Delayed optic nerve decompression for indirect optic nerve injury

OBJECTIVE: To test the efficacy of delayed optic nerve decompression in traumatic optic nerve injury. STUDY DESIGN: Critical analysis of Proforma-based, prospectively accrued data of all cases with injury to surgery interval of greater than 2 weeks. METHODS: Thirty-five cases with a median injury to surgery interval of 56 days (range, 16-374 d). Surgical decompression was undertaken only in cases that continued to have poor vision after treatment with steroids in conventional doses (1 mg/kg prednisolone). Pre- and postoperative visual acuity measurements were converted to the logMAR scale of visual acuity and the percentage of visual improvement was calculated. RESULTS: Surgery was universally unrewarding in all 9 cases with persistent and complete blindness of greater than 2 weeks and no response to steroid therapy. Of the cases with some residual vision, 20 of 26 cases improved (mean percentage improvement, 41.0 +/- 5.7%). Cases were categorized on the basis of the injury to surgery interval into groups of 2 weeks to 2 months, 2 months to 4 months, and greater than 4 months. No significant difference was demonstrated in the probability or quantum of improvement in these groups (P =.97). CONCLUSIONS: Optic nerve decompression remains useful as a salvage procedure for conventional dose steroid failed cases of traumatic optic neuropathy. In cases that are not completely blind, vision can be improved even when surgery is undertaken a few months after the injury.     

Transethmoid decompression of the optic nerve

Delayed visual deterioration following trauma to the head can result from injury to the optic nerve or central visual pathways. Surgical decompression of the medial optic canal is indicated when central nervous system causes are ruled out and vision fails to improve on megadose intravenous steroids.     

Visual loss due to orbital fracture. The role of early reduction

Serious injury to the optic nerve is an uncommon, usually permanent, complication of orbital fractures. Occasionally it is due to reversible changes, such as edema, contusion, or compression of the optic nerve. The early management of visual loss due to orbital fracture is controversial. Some authors advocate emergency optic nerve decompression; others recommend steroid therapy alone. We present a case of nearly complete unilateral loss of vision after a lateral orbital fracture with compression of the optic nerve by bony fragments. Computed tomographic scanning of the orbit helped us to pinpoint the cause of visual compromise and also served as a guide in planning surgery. Large dosages of steroids, combined with early reduction of the fracture, resulted in substantial recovery of vision. This case illustrates the importance of precisely determining the nature of the injury and the cause of visual compromise. A protocol for management of these injuries is presented.     

Traumatische Optikusneuropathie

Background

Traumatic optic nerve neuropathy (TON) is defined as injury to the optic nerve with subsequent vision loss due to head or craniocerebral trauma. The treatment of this disease is the subject of controversial discussions. The purpose of the present study was to investigate pre- and immediate postoperative visual acuity in patients with unilateral TON and to compare the results with the time interval between trauma and surgical intervention.

Patients and Methods

A total of 20 patients with unilateral TON and considerable vision loss were examined. All were treated with high dose corticoids and underwent microsurgical optic nerve decompression. Visual acuity was determined pre- and postoperatively. In long-term follow-up visual acuity was determined 3?months postoperatively.

Results

Postoperatively, nine patients (45%) achieved an improvement in visual acuity of more than 0.4, and another three patients (15%) an improvement of ??0.2. At 3?months postoperatively another four patients achieved a further improvement of their visual acuity of >0.2. A decrease in visual acuity was not observed in any case, nor were major surgical complications.

Conclusions

Factors which predict good prognosis for vision recovery include a short time interval between trauma and intervention, edema, and/or hematoma of the optic nerve sheath. Factors which predict a worse prognosis are a fracture line directly through the nerve canal, a time period between trauma and intervention of more than 24?h, and initial complete amaurosis.     

