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Compressive Optic Neuropathy Treatment & Management

  • Author: Jonathan W Kim, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Nov 16, 2015
 

Approach Considerations

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. 

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Medical Care

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.

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Surgical Care

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.[9]

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.

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Consultations

Patients with compressive optic neuropathy should be managed in consultation with a neuro-ophthalmologist or an orbital surgeon whenever possible.

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Activity

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.[10]

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Contributor Information and Disclosures
Author

Jonathan W Kim, MD Director of Oculoplastic and Orbital Surgery, Co-director of Ocular Oncology Service, Co-director of Neuro-ophthalmology Service, Department of Ophthalmology, Stanford Medical Center

Jonathan W Kim, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Talmadge (Ted) Cooper, MD Clinical Associate Professor, Department of Ophthalmology, Stanford University School of Medicine

Talmadge (Ted) Cooper, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Medical Informatics

Disclosure: Nothing to disclose.

Diana Katherine Lee Georgetown University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Edsel Ing, MD, FRCSC Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital

Edsel Ing, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada, Canadian Ophthalmological Society, North American Neuro-Ophthalmology Society, Canadian Society of Oculoplastic Surgery, European Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Ontario Medical Association, Statistical Society of Canada, Chinese Canadian Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Brian R Younge, MD Professor of Ophthalmology, Mayo Clinic School of Medicine

Brian R Younge, MD is a member of the following medical societies: American Medical Association, American Ophthalmological Society, and North American Neuro-Ophthalmology Society

Disclosure: Nothing to disclose.

References
  1. Miller NR, Newman NJ, Biousse V. Walsh and Hoyt's Clinical Neuro-Ophthalmology. 6th ed. Lippincott, Williams & Wilkins; 2004.

  2. Schiefer U, Wilhelm H, Hart W. Neuro-ophthalmic presentations of orbital disease. Clinical Neuro-Ophthalmology: A Practical Guide. Wien & New York: Springer; 2007.

  3. 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].

  4. 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].

  5. 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].

  6. 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].

  7. Thomas KW, Hunninghake GW. Sarcoidosis. JAMA. 2003 Jun 25. 289 (24):3300-3. [Medline].

  8. 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].

  9. Spoor TC. Atlas of Oculoplastic and Orbital Surgery. Informa Healthcare; 2007.

  10. Phillips ME, Marzban MM, Kathuria SS. Treatment of thyroid eye disease. Curr Treat Options Neurol. 2010 Jan. 12 (1):64-9. [Medline].

  11. Verity DH, Rose GE. Acute thyroid eye disease (TED): principles of medical and surgical management. Eye (Lond). 2013 Mar. 27 (3):308-19. [Medline].

 
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Axial MRI taken 3 weeks after the onset of distorted vision in the right eye; visual acuity is reduced to counting fingers at 1 ft. Evidence of optic nerve compression is not seen; disease in the sphenoid sinus is reported.
MRI of same patient as in the image above taken 4 months later. Patient responded well to IV Solu-Medrol, but symptoms returned when steroids were reduced. Large mass compressing the right optic nerve is seen. Biopsy revealed lymphoma.
A 72-year-old man with a moderate decrease in vision in the left eye (20/20 right, 20/25 left). Fundus examination revealed a normal right optic nerve.
Same patient as in image above of a 72-year-old man with a moderate decrease in vision in the left eye (20/20 right, 20/25 left). Fundus examination revealed an atrophic left optic nerve.
Neuroimaging study (MRI of brain and orbits) revealed an extensive meningioma involving the left orbital apex (arrow).
 
 
 
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