Compressive Optic Neuropathy Treatment & Management
- Author: Jonathan W Kim, MD; Chief Editor: Hampton Roy, Sr, MD more...
Factors related to the cause of compression are important in determining the appropriate treatment approach.
A favorable response to treatment with corticosteroids should not be considered as confirmation of a diagnosis until good quality MRIs and CT scans are obtained.
A practical approach for those cases in which the MRI and/or CT scan strongly indicates a meningioma (both intraorbital and intracanalicular) is to monitor the patient with serial visual acuity measurements and field testing. If visual loss progresses, consider treatment with radiation, and, if growth continues, then also consider surgery.
Decisions for surgical interventions to address vision loss should be made based on careful examination. Realistic expectations regarding the probability of improvement need to be discussed with the patient.
Corticosteroids are useful in compressive optic neuropathy caused by inflammation and thyroid ophthalmopathy.
Symptoms from other causes of compressive optic neuropathy also may improve with use of corticosteroids.
Radiation therapy often is appropriate for malignant lesions and may benefit intracanalicular and possibly intraorbital meningiomas.
Consider surgical excision or decompression as a treatment option when orbital tumors compress the optic nerve. Apical optic nerve tumors (eg, cavernous hemangioma) may require an orbitocranial approach.
The definitive procedure for optic neuropathy of Graves disease is orbital decompression. Although advocates of steroids and radiation exist, decompression is the best and most assured way of reversing the compression aspect of this disorder.
Optic canal decompression for tumors in the intracanalicular area is extremely risky and not uncommonly results in the loss of any remaining vision, unless the tumor has a large exophytic component.
If the tumor is intimately involved with the optic nerve, as often is the case with nerve sheath meningiomas, surgical removal often results in further loss of vision. This is thought to be due to a compromise of the shared blood supply.
Patients with compressive optic neuropathy should be managed in consultation with a neuro-ophthalmologist or an orbital surgeon whenever possible.
Prescribe polycarbonate safety glasses to patients with compressive optic neuropathy to protect the vision in the unaffected eye.
Smoking cessation in patients with thyroid ophthalmopathy has been associated with less severe disease, and may slow the development of diplopia and proptosis.
Miller NR, Newman NJ, Biousse V. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 6th ed. Lippincott, Williams & Wilkins; 2004.
Schiefer U, Wilhelm H, Hart W. Neuro-ophthalmic presentations of orbital disease. Clinical Neuro-Ophthalmology: A Practical Guide. Wien & New York: Springer; 2007.
Bulters DO, Shenouda E, Evans BT, Mathad N, Lang DA. Visual recovery following optic nerve decompression for chronic compressive neuropathy. Acta Neurochir (Wien). 2009 Apr. 151(4):325-34. [Medline].
Shields AJ, Shields CL, Scartozzi R. Survey of 1264 patients with orbital tumors and simulating lesions: the 2002 Montgomery Lecture, Part 1. Ophthalmology. 2004. 111(5):997-1008. [Medline].
Hodson KE, Bowman RJ, Mafwiri M, et al. Low folate status and indoor pollution are risk factors for endemic optic neuropathy in Tanzania. Br J Ophthalmol. 2011 Oct. 95(10):1361-4. [Medline].
Lee AG, Chau FY, Golnik KC, Kardon RH, Wall M. The diagnostic yield of the evaluation for isolated unexplained optic atrophy. Ophthalmology. 2005 May. 112(5):757-9. [Medline].
Thomas KW, Hunninghake GW. Sarcoidosis. JAMA. 2003 Jun 25. 289 (24):3300-3. [Medline].
Alvarez L, Guañabens N, Peris P, Monegal A, Bedini JL, Deulofeu R, et al. Discriminative value of biochemical markers of bone turnover in assessing the activity of Paget's disease. J Bone Miner Res. 1995 Mar. 10 (3):458-65. [Medline].
Spoor TC. Atlas of Oculoplastic and Orbital Surgery. Informa Healthcare; 2007.
Phillips ME, Marzban MM, Kathuria SS. Treatment of thyroid eye disease. Curr Treat Options Neurol. 2010 Jan. 12 (1):64-9. [Medline].
Verity DH, Rose GE. Acute thyroid eye disease (TED): principles of medical and surgical management. Eye (Lond). 2013 Mar. 27 (3):308-19. [Medline].