外伤性视神经损伤经鼻内镜视神经减压手术时期选择及疗效观察

目的 观察鼻内镜下视神经减压术治疗外伤性视神经损伤的疗效和最佳手术时间.方法 对1998年4月至2007年3月90例头部和(或)颌面外伤后发生93眼外伤性视神经损伤的患者进行回顾性分析.所有患者接受鼻内镜视神经减压术前对药物治疗均无反应或效果不佳.受伤至手术时间1～97 d,中位手术时间5.5 d.术前无视力71眼,有视力22眼(1眼光感,5眼眼前手动,13眼眼前指数,1眼视力0.04,2眼视力0.1).随访时间6 d～2年,中位随访时间8 d.结果 视神经减压术后35例(36眼,38.7%)视力有改善,53例(55眼,59.1%)无变化,2例(2眼,2.2%)视力下降.术前有视力的患者中,视力改善者达68.2%(15/22眼),外伤后立即或逐渐失明的患者中视力改善分别只有22.9%(8/35眼,仅2眼视力恢复到大于0.02)和36.1%(13/36眼,5眼视力恢复到大于0.02),术前有视力和无视力两组视力术后恢复差异非常显著(X2=11.864,P<0.01).无视力的患者中,伤后3 d内手术视力改善为41.2%(7/17眼),3 d后手术视力改善下降到25.9%(14/54眼),但两者之间差异无统计学意义(X2=1.46,P>0.05).不同受伤部位比较,视神经管内外侧壁同时骨折手术效果最好(55.6%,10/18眼),其次为内侧壁骨折(45.7%,21/46眼),最差为没有骨折(20%,4/20眼)和单纯外侧壁骨折患者(11.1%,1/9眼).结论 为了挽救患者视力,应尽早行鼻内镜视神经减压手术,即使伤后立即丧失视力也不要放弃手术治疗.但手术后所获得的满意的视力恢复仍然需要进一步研究.     

Optic nerve decompression

Post-traumatic deterioration of vision requires thorough ophthalmologic evaluation, as well as computed tomographic scanning of the orbits and central visual pathways if no obvious ocular origins of the visual decrement are detected. When optic nerve trauma is a suspected etiology, the patient should be treated with megadose intravenous steroids, as well as optic nerve decompression performed after 12 to 24 hours if improvement of vision fails to occur.     

Traumatic optic neuropathy: visual outcome following combined therapy protocol

OBJECTIVE: To assess the visual outcome in cases of traumatic optic neuropathy treated with a combined therapy protocol of methylprednisolone injections and endoscopic optic nerve decompression. DESIGN: Prospective, nonrandomized study. SETTING: Academic tertiary care referral center. PATIENTS: The study included 44 patients with posttraumatic indirect optic nerve injury. MAIN OUTCOME MEASURES: Visual acuity. RESULTS: Visual improvement was achieved in 31 patients (70%) when treatment was initiated within 7 days of injury, whereas only 10 patients (24%) showed improvement when the treatment was started after more than 7 days. The time lapse after injury and treatment, degree of visual loss, and computed tomographic evidence of canalicular and pericanalicular fractures were found to be significant prognostic factors. CONCLUSIONS: Endoscopic optic nerve decompression is a minimally invasive procedure that does not cause any adverse cosmetic effects. The risk-benefit ratio suggests that the combined therapy protocol of methylprednisolone injections and endoscopic optic nerve decompression results in a better visual outcome, without any major risks.     

Visual risks of facial fracture repair in the setting of traumatic optic neuropathy

OBJECTIVE: To identify whether facial fracture repair in patients with traumatic optic neuropathy results in visual deterioration. DESIGN: A retrospective analysis was performed of all patients admitted from 1992 through 1997 with the diagnosis of facial fracture and traumatic optic neuropathy. Vision was recorded before and after fracture repair using logarithm of the minimum angle of resolution measurements. Visual outcome was compared with a nonsurgically treated group of patients with a similar diagnosis. SETTING: University trauma hospital. PATIENTS: A total of 700 medical charts were reviewed, and 54 patients met study criteria. All patients received megadose corticosteroid treatment and were divided into 3 groups: (1) facial fracture repair alone, (2) optic nerve decompression (OND) + facial fracture repair, or (3) nonsurgical treatment. RESULTS: For the 16 patients in the fracture repair alone group, 12 (75%) had improved vision and 4 (25%) had no change postoperatively. For the 10 patients in the OND + fracture repair group, 3 (30%) had improved vision, 5 (50%) had no change, and 2 (20%) had worsened vision postoperatively. For the 28 patients in the nonsurgical group, 18 (64%) had improved vision, 9 (32%) had no change, and 1 (4%) had worsened vision by discharge. Facial fracture repair alone and the nonsurgical groups both demonstrated significant visual improvement by discharge. The amount of improvement was not significantly different between all 3 groups (facial fracture repair, 0.38 +/- 0.40; OND + facial fracture repair; 0.32 +/- 1.38; and nonsurgical, 0.69 +/- 1.07). CONCLUSIONS: Facial fracture repair in the setting of traumatic optic neuropathy had no adverse effect on vision. Patients requiring OND + fracture repair had a significantly worse visual prognosis.     

