and visual improvement was taken as dependent variable for multivariate Cox regression analysis to observe the factors that may affect the efficacy. Results: There were 47 patients in this study, including 35 males and 12 females, and the age ranged from 3.0 to 12.0 (7.2±2.3) years. After surgery and hormone treatment, 28 (59.6%) cases obtained visual improvement. Univariate analysis showed that the improvement rate of visual acuity in patients with residual vision after injury was higher than that in patients without vision [85.0% (17/20) vs 40.7% (11/27), P=0.002], while the improvement rate of visual acuity in patients with dislocated optic canal fracture was lower than that in those without fracture [42.1% (8/19) vs 71.4% (20/28), P=0.044]. The improvement rate of visual acuity in patients with operation time interval ≤7 d was higher than that in patients with operation time interval>7 d [80.8% (21/26) vs 33.3% (7/21), P=0.001]. Multivariate Cox regression analysis showed that post-traumatic residual visual acuity (HR=3.805, 95%CI: 1.087-13.318, P=0.037) and operation time interval≤7 d (HR=2.883, 95%CI: 1.084-7.662, P=0.034) were protective factors for post-surgical visual acuity. Conclusions: Endoscopic optic nerve decompression can effectively improve the visual acuity of children with TON. Post-traumatic residual visual acuity and operation time interval ≤7 d are independent protective factors for post-surgical visual acuity.

Nursing Research of Optic Canal Decompression Operation under Nasal Endoscopic Medical Treatment Based on Intelligent Internet of Things for Traumatic Vision Disorders

Traumatic vision is an important factor that causes people to have a vision. In our country, the vast majority of vision is caused by trauma. To understand the role of optic nerve decompression in the treatment of traumatic visual disturbances based on the pathological states of traumatic visual disturbances and intelligent Internet of tumors medical nasal endoscopy optic nerve decompression. This article collects relevant information by investigating patients, investigating relevant literature, interviewing professionals, etc., constructing a case template and using a comprehensive quantitative and qualitative analysis method to create a damage assessment matrix. The results of the study found that most traumatic vision disorders occur in the young and middle-aged stage, which is more than three times that of other age groups. The permanent blindness rate of patients reaches 8%, which is extremely harmful. Optic canal decompression surgery can play a great role in the treatment of patients. It can greatly reduce the patient's neurological damage. The effect is about 30% higher than that of general treatment methods, and it can also play a certain role in the prognosis of rehabilitation. It can effectively prevent related postoperative complications. This shows that optic canal decompression in the treatment of traumatic vision disorders should attract people's attention and increase research and development efforts and promotion efforts so that optic canal decompression can be used in the diagnosis and treatment of patients with traumatic vision disorders based on smart Internet of things China can play a greater role.

Optic nerve avulsion after blunt ocular trauma - Case report

INTRODUCTION

Avulsion of the optic nerve head is a rare and severe complication of ocular blunt trauma. The case reported is a 28-year old man presenting to the emergency department due to blunt trauma to his right eye globe with a tree branch. Lid haematoma and subconjunctival haemorrhage were present. Visual acuity soon after the injury was counting fingers (CF) and on admission to the Department of Ophthalmology he had no light perception (NLP). Fundus examination revealed prepapillary haemorrhage, which after few days dispersed into the vitreous cavity. Despite no light perception in the affected eye, the patient was qualified for vitrectomy. During surgery, an optic nerve avulsion with cicatricial gliosis was diagnosed. Six months after vitrectomy, the visual acuity was NLP in the right eye.

DISCUSSION

The clinical signs, mechanism, treatment and natural history of this poorly known disease are described.

CONCLUSION

Optic nerve avulsion must be considered in cases of trauma with forced rotation of the eye. Damage occurring at the disc may suggest mechanisms involving anterior luxation of the globe, retropulsion of the nerve, forced globe rotation, or a sudden explosive rise in intraocular pressure blowing the nerve off the sclera into its dural sheath. Damage and break of the nerve fibres are responsible for immediate visual impairments, and involving secondary haematomas and oedemas In spite of required safety precautions in agriculture work, eye injuries are still prevalent. Blunt ocular trauma remains a large part of this group, leading even to irreversible blindness.

Unusual case of traumatic neuroma of the orbit

Traumatic or amputation neuromas are neoformations developing after damage to a peripheral nerve. They are not proper tumors but rather a reactive process or a frustrated attempt of nerve regeneration. Traumatic neuromas are potentially found in every sensory peripheral nerve and often at the site of past surgical intervention, including orbital surgery. A 29-year-old Northern African migrant presented progressive exophthalmos and progressive loss of acuity in left eye, which had started about 6 months before after a cranio-facial trauma caused by a violent assault. MRI of the orbits showed a massive intra-orbital, intra-conical lesion, clearly compressing and dislocating the optic nerve and extending posteriorly to the orbital apex. Surgery was performed through lateral approach of Kroenlein and led to complete excision of the lesion. Histology revealed fibrotic, adipose and striated muscle tissues, a disordered, non-neoplastic overgrowth of small and large fascicles of nerves, inflammatory infiltrates, and fibrosis with sparse calcifications were diffusely observed in a background of fat, scar and striated muscle tissued. Patient was discharged on the fifth day in good health condition, without deficit of eye motion but without recovery of visual acuity. In conclusion, this case demonstrates that traumatic neuromas may arise in the orbit in patients with minor direct trauma to nerves and without previous surgical treatment.

Is there treatment for traumatic optic neuropathy?

PURPOSE OF REVIEW

The purpose of this study is to discuss current controversies surrounding the proposed treatments for traumatic optic neuropathy (TON) and review recent evidence from the literature relating to these therapeutic options.

RECENT FINDINGS

No recent randomized controlled trials investigating surgical or medical interventions for TON exist. The current literature regarding treatment of TON consists mainly of small, mostly retrospective, observational studies. Treatment of TON with corticosteroids, surgical decompression of the optic canal or combinations of surgery and corticosteroids does not appear to offer improved visual outcomes compared with observation alone. Recent evidence suggests that there may be diminished functional reserve of the optic nerve following trauma. Novel neuroprotective therapies, such as erythropoietin, are currently under investigation in the treatment of TON.

