Traumatic optic neuropathy: a review of 24 patients

IP International Journal of Ocular Oncology and Oculoplasty, 2018

Aim: To study the clinical profile and outcome of traumatic optic neuropathy in a tertiary care eye center of India. Materials and Methods: This prospective study was conducted in 24 eyes of 22 consecutive patients with traumatic optic neuropathy who attended the outpatient ophthalmology department of a tertiary health care center of India from January 2014 to December 2016. The patients were equally divided into 2 groups. Those patients treated with intravenous methylprednisolone with a dose of 1gmfor 3 days followed by oral prednisolone with a dose of 1 mg/kg body weight for 11 days were included in group A and those observed with placebo treatment only were included in group B. Results: Twenty-one patients were males and only one patient was female. The most common age group was 21-30 years with mean age of 29.29 years. The causes of traumatic optic neuropathy were found to be motor vehicle accident (68.18%) followed by blunt trauma (22.72%) and fall (9.09%). Most of the eyes had the vision of hand movement to no perception of light on presentation (54.16%). The common extraocular associations were the periorbital hematoma (91.66%) and lid laceration (83.33%). Most of the patients (86.36%) were associated with multiple fractures of the skull and orbital bone and 13.63% of patients were not associated with any fracture. Eight of eleven patients (72.72%) in group A had shown 1 line improvement of visual acuity following treatment whereas six of eleven patients (54.54%) of Group B had shown 1 line improvement.The followup period of each patient in our study was 6 months. Conclusion: The common extraocular manifestations observed in our study were the periorbital hematoma, lid laceration, and bony fractures.Traumatic optic neuropathy in our study had a better visual outcome in steroid treatment group than those observed with placebo management.

Acta Clinica Croatica

Traumatic optic neuropathy (TON) is a serious vision threatening condition that can be caused by ocular or head trauma. Indirect damage to the optic nerve is the most common form of TON occurring in 0.5% to 5% of all closed head trauma cases. Although the degree of visual loss after indirect TON may vary, approximately 50% of all patients are left with 'light perception' or 'no light perception' vision, making TON a signifi cant cause of permanent vision loss. We present a 47-year-old male patient with a history of right eye keratoconus following a motorcycle crash. Visual acuity was of 'counting fi ngers at 2 meters' on the right eye due to keratoconus and 'counting fi ngers at 1 meter' on the left eye as a consequence of trauma. Th e Octopus visual fi eld showed diff use reduction in retinal sensitivity and the Ishihara color test indicated dysfunction of color perception on the left eye. Relative aff erent pupillary defect was also present. Computed tomography revealed multifragmentary fracture of the frontal sinus and the roof of the left orbit without bone displacement. Based on the fi ndings, conservative corticosteroid therapy without surgery was conducted. Th e patient responded well to treatment with complete ophthalmologic recovery.

Background: Optic nerve injuries occur in the setting of head injury which is often a consequence of road traffic accidents or falls. Traumatic optic neuropathy (TON) is a potentially blinding complication of head and orbital trauma. Different treatment approaches like different dosages of steroids, surgical decompression and observation alone have been suggested but there is no standardized protocol till date. Object: To study the clinical profile, risk factors, visual outcome in a series of forty five patients of Traumatic Optic Neuropathy (TON) after medical management at our tertiary centre. Methods: Forty five patients reported to outpatient department from January 2018 to June 2019 who have a history of trauma were studied prospectively. After relevant and detailed ocular examination, Intravenous methyl prednisolone 1 gram for 5days and thenoral prednisolone 1 mg/kg in tapering doses for two weeks was administered in all patients irrespective of duration of presentation to the hospital after trauma. Results: The age group involved was predominantly 16 to 45years (80%) with a mean age of 35.31 years. Range of follow up was seen from 5days to 5 months. Males (91%) were outnumbered. Road traffic accidents (73.33%) were found to be the most common cause for TON in our series. Of 45, 10 patients were lost to follow up, rest 35 patients who have been followed steroid regime, 18 (51.43%) showed visual improvement (12 patients had >/=2 line improvement, rest 06 patient had one line improvement). 17(48.57%) patients did not show any improvement. 08 patients were same (no perception of light) till the final follow up. Conclusion: IV methyl prednisolone along with oral steroids as proposed by ONTT has been found effective in our case series of TON even in patients who have very low initial visualacuity and who presented late even after 24 hours of injury till the irreversible damage to optic nerve.No major side effects have been encountered with this steroid regimen. High dose steroid has proven its role in traumatic optic neuropathy.