Salvage optic nerve decompression for traumatic blindness under nasal endoscopy: risk and benefit analysis

Objectives: Transnasal endoscopic optic nerve decompression was recommended to treat traumatic optic neuropathy as an effectively adjunctive procedure. The aim of this study was to assess the risks and benefits of salvage surgical decompression for complete vision loss (no light detection) after failure of mega‐dose steroid therapy. Design: Retrospective study. Setting: Two hospitals in Guangzhou and Nanjing, China. Participants: Forty‐two patients of traumatic optic neuropathy with complete vision loss and failed to improve after steroid therapy for at least 3 days. Main outcome measures: All patients were treated by transnasal endoscopic optic nerve decompression and received follow‐up for at least 6 month. Vision improvement and complications were evaluated. Results: Transnasal endoscopic optic nerve decompression was performed successfully in 40 patients and was incomplete in two patients due to bleeding. Vision improved in four of 42 patients (9.5%) of traumatic optic neuropathy with complete vision loss and failed steroid therapy. Complications and sequelae included severe bleeding (two cases), cerebrospinal fluid rhinorrhea (one case), nasal polyps (seven cases), chronic sinusitis (four cases) and nasal synechia (17 cases). Conclusion: Transnasal endoscopic optic nerve decompression was recommended as a minimally invasive, safe procedure, but complications and sequelae of the surgery should not be neglected. Based on the risk and benefit analysis, we conclude that the very poor surgical outcomes of this series do not support endoscopic optic nerve decompression for traumatic blindness.     

Transethmoid decompression of the optic nerve in head injuries: an update

Sixty-three patients with loss of vision following head injury were subjected to decompression of the optic nerve by the transethmoid route. This paper discusses the criteria for selection of patients for surgery, the results of the operation and the prognostic factors determining the results.     

鼻内镜下视神经减压术治疗外伤性视神经损伤临床观察

目的探讨鼻内镜下视神经减压术治疗外伤性视神经损伤的临床疗效,并分析其手术预后的相关因素。方法回顾性分析广东省人民医院耳鼻咽喉科2004年11月～2016年3月期收治且具有完整随访资料的109例（110眼）外伤性视神经损伤患者的临床资料,其中男95例,女14例;年龄6~65岁,平均年龄27岁。所有患者均接受鼻内镜视神经减压术,评估手术的临床疗效及预后相关因素。采用SPSS 22.0软件进行统计学分析。结果所有患者均随访3个月以上,手术的总体视力改善率为55.5%（61/110）,其中有效率21.8%（24／110）,显效率33.7%（37／110）;术前视力有光感者视力改善率达100%（24/24）,无光感者为44.2%（38/86）;没有病例术后视力较术前变差。手术时间距离受伤时间＜3 d者视力改善率为59.5%（22/37）,3~7 d为53.3%（32/60）,＞7 d为53.9%(7/13);术中切开视神经鞘膜者视力改善率为50.0%（4/8）,不切开者为55.9%（57/102）。单因素分析结果显示,术前视力与患者的手术预后呈显著的正相关（P=0.001）。而Logistic回归分析显示,年龄、性别、术前视力、外伤到手术间隔的时间以及术中是否行视神经鞘膜切开均不是影响患者手术预后的显著因素。结论鼻内镜下视神经减压术是治疗外伤性视神经损伤的有效手段,且外伤至手术的时间及术中是否行鞘膜切开与手术预后无显著相关。     