SUMMARY

TON may lead to profound visual disability. Because of the absence of Class I evidence relating to treatment of TON, a lack of consensus exists among clinicians regarding the appropriate treatment for TON. Our review of the recent literature finds that there is still no reliable evidence that treatment of TON with corticosteroids, surgical optic canal decompression or both confers any benefit over observation alone, and yet these interventions incur an additional risk that may not warrant their routine use.

[Long-term efficacy of nasal endoscopic opticnerve decompression for traumatic optic neuropathy]

OBJECTIVE

To analyze the long-term efficacy of nasal endoscopic opticnerve decompression for traumatic optic neuropathy(TON) and to explore its possible influencing factors.

METHOD

To summarize the clinical data of 39 cases underwent transnasal decompression, which were followed-up for more than 1 year. The data, including optic canal CT scanning, flashed-elicited visual-evoked potential (FVEP), preoperational vision and visual field examination were reviewed. Nasal endoscopic optic nerve decompression was preformed. Whether or not optic nerve sheath incision decided to perform was according to preoperative CT and situations in operation. Postoperative follow-up including vision, visual field, funduscopy, nasal endoscopy were performed.

RESULT

Total efficacy rate was 30. 77% (12/39), inefficacy rate was 69. 23%(27/39). The efficacy rate was 85. 71% with better than nolight perception, and the efficacy rate was 18. 75% with nolight perception, the clinical effect in the group of preoperative better than nolight perception was better than that of nolight perception, the difference was statistically significant (P<0. 05). The efficacy rate was 34. 38% with duration of less than 7 days from the traumatic point to the operation point, and the efficacy rate was 14. 29% for more than 7 days, but the difference was not statistically significant (P> 0. 05). The efficacy rate was 26. 32% with optic nerve sheathincision, while the efficacy rate was 35. 00% without optic nerve sheath incision, and there was no statistically significant difference (P>0. 05); Postoperative vision tended to stabilize until about 6 months post-operation, without complications.

CONCLUSION

The long-term efficacy of nasal endoscopic opticnerve decompression for TON was certain; The efficacy with preoperative residual vision was better than that of nolight perception, the factor of long or short duration from the trauma point to the operation point and the factor of optic nerve sheath incision didn't influence long curative effect. To avoid the secondary damage to the optic nerve after trauma was the key to increase long curative effect in TON.

Reduction in visual acuity and intraocular injuries in orbital floor fracture

Blow-out fracture of the floor of the orbit is an increasingly recognized trauma. It may be an isolated injury, but because of various mechanisms may be also accompanied by the damage of other components of the visual system. The triad of clinical symptoms in blow-out fracture of the orbital floor includes: double vision, the enopthalmos and impaired sensation in the area of infraorbital nerve. Change of the position of the eyeball may lead to displacement and stretching of the optic nerve, which may result in the traumatic optic neuropathy. The aim of this paper is the evaluation of effectiveness of surgical and conservative tactics in the treatment of blow-out fracture of the floor of the orbit, accompanied by intraocular injuries, on the basis of retrospective study of the patients treated from 1971 to 2014.

MATERIAL AND METHODS

Based on a retrospective analysis of medical records of a group of 752 patients treated in our Department due to blow-out fracture of the orbit, during 44 years (1971-2015), intrabulbar injuries were found in 98 (13%) patients, and decrease in visual acuity was observed in 84 (11.2%) patients. In patients with decreased visual acuity values of sight acuity ranged from light perception to 0.8, in 3 patients the blow-out fracture of the orbit was accompanied by the superior orbital fissure syndrome, while in four patients orbital apex syndrome was observed. Statistical analysis of parameters of sight acuity before and after treatment was performed. The Wilcoxon test was used for dependent measurements (repeated), visual acuity after treatment was significantly higher than before. Due to the complexity of the injury, treatment of orbital floor fracture requires a multidisciplinary approach, in the team of maxillofacial surgeon, ophthalmologist, radiologist and neurologist.

Analysis of prognostic factors of endoscopic optic nerve decompression in traumatic blindness

CONCLUSIONS

Hemorrhage within the ethmoid and/or sphenoid sinus and an interval between the time of injury and the time of operation exceeding 3 days are the risk factors for the visual prognosis of traumatic blindness.

OBJECTIVES

To investigate the therapeutic efficacy of endoscopic optic nerve decompression in the treatment of traumatic blindness and to evaluate the relevant prognostic factors.

METHODS

Eighty-five cases of traumatic blindness were analyzed retrospectively. Univariate analysis and multiple logistic regression were performed to evaluate potential prognostic factors.

RESULTS

The overall rate of vision acuity improvement was 44.7% (38 of 85). Univariate analysis indicated that hemorrhage within the ethmoid and/or sphenoid sinus was significantly associated with unrecovered visual acuity. However, multiple logistic regression analysis identified that an interval between the time of injury and the time of operation exceeding 3 days, and hemorrhage within the ethmoid and/or sphenoid sinus were significantly correlated with the efficacy of treatment of traumatic blindness.

Traumatic avulsion and bilateral eye loss: report of two cases

BACKGROUND

The optic nerve and the globes are resistant to mild to moderate trauma and bilateral avulsion of the eyes is rare with only a few cases reported in the literature.

CASE

We report two cases of traumatic bilateral eye avulsion. The first case was secondary to a bear bite and was managed successfully, although the eyes were not salvageable whereas the second case which was due to physical assault expired due to associated severe head injury.

CONCLUSION

Traumatic bilateral globe avulsion/loss is a rare complication of trauma. In developing countries like Nepal, poverty, forest encroachment activities, extensive deforestation, frequent domestic disturbances and lack of education are some of the circumstances that increase the probability of such visual injuries.

Surgery for traumatic optic neuropathy

BACKGROUND

Traumatic optic neuropathy (TON) is an important cause of severe visual loss following blunt or penetrating head trauma. Following the initial insult optic nerve swelling within the optic nerve canal or compression by bone fragments are thought to result in secondary retinal ganglion cell loss. Optic nerve decompression with steroids or surgical interventions or both have therefore been advocated to improve visual prognosis in TON.