Neuro-Ophthalmology, 2017

This study aims to report the clinical features and role of different treatment modalities in final visual outcome in traumatic optic neuropathy (TON). The authors retrospectively reviewed the records of patients with TON over 4 years. There were 37 patients of unilateral TON. Mean age was 28.70 ± 15.20 years (range: 8-90) and 89% (n = 33) were males. Road traffic accident was the common cause (43.2%), followed by fall injury (35.1%). There was improvement of visual acuity in 51.4% (n = 19) cases. Out of different treatment modalities, high-dose intravenous methylprednisolone (1 g/day) led to significant improvement in final visual acuity (p = 0.013). There was no significant improvement in final visual outcome in patients with poor initial visual acuity and those with intracranial injuries.

IP Innovative Publication Pvt. Ltd., 2018

Objectives: To find the prevalence of traumatic optic nerve injury in neurosurgical patients admitted to this rural tertiary care hospital and to assess the clinical profile and visual outcomes in these patients. Materials and Methods: This case series of the prevalence, profile and outcomes of patients with Traumatic optic nerve injury (TONI) admitted to the neurosurgical department of this rural teaching hospital during the year 2014 received the approval of the Institutional Review Board and the Institutional Ethics Committee. Data was accessed from the medical records of these patients for one year. Results: Of the 3466 neurosurgical admissions, 15 were found to have traumatic optic nerve injury making the prevalence of TONI in this institution 0.43%. Of the 15 patients with TONI, 14 (93%) were males and the mean age was 33 years and more than half were over the age of 30 years. Road Traffic Accidents remained the main cause for TONI (93%). Ten of these patients (66.7%) presented with fracture skull or orbit and 5 (33.3%) had no fractures. Most of the bony injuries were lateral orbital wall fractures accounting for 7 (70%). None of the patients had evidence of optic nerve compression. Fourteen of the 15 patients with TONI (93%), received intravenous and oral corticosteroids and one patient was treated conservatively. Twelve patients showed improved visual acuity on discharge while three did not improve. Conclusion: Traumatic optic nerve injury is a vision-endangering condition which is a comorbidity of blunt head trauma. Most of the patients with optic nerve injury presented with periorbital edema, subconjunctival haemorrhage and orbital wall fracture, lateral orbital wall fracture being the commonest. Patients treated with intravenous corticosteroids followed by oral route of the same were found to have good visual outcomes. There is a great need to develop clinical databases for better understanding of the natural history and management of this condition. Keywords: Head injury, Orbital fracture, Road traffic accidents, Traumatic optic nerve injury, Visual acuity

Innovative Publication, 2016

Purpose: To study the clinical profile, prognostic factors and the effect of systemic steroids in the management of traumatic optic neuropathy. Materials and Method: A minimum of forty four patients with closed head injury with complaints of any of the following: decreased visual acquity following trauma, RAPD, defective colour vision, visual field defects or CT scan showing fracture of any orbital wall were selected randomly and detailed ocular examination was done. Patients were treated with IVMP. Results: Patient age ranged from 11-69 years. The causes of head injury were road traffic accidents (86.4%), accidental falls (9.1%), and assault (4.5%). Majority of patients were male (93.18%). Unilateral involvement was seen in 95.45% cases. 61.36% cases were drowsy, 36.36% cases conscious and 2.27% cases were unconscious after the injury. In this study 34.78% of patients had profound loss of vision PL+ or HM (hand movements) as the initial vision. 13.04% cases had a visual acquity 6/18 or better. In 43.47% cases extraocular movements were restricted. RAPD was present in 95.5% of eyes. 82.60% of patients presented with sub conjunctival hemorrhage. CT scan coronal view showed optic nerve sheath thickening in 17.39% patients. The most common fractures noted were fracture floor of orbit in 23.19% cases and medial wall of orbit in 15.21% cases. 38 patients were treated with intravenous Methyl prednisolone within 24-72 hrs. of suspicion of traumatic optic neuropathy. Initial ophthalmoscopic examination was conducted on 46 eyes and optic disc was normal in all cases except one who showed mild disc edema. In 6 to 12 weeks more than 50% optic discs became pale. Optic disc pallor developed in about 81.5 % cases in 6 months. In the present study out of six; 5 patients showed spontaneous improvement without treatment, but treated patients appeared to have a better visual acuity and visual fields. Conclusion: Road traffic accidents were the most common cause associated with TON and males being more commonly involved. Treated patients had a better visual prognosis. On follow up, it was noted that visual acuity improved in patients who had initial vision more than light perception and in patients with no optic canal fractures.

