eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Trauma

Traumatic Optic Neuropathy: Follow-up

Author: Christopher I Zoumalan, MD, Clinical Instructor, Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, New York University Medical Center and Manhattan Eye, Ear, and Throat Hospital
Coauthor(s): 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; James W Gigantelli, MD, Professor of Ophthalmology, Assistant Dean of Government Relations, University of Nebraska Medical Center
Contributor Information and Disclosures

Updated: Jul 28, 2008

Outcome and Prognosis

Most studies show a significant association between initial and final visual acuities. Patients with no light perception (NLP) likely have little to no recovery in vision.  However, studies show that up to 50% of patients with traumatic optic neuropathy (TON) can have some improvement in vision, with or without treatment, although most of the time improvement is minimal. No well-designed study has shown whether surgical decompression or steroids has any better outcome than observation alone. In fact, the rate of minimal but spontaneous visual improvement in indirect TON is relatively high, ranging from 20-57% in published series.
 
Studies have shown that TON with concomitant orbital fractures tends to have more severe visual loss.8,9 Up to 85% of the patients with an orbital fracture (29 out of 34) presented with NLP in one particular study.9 The presence of an orbital fracture implies a greater transmission of force to the optic canal, and hence, a greater injury to the optic nerve.

Future and Controversies

Traumatic optic neuropathy (TON) can lead to profound visual loss from either indirect or direct mechanisms. The diagnosis can be made with accurate history taking and clinical examination, based on the presence of visual loss (with accompanying loss of color vision and possible visual field defects) and an accompanying relative afferent pupillary defect (APD).

The optimal treatment for TON, however, remains debated among physicians. A review of the available literature, especially the IONTS and CRASH studies, provides insufficient evidence to conclude that corticosteroid therapy and/or optic canal surgery provides a therapeutic benefit over observation alone in patients with TON. Patients with TON treated with systemic steroids appear to have similar rates of visual recovery as untreated patients, and both animal and human studies suggest that under certain conditions, systemic steroids may actually be harmful, particularly at higher doses.

Therefore, corticosteroids should not be used in cases with concomitant traumatic brain injury or in patients who present 8 hours or more after initial injury. Based on the available evidence, surgical decompression of the optic canal in cases is not routinely recommended in TON. If treatment with either steroids or surgical intervention is considered, appropriate counseling should be given to the patient and their family about their potential benefits and risks in order to help them make an informed decision. 
 

 


More on Traumatic Optic Neuropathy

Overview: Traumatic Optic Neuropathy
Workup: Traumatic Optic Neuropathy
Treatment: Traumatic Optic Neuropathy
Follow-up: Traumatic Optic Neuropathy
Multimedia: Traumatic Optic Neuropathy
References
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References

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Further Reading

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Keywords

traumatic optic neuropathy, optic neuropathy, optic nerve injury, vision loss, trauma, frontal trauma, orbital trauma, optic nerve avulsion, optic nerve transection, diffuse orbital hemorrhage, localized orbital hemorrhage, optic nerve sheath hematoma, orbital emphysema, TON

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Contributor Information and Disclosures

Author

Christopher I Zoumalan, MD, Clinical Instructor, Ophthalmic Plastic and Reconstructive Surgery, Department of Ophthalmology, New York University Medical Center and Manhattan Eye, Ear, and Throat Hospital
Christopher I Zoumalan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

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, and North American Neuro-Ophthalmology Society
Disclosure: Nothing to disclose.

James W Gigantelli, MD, Professor of Ophthalmology, Assistant Dean of Government Relations, University of Nebraska Medical Center
James W Gigantelli, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Hassan H Ramadan, MD, MSc, Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University
Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Rhinologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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