OBJECTIVES

To examine the effects and safety of surgical interventions in the management of TON.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE, (January 1950 to May 2013), EMBASE (January 1980 to May 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to May 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (http://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 28 May 2013. We also searched the reference lists of other reviews and book chapters on TON. We also contacted researchers in the field.

SELECTION CRITERIA

We planned to include only randomised controlled trials (RCTs) of TON in which any form of surgical intervention either on its own or in combination with steroids was compared to steroids alone or no treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the titles and abstracts identified from the search strategy. No studies were found that met our inclusion criteria and therefore none were included for analysis.

MAIN RESULTS

No studies were found that met our inclusion criteria.

AUTHORS' CONCLUSIONS

The current body of evidence consists mostly of small, retrospective case series. Given the wide range of surgical interventions used in TON it is very difficult to compare these studies, even qualitatively. However, there is a relatively high rate of spontaneous visual recovery and no evidence that surgical decompression of the optic nerve provides any additional benefit. On the other hand, surgery carries a definite risk of complications such as postoperative cerebrospinal fluid leak and meningitis. The decision to proceed with surgery in TON therefore remains controversial and each case needs to be assessed on its own merits. Although there is an urgent need for an adequately powered, RCT of surgical intervention in TON, this will prove a difficult endeavour.

[Hematoma of the eye: there's more to this than meets the eye!]

A 3 1/2-year-old boy accidentally rode a bike into a shrubbery 1 day before he was presented at the clinic. He exhibited a hematoma of the right eyelid with ptosis without any obvious further injuries or visual complaints; however, a detailed examination revealed a profound loss of visual acuity of the right eye resulting from a serious traumatic optic neuropathy after being accidentally pierced by a twig through the left nostril.

Pathology of the optic nerve injury

The optic nerve injury is produced by damaging the optic nerve within a craniocerebral trauma. The anatomo-pathology and the pathology of posttraumatic visual impairments are fundamental data for the therapeutic indications. The microscopic examination reveals only the particular cases of very serious or severe extensive lesions. Damage to the vessels of the optic nerve, damage and break of the optical fibers are responsible for immediate visual impairments and secondary hematomas and edemas involving. The factors for the late appearance of visual impairments are numerous and often confounding.

MATERIAL AND METHODS

In the present research, we have a female patient D.A., aged 29, diagnosed with closed fracture in the right frontal lobe, irradiated to the optic canal; blindness in the right eye.

RESULTS

Break of the optical fibers is a result of bone fragments or of traction and torsion. Damage to the vessels of the optic nerve represents the main cause of blindness for most authors. Traction and torsion of the vessels at the moment of injury may cause thrombosis and small hemorrhages which lead to severe ischemia of the, optical fibers.

CONCLUSIONS

The optic nerve injury is produced by damaging the optic nerve within a craniocerebral trauma, through an indirect mechanism most of the times.

A novel animal model of partial optic nerve transection established using an optic nerve quantitative amputator

BACKGROUND

Research into retinal ganglion cell (RGC) degeneration and neuroprotection after optic nerve injury has received considerable attention and the establishment of simple and effective animal models is of critical importance for future progress.

METHODOLOGY/PRINCIPAL FINDINGS

In the present study, the optic nerves of Wistar rats were semi-transected selectively with a novel optic nerve quantitative amputator. The variation in RGC density was observed with retro-labeled fluorogold at different time points after nerve injury. The densities of surviving RGCs in the experimental eyes at different time points were 1113.69±188.83 RGC/mm² (the survival rate was 63.81% compared with the contralateral eye of the same animal) 1 week post surgery; 748.22±134.75/mm² (46.16% survival rate) 2 weeks post surgery; 505.03±118.67/mm² (30.52% survival rate) 4 weeks post surgery; 436.86±76.36/mm² (24.01% survival rate) 8 weeks post surgery; and 378.20±66.74/mm² (20.30% survival rate) 12 weeks post surgery. Simultaneously, we also measured the axonal distribution of optic nerve fibers; the latency and amplitude of pattern visual evoke potentials (P-VEP); and the variation in pupil diameter response to pupillary light reflex. All of these observations and profiles were consistent with post injury variation characteristics of the optic nerve. These results indicate that we effectively simulated the pathological process of primary and secondary injury after optic nerve injury.

CONCLUSIONS/SIGNIFICANCE

The present quantitative transection optic nerve injury model has increased reproducibility, effectiveness and uniformity. This model is an ideal animal model to provide a foundation for researching new treatments for nerve repair after optic nerve and/or central nerve injury.

In vivo MRI of olfactory ensheathing cell grafts and regenerating axons in transplant mediated repair of the adult rat optic nerve

The purpose of the present study was to use magnetic resonance imaging (MRI) as a tool for monitoring transplant-mediated repair of the adult rat visual pathway. We labelled rat olfactory ensheathing cells (OECs) using micron-sized particles of iron oxide (MPIO) and transplanted them by: i) intravitreal injection (ivit) and ii) intra-optic nerve (ON) injection (iON) in adult rats with ON crush (ONC) injury. We applied T(2)-weighted MRI and manganese-enhanced MRI (MEMRI) to visualise transplanted cells and ON axons at specific times after injury and cell engraftment. Our findings demonstrate that ivit MPIO-labelled OECs are unequivocally detected by T(2)-weighted MRI in vivo and that the T(1)-weighted 3D FLASH sequence applied for MEMRI facilitates simultaneous visualisation of Mn(2+-) enhanced regenerating retinal ganglion cell (RGC) axons and MPIO-labelled OEC grafts. Furthermore, analysis of MRI data and ultrastructural findings supports the hypothesis that iON OEC transplants mediate regeneration and remyelination of RGC axons post injury.

[Application of image guidance system in endoscopic optic nerve decompression of traumatic occlusion optic neuropathy affiliated with cerebrospinal rhinorrhea]

OBJECTIVE

To investigate the advantages of image guidance system in endoscopic optic nerve decompression of traumatic occlusion optic neuropathy affiliated with cerebrospinal rhinorrhea.