The Open Ophthalmology Journal, 2023

To report the aetiology, visual outcome, and clinical features of indirect traumatic Optic Neuropathy (TON) patients from the tertiary eye care center in South India. Methods: It is a retrospective and observational study. Details of age, gender, number of days of presentation after injury, Snellen visual acuity at presentation and last follow-up, visual evoked potentials, visual field findings using the Humphrey visual field analyser, associated ocular complications, and mode and time of treatment were obtained from the medical records of all indirect TON patients. Results: Indirect TON patients are mainly young males (94%) and road traffic accident (RTA) (65%) is the main cause of TON, followed by falls (19%) and sport-related activities (11%). Visual acuity loss was severe in more than 50% of the subjects and only 16%% of the patients showed improvement in visual acuity greater than one line. Pattern visual evoked potentials and visual fields are recordable only in 15% of the subjects. Commonly associated ocular complications in indirect TON patients were orbital fracture (43%), lid tear (16%), sub-conjunctival haemorrhage (13.5%), and angle recession (13.5%). Three out of four patients who received methylprednisolone and oral steroids within a week showed an improvement in visual acuity of greater than three lines, while just one patient out of four who received the same medication after a week improved visual acuity of three lines. Conclusion: RTA (road traffic accidents) is the most common cause of indirect TON and mainly young males were the affected individuals. IVMP along with oral steroids within a week, would help TON patients for reasonable visual recovery. Presenting Visual acuity of > 6/600 and recordable pattern VEPs would be the prognostic factors for good visual outcomes in indirect TON patients.

Otolaryngology - Head and Neck Surgery, 1999

The management of traumatic optic neuropathy remains controversial. In this report, we present the results of 45 patients treated with extracranial optic nerve decompression after at least 12 to 24 hours of corticosteroid therapy without improvement. Vision improved in 32 patients after surgery (71%), and the mean percentage of improvement from preoperative visual deficit was 40.7% ± 6.9% (median improvement 41.2%). Worsening of vision occurred in none of the patients as a result of the surgery, and no intraoperative or postoperative complications were encountered. We present a treatment protocol for traumatic optic neuropathy with the use of megadose corticosteroids and optic nerve decompression.

British Journal of Ophthalmology, 1992

Twenty three patients with traumatic optic neuropathy were managed by medical and surgical treatment as follows. High dose intravenous steroids were initiated in all patients. If visions did not improve significantly after 24 to 48 hours decompression of an optic nerve sheath haematoma by medial orbitotomy and neurosurgical decompression of the optic canal were considered based on computed tomographic scan findings. Nine of 16 patients who received steroids only showed significant improvement. One of three showed improvement on optic nerve decompression after steroid failure; three or four showed improvement with combined optic nerve sheath decompression by the medial orbitotomy and decompression of the optic canal by frontal craniotomy. A lucid interval of vision after injury and an enlarged optic nerve sheath were associated with an improved prognosis. Five of the 23 patients had a lucid interval and all five had a final improved vision, while only five of 18 patients without a lucid interval improved. Similarly seven of the nine with an enlarged optic nerve sheath showed improvement while only three of 10 patients (three bilateral cases) who presented with no light perception improved with medical and surgical treatment. While a prospective controlled study of the management of traumatic optic neuropathy is necessary this preliminary study suggests that treatment of traumatic optic nerve sheath haematoma by optic nerve sheath decompression should be considered in selected patients.

Objective: To investigate a possible correlation between final visual acuity and the presence at baseline of various systemic and local (orbital/ocular) signs in patients affected by indirect traumatic optic neuropathy. Methods: 35 cases of traumatic optic neuropathy were examined retrospectively and 13 variables were tested. Univariate analysis with " no recovery of visual acuity " as the primary outcome was performed. Relative risk (RR) and 95% confidence intervals (CI) were calculated. Fisher's exact test was used for two variables to test differences between proportions. Results: Four variables showed a significantly increased risk for no recovery of visual acuity: presence of blood within the posterior ethmoidal cells (RR = 2.25, 95% CI 1.25 to 4.04); age over 40 years (RR = 1.79, 1.07 to 2.99); loss of consciousness associated with traumatic optic neuropathy (RR = 2.21, 1.17 to 4.16); and absence of recovery after 48 hours of steroid treatment (p < 0.01, Fisher's exact test). Recovery documented at the first follow up visit after treatment was significantly associated with recovery at the last follow up visit (p < 0.01, Fisher's exact test). Conclusions: These four negative prognostic signs in patients affected by traumatic optic neuropathy may be useful in predicting the visual outcome in patients developing visual loss after head trauma and in deciding on the need for surgical treatment.