鼻内镜下视神经减压术治疗外伤性视神经病72例

目的 探讨视神经减压术治疗外伤性视神经病的疗效。方法 对大剂量糖皮质激素冲击治疗无效的外伤性视神经病患者72例（73眼），采用鼻内镜下视神经减压术治疗。外伤至手术时间1～57d，其中≤3d15例，4—7d37例，8—10d9例，11—15d5例，16～30d5例，〉30d1例。术前视力：光感以上18眼；无光感55眼。结果 术后随访3个月-5年。73眼中46眼视力有不同程度的提高，总有效率63．01％。原无光感的55眼中，31眼视力有提高，有效率56．36％。有光感以上视力的18眼中，15眼视力有提高，有效率83．33％。术后全部患者术腔上皮化，术中无并发症发生。结论 经鼻内镜筛蝶窦入路视神经减压术进路简捷，损伤较小、疗效确切，且不遗留面部瘢痕，容易为患者所接受。对伤后时间较长、大剂量激素治疗无效、视力损伤严重的患者，手术仍有挽救视力的可能。     

视神经外伤经筛、蝶窦径路减压术治疗(附35例报告)

为了解经筛，蝶窦径路行视神经减压术对外伤视神经损伤治疗的有效性及手术时机的选择作回顾性研究。对４１你外伤性视神经损伤患者中的３５列行经筛，蝶窦径路减压术，另６例应用大剂量皮质激素保守治疗。结果手术后中１３２例视力得到改善，保守治疗者中１例视力改善。１２例治疗前有残余和的患者，８例接受手术治疗，其中７例视力理以改善；４例接受保守治疗者１，例视保守治疗者，视力均未得到改善。结论：经筛蝶窦径路视神经减压     

Optic nerve decompression in trauma and tumor patients

Optic nerve decompression is a procedure that is now receiving increasing clinical attention. However, there are currently no standardized treatment protocols in the therapy of traumatic or pressure insults to the nerve. The present retrospective study was designed to report our experience with microscopic endonasal transethmoid-sphenoid optic nerve decompression in 24 unilateral trauma cases and 11 unilateral skull base tumor patients. In general preoperative visual acuities in the trauma patients were worse than in the tumor patients. Following surgery, 9 of 11 tumor patients (82%) had at least some improvement of their vision, including 5 complete recoveries. In the group with traumatic visual impairment, 16 of the patients had no light perception preoperatively. Postoperatively, 13 patients (54%) had at least some improvement, with 4 patients regaining normal or near normal vision. Compared to other techniques and approaches, our technique is a minimally invasive procedure for optic nerve decompression, reducing unnecessary operative trauma to nasal structures, skin incisions or even craniotomy and frontal lobe retraction. Received: 23 June 1998 / Accepted: 4 December 1998     

Optic nerve decompression in the comatose and conscious patients after trauma

OBJECTIVE: To investigate the efficacy of early optic nerve decompression in comatose and conscious patients with indirect traumatic optic neuropathy. STUDY DESIGN: Retrospective analysis of 65 optic nerve decompressions. METHODS: The total collective of optic nerve decompressions comprised 65 patients treated within the period between February 1987 and December 1998. Thirteen of these 65 patients (average age, 32 y) were comatose and required critical care treatment, so visual acuity could not be measured. The indication for surgical decompression in all patients was based on the ophthalmological examination and the finding on computed tomography (CT) scan of a lesion inside the optic nerve canal or the orbit apex, respectively. RESULTS: In the comatose patients the time interval between trauma and surgery was 16.1+/-12.1 hours (mean +/- standard deviation). During the subsequent postoperative examinations (on average, 12.3 mo postoperatively) five patients showed a normal visual acuity (20/20), two patients a visual acuity of 20/30 and 20/50, and one a visual acuity of 20/200. Three patients (three eyes) remained amaurotic. Two patients died of the general and severe consequences of injury. The beneficial visual acuity results achieved within the group of comatose patients were equivalent to those achieved within the group of patients who were conscious during the preoperative examination. The success rate, defined as an improvement of three lines with a final visual acuity of at least 20/1000, was 57.7% versus 61.5%. CONCLUSION: The results confirm our concept of early decompression of the optic nerve, based on close interdisciplinary cooperation and the ophthalmological findings.     