METHOD

Retrospective review of 15 traumatic occlusion optic neuropathy affiliated with cerebrospinal rhinorrhea at our department between June 2006 and June 2010. Witch were performed endoscopic optic nerve decompression and cerebrospinal rhinorrhea euplastic by image guidance system.

RESULT

After 3 months to 1 year follow-up, All the cases with cerebrospinal rhinorrhea euplastic were successful. Two cases recovered to 0.3-0.6 in visual activity. Two cases to 0.1-0.3. One case was less than 0.1. Two cases could see hand movement and 2 cases had light perception. Total effective rate was 60 percent (9/15).

CONCLUSION

Image guidance system combined with endoscopy provides accurate localization and identifies the operative borders and critical anatomical structure of skull base, optic nerve and internal carotid artery,and also clearly indicate their adjacent relations,also decreases surgical invasions and complications. Image guidance system can improve the accuracy and safety, particularly in local anatomic structure due to the trauma caused by changes in the relationship. It is a safety and effective therapy method.

[Current situation of surgery for traumatic optic neuropathy]

Although corticosteroid therapy remains the mainstream of various treatment procedures in traumatic optic neuropathy, some patients are still unable to benefit by this procedure. Therefore, optic nerve decompression has become an important choice for treating traumatic optic neuropathy. However, several problems have been raised on optic nerve decompression, such as who is suitable for this operation; as well as when to do and how to do this operation. The answers to these questions are controversial. We systematically review the current clinical evidence, and suggest that surgical decompression is indicated in cases with late onset and progressive visual loss; it is not indicated in primary complete loss of vision. Furthermore, it has been recommended that an adequate decompression requires the addition of an optic nerve sheath incision to the osseous optic canal, and it must be undertaken within seven days after the injury.

Visual outcome after extended endoscopic endonasal transsphenoidal surgery for tuberculum sellae meningiomas

BACKGROUND

The purpose of this study was to evaluate the visual outcome after extended endoscopic endonasal transsphenoidal surgery in patients with tuberculum sellae meningiomas (TSM).

METHODS

A retrospective analysis was performed for 12 patients (4 men and 8 women) with TSMs who underwent extended endonasal transsphenoidal surgery with pure endoscopy between 2003 and 2008. Neuro-ophthalmic evaluation was performed preoperatively and postoperatively. Visual acuity, visual fields, and funduscopy results were documented during the preoperative and follow-up periods.

RESULTS

There were three patients with bilateral optic foramen invasion and four patients with unilateral optic foramen invasion on radiologic findings preoperatively. Eleven patients had total tumor resection (Simpson grade I and II), and one patient had a subtotal tumor resection with a small asymptomatic tumor regrowth seen on magnetic resonance imaging at 14 months after surgery. Patients were observed for a mean follow-up time of 2.1 years (range 6 months-5 years), and the median was 28 months. Visual acuity improved in 92% of patients and was unchanged in 8% of patients. Eleven patients with visual field problems were better in various degrees at postoperative follow-up than before operation. No patients showed worsening of vision or visual field after surgery.

CONCLUSIONS

In this small, selected series with a relatively short follow-up, the extended endoscopic endonasal transsphenoidal approach to TSMs was a feasible alternative to the transcranial approach with minimal manipulation of the optic nerve. Procedures in the subchiasmatic space can be performed effectively with excellent visualization of the blood network supply to the optic apparatus while preserving the optic nerve in most cases.

Increased intrinsic neuronal vulnerability and decreased beneficial reaction of macrophages on axonal regeneration in aged rats

Previously we showed that macrophage activation in the eye by intravitreal application of zymosan increased retinal ganglion cell (RGC) survival and axonal regeneration after optic nerve injury. It is known that the intrinsic ability of CNS neurons to survive and to regrow axons after optic nerve injury differs between developing and adult mammals. However, whether aged animals also differ in their ability to survive and regrow injured axons are not known. In this study we investigated whether the abilities of RGCs to survive and to regrow injured axons differed between rats aged 6-8, 60 and over 96 weeks, and whether macrophage responses in the eye were different at different ages. We found that the intrinsic viability of RGCs, as shown in vitro, was reduced in aged rats, but RGC viability after optic nerve injury in vivo was similar among rats of the different ages. The ability of RGCs to regrow injured axons into a peripheral nerve graft also remained similar between young and aged rats. Macrophage activation in the eye was confirmed to be beneficial and provided the basis for zymosan treatment-dependent RGC protection. However, reduced activation of macrophages in zymosan-treated eyes was seen in aged rats. Importantly, this reduced macrophage activation in aged rats led to a decreased level of RGC axonal regeneration when compared with that in young rats of the same treatment. Thus age influences the intrinsic viability of RGCs and the beneficial impact of macrophages on RGC axonal regeneration after optic nerve injury.

[The complications of traumatic optic neuropathy]

OBJECTIVE

To investigate the complications of traumatic optic neuropathy and to call the surgeons attention to precaution.

METHOD

Retrospectively analysis of 122 cases patients with traumatic optic neuropathy and 3 cases were analyzed in detail including 1 case with purulent meningitis, another 1 case with internal carotid artery pseudoaneurysm and the other 1 case with internal carotid artery cavernous sinus fistula.

RESULT

Most of the patients had the complications of orbital fracture, maxillofacial fracture, ocular and craniocerebral injury. A few of patients had other injuries all over the body. The case with purulent meningitis was cured with antibiotics. The case with internal carotid artery pseudoaneurysm was cured with neurosurgery. The visual acuity of the both cases were improved. The case with internal carotid artery cavernous sinus fistula died of severe hemorrhage.

CONCLUSION

The patient with traumatic optic neuropathy has the possibility of severe cranial disorders, orbital fracture, maxillofacial fracture and injuries of viscera or limbs. It should be paid more attention and treated accordingly.

[Timing of operation and therapeutic effect of endoscopic optic nerve decompression for traumatic optic neuropathy]

OBJECTIVE

To observe the optimal timing of operation and the therapeutic effect of endoscopic optic nerve decompression for traumatic optic neuropathy (TON).

METHODS

The clinical records of 90 consecutive patients with TON (93 eyes) after head and/or maxillofacial trauma from April 1998 to March 2007 were reviewed and analyzed. All patients were either unresponsive or intolerant to medication before they underwent intranasal endoscopic optic nerve decompression. The time interval between the injury and operation ranged from one day to 97 days (median 5.5 days). Among the 93 eyes, there were 71 eyes with no visual acuity before operation and 22 eyes with residue visual acuity, including light perception in 1 eye, hand movement in 5 eyes, counting fingers in 13 eyes, 0.04 in 1 eye, and 0.1 in 2 eyes. Duration of follow-up ranged from 6 days to two years (median 8 days).

RESULTS

After decompression, 35 patients (36/93 eyes, 38.7%) showed improvement of visual acuity, 53 patients (55 eyes, 59.1%) remained the same as before operation, while 2 patients (2 eyes, 2.2%) showed decreased visual acuity. Among patients with visual acuity beyond light perception before decompression, 68.2% of them (15/22 eyes) experienced visual improvement, whereas only 22.9% (8/35 eyes, 0.02 in two eyes) among patients who lost visual acuity immediately after injury, and 36.1% (13/36 eyes, 0.02 in five eyes) among those who lost visual acuity gradually after injury. There was a significant difference in visual improvement between group with visual acuity and group with no visual acuity (chi(2) = 11.864, P < 0.01). Among patients with no visual acuity, 41.2% of those (7/17 eyes) who underwent operation within 3 days of injury, experienced improvement in visual acuity, compared with 25.9% (14/54 eyes) for those who underwent the operation more than 3 days after injury. It was indicated that no significant difference in visual improvement between these two groups (chi(2) = 1.46, P > 0.05). When comparing different sites of fracture, the effect of surgery was the most desirable (55.6%, 10/18 eyes improved) if the fracture occurred simultaneously in both exterior and interior walls of optic canal, followed by the interior wall fracture (45.7%, 21/46 eyes). The operation was less effective if there was no fraction (20%, 4/20 eyes) or if the fracture occurred in exterior wall alone (11.1%, 1/9 eyes).

CONCLUSIONS

Endoscopic optic nerve decompression is a minimally invasive procedure with no adverse cosmetic effects. Early operation is recommended for saving vision, even though visual acuity is lost immediately after injury. However, the satisfactory clinical effects of endoscopic optic nerve decompression require further study.

[Transnasal endoscopic optic nerve decompression for traumatic optic neuropathy: analysis of 155 cases]

OBJECTIVE

To explore the outcome of transnasal endoscopic optic nerve decompression (TEOND) for traumatic optic neuropathy (TON).

METHODS

The clinical data of 155 consecutive patients with TON treated with TEOND after failure of mega-dose steroid therapy were retrospectively analyzed, their outcomes were summarized after follow-up, and then Logistic regression was used to analyze the prognosis-related information to explore the factors influencing prognosis.

RESULTS

Patients were followed up for 3 - 60 months. The total effective rate of the 155 patients was 44.5%. The effective rate of the patients with light perception or better vision was 87.5%, much higher than that of the patients without light perception (29.6%). Eyesight was improved, mostly occurring 1 - 5 days after operation and lasting for 1 - 3 months, in 69 patients. Residual vision degree after trauma (OR = 0.04) and the interval between injury and surgery (OR = 4.62) were significant prognostic factors of the general effect (P < 0.01), and the gradual or immediate visual loss history (OR = 0.22) and the interval between injury and surgery (OR = 6.34) were significant to the outcomes of the patients with no light perception (P < 0.05). Sex, age, duration of coma after trauma, pre- and post-operative duration of steroid treatment, operators, fracture site of optic canal, and nerve sheath incision were not correlated to the outcomes of patients (all P > 0.05). Intraoperative cerebrospinal fluid rhinorrhea and postoperative transient visual loss occurred in one and the other two cases, respectively, but these conditions were resolved successfully.

CONCLUSION

TEOND is effective and safe for TON patients, but the visual outcome is poor for the immediate blindness cases. The surgery is indicated for the patients with some residual vision or with a gradual visual loss and is suggested to perform early within seven days after injury.

[Therapeutic efficacy of combined treatment with surgical decompression and drug for traumatic optic neuropathy]

OBJECTIVE

To evaluate the therapeutic efficacy of combined treatment with surgical decompression and drug for traumatic optic neuropathy (TON) and analyze the influential factors.

METHODS

A retrospective study on 69 patients (70 eyes) with TON treated with optic canal decompression through transnasal endoscopic approach and drug was conducted. The visual acuity was divided into 5 grades: no light perception (NLP), light perception (LP), hand move, count finger, > 0.02, marked as I-V respectively. Of 40 eyes with grade I, 18 eyes received emergency operation for severe optic canal fracture confirmed by CT; 22 eyes received corticosteroid therapy firstly and then operation. Of 30 eyes above grade I, 16 eyes with optic canal fracture confirmed by CT received emergency operation; 14 eyes received corticosteroid therapy firstly and 3 days later received operation. Postoperative follow-up lasted 3-12 months to observe the recovery of visual acuity.

RESULTS

The therapeutic efficacy of patients with the visual acuity of LP and above LP was better than that of NLP (90.0% to 27.5%), the difference had statistical significance (chi(2) = 26.98, P < 0.001). In operated group, the therapeutic efficacy in patients whose visual acuity was improved from NLP after glucocorticoid therapy (80.0%) was better than that of the patients with no improvement (5.9%), the difference had statistical significance (chi(2) = 12.09, P < 0.001).

CONCLUSION

The imaging findings of optic canal fracture can not be used as determinants for operation. The patients with NLP whose visual acuity had no improvement after corticosteroid therapy are poor candidates for surgical decompression. The visual acuity before treatment is the main factor affecting the therapeutic efficacy.

[Endoscopic transnasal approach for optic nerve decompression]

Optic nerve decompression is nowadays increasingly performed using endoscopic technique. THE AIM of this report is to present a clinical series of 8 patients operated on with this technique due to posttraumatic loss of vision and other visual disturbances. Technical details of this procedure and surgical anatomy will also be discussed.