鼻内镜下视神经减压术治疗外伤性视力完全丧失的预后相关因素分析

目的探讨鼻内镜下视神经减压术对外伤性视力完全丧失的疗效,并评估其预后相关因素。方法回顾性分析85例外伤性视力完全丧失患者的临床资料,通过单因素分析和Logistic回归分析来评估其潜在的预后相关因素。结果鼻内镜下视神经减压术后,患者总体视力提高44．7％（38J85）。单因素分析显示：筛窦和（或）蝶窦内积血是视力改善的负性因素。而Logistic回归分析显示：外伤到手术的时间超过3d、筛窦和（或）蝶窦内积血与外伤性视力丧失的预后呈负性相关。结论筛窦和（或）蝶窦内积血、外伤到手术的时间超过3d是外伤性视力丧失视力恢复的危险因素。视力完全丧失的患者伤后3d内如能实施手术,视力可能得以较好改善。     

Optic nerve damage following craniocerebral trauma. A critical analysis of trans-ethmoid decompression of the optic nerve

Over a period of 10 years 39 patients who suffered an optic nerve compression after a craniocerebral trauma underwent transethmoidal decompression surgery. The operation was performed bilaterally on 5 patients. Fifty per cent of the patients involved suffered a blunt head or brain injury, the others a brain concussion or space-occupying haemorrhage. At the side of optic nerve compression we found specific signs and symptoms, such as negative or sluggish direct light reaction of the pupil, a wound on the lateral side of the eyebrow, bleeding from the nose, eyelid haematoma, maximum of skull fractures and intracranial haematomas. Since the coincidence of radiological and intraoperative findings was only 67%, the ophthalmological findings such as lack of direct pupil reaction with preserved consensual light reaction or progressive loss of vision after a corresponding traumatic incident are our guideline for performing transethmoidal decompression of the optic nerve. In comparison with the results of conservative therapy as published in the literature, we achieved restitution of the visual function in about 10% more of the cases.     

鼻内镜下视神经减压治疗外伤性视神经病

目的 探讨鼻内镜下视神经减压治疗外伤性视神经病的疗效。方法 对外伤性视神经病患者应用大剂量皮质类固醇治疗,无效者15例行鼻内镜下视神经减压术。术前视力无光感者5例,光感者4例,眼前手动者3例,眼前数指者2例,视力0.1者1例。受伤至术前不足7d 4例,超过7d 11例。结果 术后随访3个月至4年, 9例视力有不同程度提高,总有效率为60%,术前无光感眼有效率为20%,有光感以上视力者术后有效率为80%。结论 鼻内镜视神经减压对外伤性视神经管内段神经病疗效确切、较其他径路创伤较小,尽管超过创伤7d,仍然是一种良好方法。     

The management of acute visual loss after sinus surgery--two cases of rhinogenic optic neuropathy

INTRODUCTION: Different causative mechanisms of ophthalmic complications during endonasal sinus surgery have been reported. Only a few cases of blindness caused by affections of the optic nerve due to inflammatory paranasal sinus disease have been described. OBJECTIVE: Inflammatory optic neuropathy shall be considered among the causative factors for amaurosis after sinus surgery. MATERIAL: We present two patients with dramatic visual decrease occurring two weeks after sinus surgery as a result of inflammatory posterior paranasal sinus disease. RESULTS AND CONCLUSION: Our therapy including surgical intervention in form of orbital or optic nerve decompression accompanied by systemic steroids and antibiotic therapy resulted in a significant increase of visual acuity in one case and a complete restoration of vision in the other case. In these two cases surgical intervention in the described fashion along with systemic steroids and antibiotic therapy represented a successful therapeutical approach.     

以失明为首发症状的后组鼻窦囊肿3例及文献复习

目的 探讨以失明为首发症状的后组鼻窦囊肿的临床特征,以期早诊断、早治疗,避免引起严重的视力损伤.方法 对近期发生的3例首发症状为失明的后组鼻窦囊肿患者,采集病史,收集实验室及影像学检查,明确诊断后急诊行鼻内镜下鼻窦开放,清除囊肿,并行视神经减压术.术后定期随访,评估视力恢复情况.结果 3例患者术后症状均改善,1例视力恢...