MATERIAL AND METHODS

Endoscopic optic nerve decompression was performed in eight patients using transnasal transethmoidal approach. The loss of vision was caused by posttraumatic optic neuropathy in 6 patients, optic neuritis in 1 patient and by cystic lesion of the orbital apex and sphenoid sinus in 1 patient.

RESULTS

Vision acuity improvement was achieved in 4 patients (50%). Complications included intraoperative cerebrospinal fluid leak occurred in 2 patients. In one of them the leak had to be sealed using intracranial approach.

CONCLUSIONS

Endoscopic optic nerve decompression can be used in appropriately selected patients with optic nerve lesions to improve the visual functions. High technical skill, proper endowment and thorough knowledge of surgical anatomy are prerequisites of success. Good interdisciplinary cooperation between the laryngologist and neurosurgeon helps in minimizing the risk of serious complications, especially in posttraumatic cases.

Optic nerve avulsion following accidental penetrating orbital injury

Traumatic enucleation with optic nerve avulsion following accidental penetrating orbital injury is a rare phenomenon. A 35 years old young active man was suddenly traumatized in his left orbit after falling down on a boat following collision of two running boats having no search light in a dark night. The patient was examined few hours after the event. The patient presented with severe pain around left periorbital region. He never lost consciousness. On examination right eye revealed no abnormality. There was left periorbital swelling with blood clots. Left eyeball was hanging from the orbit with 20mm portion of optic nerve. Left eyeball was suspended with the attachment of superior oblique, superior rectus, inferior rectus, lateral rectus muscle. Medial rectus was lacerated and could not be traced out. One V shaped lacerated injury over the root of left side of nose was noted. One arm of the injury caused full thickness laceration of upper lid and other arm entered within orbit with medial bony orbital wall in nasal side and periorbita with other structures in temporal side upto apex of the orbit. Another lacerated full thickness lower lid injury was also noted. This case was managed surgically by removal of the left eyeball with orbital implant. Conjunctival injury, upper and lower lid injuries were repaired after proper surgical toileting. Ocular prosthesis was given two weeks later to have a good cosmetic view. Postoperatively the patient was managed with systemic antibiotics, NSAIDS and topical antibiotics. Traumatic enucleation following accidental boat collision was not reported yet. Awareness of the passengers, strict maintenance of the navigation rules may prevent this type of hazards.

[Endoscopic decompression of the optic nerve in patients with post-traumatic vision impairment]

PURPOSE

Traumatic optic neuropathy (TON) is a dangerous complication of head trauma but the mechanism of the symptoms still remains obscure. Moreover, there is no uniformly accepted treatment protocol for this condition. Endoscopic, minimally invasive decompression of the optic nerve in its bony canal is an alternative to conservative approach.

MATERIAL AND METHODS

Endoscopic optic nerve decompression was performed in 6 patients, whom head trauma caused blindness or severe impairment of vision. In 5 of them direct optic nerve injury might have been suspected due to presence of bony fractures in the region of the optic canal and the orbital apex. The time from the trauma to the surgical intervention varied from 8 hours to 30 days. All the patients before the attempted surgery were treated with steroids, however the doses and time of this treatment varied significantly.

RESULTS

There were no complications of the surgery; all the patients were mobilized on the day of operation and reported no problems with nasal breathing. Vision improved in 2 of 6 patients (33.3%), interestingly both of them had experienced rather gradually developing deterioration of vision during several hours after the trauma.

CONCLUSIONS

Endoscopic optic nerve decompression is a minimally invasive and safe procedure to be employed for optic nerve decompression in patients with posttraumatic impairment of vision.

Traumatic globe luxation and enucleation caused by a human bite injury

A 55-year-old woman presented to the emergency room with complete loss of vision in the left eye after being bit in the face by her autistic grandson. She had a small upper eyelid laceration and an anophthalmic socket on the left side. A thorough history revealed that the bite had caused traumatic luxation of her globe, which had allowed the child to transect the optic nerve with his teeth. Careful attention was directed toward the prevention of retrograde infection in this unusual case of traumatic enucleation.

Endoscopically assisted transconjunctival decompression of traumatic optic neuropathy

Traumatic optic neuropathy (TON) is a severe sequel after maxillofacial trauma. Recent clinical experience has suggested that optic canal decompression is beneficial in the treatment of TON. With the advent of endoscopy in orbital reconstruction, we extended this technique to decompress the optical canal and reported its outcome. This technique was applied to 30 patients with TON who did not improve after corticosteroids treatment. The average age of the patients at the time of injury was 26 years. Nine patients presented preoperative vision of light perception (LP) or better and 21 patients had no light perception (NLP). Surgery was performed within 1 week of injury in 10 patients, between 1 and 2 weeks in another 10 patients, and between 2 and 4 weeks in the last 10 patients. Thirteen patients were found to have optic canal fractures during surgery. The average follow-up time was 9.5 months. Vision improved in 12 patients including 6 patients (28.6%) with NLP and in 6 patients (66.7%) with LP or better. The improvement degree of visual acuity was 50% in average. Only patient age reflected differences in improvement of visual acuity when analyzing the effect of optic canal fracture, timing of surgery and initial visual acuity. Two patients experienced postoperative cerebrospinal fluid leakage due to associated skull base fractures. The endoscope-assisted transconjunctival technique successfully decompresses the optic canal and improves visual acuity with minimal morbidity. Younger patients had a significantly better visual outcome.

Optochiasmal avulsion secondary to minor occipital trauma

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.

Acquisition of surgical skills for endonasal skull base surgery: a training program

INTRODUCTION

Endonasal surgery represents a radical change in the practice of cranial base surgery and requires the acquisition of new knowledge and surgical skills. The optimal training program for surgeons has not been established.

METHODS

We reviewed our experience with endonasal cranial base surgery from 1998 to 2006 to develop a training plan for the acquisition of surgical skills. It consists of a modular and incremental approach to endonasal skull base surgery that is designed to train surgeons to function as a team, learn endoscopic skull base anatomy, and develop fundamental endoscopic skills.

RESULTS

Stages of training are established for the otolaryngologist-head and neck surgeon and the neurosurgeon that are based on level of technical difficulty, potential risk of vascular and neural injury, and unfamiliar endoscopic anatomy. Mastery of each level is recommended before attempting procedures at a higher level.

CONCLUSIONS

Standardization of training and the adoption of a modular, incremental training program are expected to facilitate the training of endonasal surgeons in both surgical specialties. Adherence to such a program during the growth phase of endoscopic skull base surgery may decrease the risk of complications as the surgeon's knowledge and surgical expertise develop.

Erythropoietin is both neuroprotective and neuroregenerative following optic nerve transection

The cytokine hormone erythropoietin (EPO) is neuroprotective in models of brain injury and disease, and protects retinal ganglion cells (RGC) from cell death after axotomy. Here, we assessed EPO's neuroprotective properties in vivo by examining RGC survival and axon regeneration at 4 weeks following intraorbital optic nerve transection in adult rat. EPO was administered as a single intravitreal injection at the time of transection (5, 10, 25, 50 units, PBS control). Intravitreal EPO (5, 10 units) significantly increased RGC somata and axon survival between the eye and transection site. Twenty five units did not improve survival of RGC somata but did increase axon survival between the eye and transection site. In addition, a small proportion of axons penetrated the transection site and regenerated up to 1 mm into the distal nerve. In a second series, intravitreal EPO (25 units) doubled the number of RGC axons regenerating along a length of peripheral nerve grafted onto the retrobulbar optic nerve. Our in vivo evidence of both neuroregeneration and neuroprotection, taken together with the natural occurrence of EPO within the body and its ability to cross the blood-brain barrier, suggests that it offers promise as a therapeutic agent for central nerve repair.

Extradural anterior clinoidectomy as an alternative approach for optic nerve decompression: anatomic study and clinical experience

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.

Avulsion of the optic nerve with luxation of the eye after motor vehicle accident

A 27-year-old man suffered simultaneous avulsion of the optic nerve and luxation of an intact globe in a motor vehicle accident. CT was not diagnostic of the nerve avulsion. The injury was addressed by emergent replacement of the globe within the orbit. The patient obtained psychological benefit by retaining the eye initially, but required subsequent enucleation for prolonged ocular inflammation. Initial repositioning of intact, luxated globes offers potential cosmetic and psychological benefits. If necessary, enucleation can be performed later.

Traumatic optic neuropathy in pediatric population: early intervention or delayed intervention?

PURPOSE

The aim of this randomized prospective study was to evaluate role of early decompression in the cases of traumatic optic neuropathy in children.

MATERIALS AND METHODS

Thirty-one children with a diagnosis of traumatic optic neuropathy were operated upon by transnasal trans-sphenoidal optic nerve decompression and the results were evaluated.

RESULTS

Patients presenting early and those who were operated early in the course of their illness showed a better recovery.

CONCLUSION

Early intervention can help preventing the blindness in as many as 80 and of the cases following the injury.

Early decompression of the injured optic nerve reduces axonal degeneration and improves functional outcome in the adult rat

The putative beneficial role of an early decompression of injured CNS tissue following trauma remains controversial. In this study, we approach this scientific query using a standardized injury of the optic nerve in adult rats. Adult Sprague-Dawley rats were subjected to a standardized optic nerve constriction injury by applying a loose ligature around the nerve for 5 min, 1, 6 or 24 h. All animals were sacrificed at 28 dpi. Viable axons distal to the injury were quantified using semithin sections, and regenerative fibers were studied using antisera to neurofilament and GAP43. Axonal degeneration and glial scar development were analyzed using Fluoro-Jade staining and anti-GFAP, respectively. Visual function was studied with visual evoked potentials (VEP). No significant differences were observed between 1 and 6 h of optic nerve compression. However, the number of viable axons analyzed with neurofilament and on semithin sections, decreased significantly between 6 and 24 h, paralleled by an increase in Fluoro-Jade labeled axonal debris (P < 0.001). GFAP-IR density was significantly higher (P < 0.001) in the 24 h compression group in comparison to 6 h. VEP showed preserved, but impaired visual function in animals subjected to compression up to 6 h, compared to an abolished cortical response at 24 h. Regenerative GAP43-positive sprouts were occasionally found distal to the lesion in animals subjected to compression up to 6 h, but not at 24 h. These findings suggest that early optic nerve decompression within hours after the initial trauma is beneficial for functional outcome.

Traumatic optic nerve avulsion

A 10-year-old boy presented with optic nerve avulsion associated with ptosis and limitation of elevation and adduction secondary to blunt ocular trauma. At the initial examination the funduscopic view was hazy because of concurrent vitreous hemorrhage. Ultrasonography revealed a posterior ocular wall defect and a hypolucent area in the region of the optic nerve head.

[Traumatic optic nerve avulsion by high caliber bullet: case report]

Traumatic optic nerve avulsion occurs most commonly after blunt ocular trauma. Optic nerve avulsion by high caliber bullet is exceptional and must be thought of in the management of those patients victims of gunshot wounds to the globe and orbit. The present paper reports the first documented case of this singular condition of optic nerve injury and comments on several other related causes, pathophysiology mechanisms, histology and management.

Lens epithelial cells promote regrowth of retinal ganglion cells in culture and in vivo

Lens damage has been demonstrated to promote axonal regeneration of retinal ganglion cells. Various mechanisms associated with this enhancement have been proposed, including macrophage recruitment and stimulatory factors from the lesioned lens. Lens epithelial cells, which become activated as a result of injury, are another potential stimulus. A recent study of co-culturing lens epithelial cells adjacent to retinal explants without direct contact showed that neurites were attracted to grow towards them. We explored the ability of lens epithelial cells to act as a favorable substrate for ganglion cell axonal regeneration, by culturing retinal explants on top of a lens epithelial cell layer, as well as in vivo by transplanting freshly isolated lens epithelial cells to the cut optic nerve. Retinal explants cultured on lens epithelial cells regenerated more and longer neurites than those cultured on either an acellular substrate or a substrate of corneal cells, while lens epithelial cells transplanted to the optic nerve stimulated axons to regenerate in close association with them.

[Surgical treatment for bilateral traumatic optic neuropathy through intranasal endoscopic approach]

OBJECTIVE

This study was aimed to explore the necessity of nasal endoscopic operation for bilateral traumatic optic neuropathy.

METHODS

Four patients with complete blind resulted from traumatic impairment of bilateral optic nerves were selected to receive a combined treatment of nasal endoscopic optic nerve decompression (NEOND) with all-around medication.

RESULTS

The vision of all patients was improved except one who lost vision immediately after trauma. Thirty days after injury, patient 1 was treated with NEOND, and the vision of left eye was restored to 1.5, however, the vision of right side was just from light perception (LP) to hand motion (HM). Patient 2 was treated with NEOND 3 days after injury, and the vision was improved from LP to 0. 2 in left side, no change in right eye. The operation of patient 3 was performed 6 days after injury, but no improvement was observed in both visions. Patient 4 received NEOND 28 days after injury, the vision was improved in both sides with left eye from NLP to 0. 8 and right eye from NLP to 0.2.

CONCLUSIONS

NEOND can be regarded as an effective treatment for bilateral traumatic blindness, even delayed NEOND may be effective. Both gradual vision loss and residual vision should be the indications for an effective NEOND, but immediate blindness after injury might be the index for poor result of NEOND.

Optic nerve avulsion from door-handle trauma in children

AIM

To report severe visual loss caused by optic nerve avulsion (ONA) in children with door-handle trauma.

METHODS

Clinical records at a tertiary eye care hospital, of 14 children who sustained severe visual loss as a result of door-handle injuries, were reviewed. The data were analysed for location, presenting symptoms and signs, diagnostic studies, intervention, and the cause of visual loss.

RESULTS

There were 11 males and three females with an average age of 8 years and an average height of 125 cm. The place of trauma was home in 11 and school in three children. Presenting visual acuity (VA) was light perception (LP) in five patients and no light perception (NLP) in nine. All the 14 children had evidence of ONA and four patients had ruptured eye globes that required initial repair. The diagnosis of ONA was made clinically or by imaging studies and confirmed histopathologically in eyes that were enucleated. Average follow up was 28.8 months (range 4 months to 8 years). Final VA was LP in one patient and NLP in 13 patients, eight eyes required enucleation for painful blind eye or to achieve optimal cosmesis.

CONCLUSION

ONA was the common cause of visual loss in children who sustained ocular trauma caused by door-handles.

[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.

[Endoscopic optic nerve decompression in traumatic optic neuropathy: analysis of 72 cases]

OBJECTIVE

To review the effects of optic nerve decompression by endoscopic technique in traumatic optic neuropathy.

METHODS

Seventy-two patients (73 eyes) with traumatic optic neuropathy which were treated with large dose of glucocorticoid but inefficacious were undergone endoscopic optic nerve decompression. The days from injury to surgery were 1-57 d. Among that, < or = 3 d 15 cases, 4-7 d 37 cases, 8-10 d 9 cases, 11-15 d 5 cases, 16-30 d 5 cases, >30 d 1 cases. The vision of pro-operation: with light perception or higher grades 18 eyes; with no light perception 55 eyes.

RESULTS

All patients were followed up for more than 3 months. Fourty-six of 73 eyes had improvements in visual acuity, the total effective rate was 63.01%. Thirty-one of 55 eyes with no light perception had raises in visual acuity (56.36%). Fifteen of 18 eyes with light perception or higher grades had improvements (83.33%). No complication had happened.

CONCLUSIONS

Endoscopic optic nerve decompression is an appropriate technique for patients with traumatic optic neuropathy. Even though the patient has injured in longer time and high-dose steroid treatment has failed, optic nerve decompression may improve visual acuity.

Manual enucleation of both eyes during assault

Manual enucleation of the eyeball from the orbit during physical assault is rare. Management includes removal of such sightless eyeballs when the optic nerve and extraocular muscles are avulsed. However, other authors recommend replacement of these eyeballs even though visual prognosis is nil and phthisis bulbi is expected. A patient who had bilateral enucleation after assault is described.

Enhanced expression of heat shock protein 27 is correlated with axonal regeneration in mature retinal ganglion cells

The small heat shock protein, Hsp27, promotes axonal regeneration in peripheral neurons; however, an analogous role in the central nervous system has not been described. This study examined the relationship between Hsp27 expression and regeneration in mature retinal ganglion cells (RGCs). Adult rat optic nerves were transected and exposed to peripheral nerve autografts to stimulate regeneration of cut RGC axons. There was a five-fold increase in the Hsp27-positive fraction of RGCs that extended new axons into the graft when compared with those that survived injury but did not regenerate (30% versus 6% respectively, P = 0.001). Hsp27 protein was located throughout somata and neuritic processes, and there was a significant positive correlation between Hsp27 expression and axonal regeneration in injured neurons (R = 0.92, P < 0.0001). These findings are consistent with the growth-associated role of Hsp27 demonstrated in peripheral neurons and suggest that Hsp27 may mediate similar physiological functions in the central nervous system.

[Endoscopic decompression of optic canal]

OBJECTIVE

To evaluate the effectiveness of endoscope in the treatment of optic nerve injury.

METHODS

Thirteen patients with fracture at the inner and lower walls of optical canal underwent endoscopic decompression. The posterior 1/3 of the middle concha, the posterior ethmoid sinus and sphenoid sinus were opened, chips of bone and old hematocele were scavenged, and the optic ring of the optic canal was polished; however, the sheath of the optic nerve remained intact. In 2 cases with the dura broken at the cranial part of optic nerve, the broken site was covered with mucosa of middle concha, and the sphenoid sinus and the middle nasal meatus were covered with oil ribbon gauze. Three days after the operation, the ribbon gauze was pulled put, however, if cerebro-spinal fluid leakage was suspected, the ribbon gauze was pulled out 7-10 days after. After the operation the visual acuity improvement reaching one grade or more and improvement of visual field were defined as effective.

RESULTS

Five of the 6 patients without light perception before the operation showed improvement in visual acuity. The other 7 patients with residual visual acuity all recovered to different extents.

CONCLUSION

A mini-invasive surgery, decompression of optic canal with endoscope is effective in decompressing optic nerve, decreasing the injury of optic nerve, and the patients recover quickly after operation.