Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Optic Nerve Decompression for Traumatic Optic Neuropathy Workup

  • Author: Christie Anne Barnes, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Oct 05, 2015
 

Laboratory Studies

Hemostasis is essential during optic canal decompression. Obtain the following tests as suggested by the patient's medical history:

  • Hemoglobin/hematocrit
  • Platelet count
  • Prothrombin time (PT)/activated partial thromboplastin time (aPTT)
  • Bleeding time
Next

Imaging Studies

Perform thin-slice CT scanning of the nose, sinuses, and orbits. CT scanning provides adequate imaging of orbital soft tissue and is better than MRI at delineating bony defects. A thin-section CT scan also provides an intraoperative road map for the surgeon in patients who require surgical decompression.

The decision for surgical decompression should still be based primarily on the clinical examination findings and not the CT scan findings. Small-review series have concluded that the extent of bony canal injury documented at surgery was underestimated by CT scan findings.

In polytraumatized patients with poor awareness, CT scan with clinical exploration is the most important method for the assessment of traumatic optic neuropathy in the acute emergency setting. Fractures through the optic canal can be best depicted with thin-section CT scanning (eg, 1.5-mm cuts with 1-mm intervals).

Surgeons who wish to perform image-guided optic canal decompression need to obtain a special-order CT scan that is formatted to their computerized stereotactic localizing system.

Diffusion tensor magnetic resonance imaging (DT-MRI) may provide valuable information for evaluating the fibers of the optic nerve in traumatic optic neuropathy.[12, 13]

Previous
Next

Other Tests

Patients suspected of sustaining traumatic optic neuropathy should undergo visual field testing. Although no visual field defects are pathognomonic of traumatic optic neuropathy, quantification of visual field defects is useful to assess convalescent visual improvements. Simple visual field screening can be accomplished at the bedside for unstable patients, but formally assess patients who can be evaluated in the clinic setting.

Multifocal visual-evoked potential (VEP), multifocal electroretinography (mfERG), and optical coherence tomography are 3 promising techniques in the future diagnoses of subclinical vision loss. Some of these tests are already used in neuro-ophthalmology for the studies of the retina and glaucoma. Although none of these techniques should replace a careful history and clinical examination, these techniques might be important as adjunct procedures in the evaluation of the unconscious patient or patients with bilateral optic neuropathy. Flash visual-evoked potential (FVEP) was studied in patients with traumatic optic neuropathy with calculation of a ratio of the amplitude of the injured to the uninjured eye. A ratio of greater than 50% was associated with favorable visual outcome.[14]

Previous
Next

Histologic Findings

Histopathology is not integral to the clinical management of traumatic optic neuropathy. Clinicopathologic studies, however, have anecdotally demonstrated several features of traumatic optic neuropathy, as follows:

  • Blood within the optic nerve sheath
  • Interstitial optic nerve hemorrhage
  • Fibrosis of the pial septa
  • Lymphoplasmacytic infiltration
  • Iron-laden macrophages
  • Triangular-shaped axonal degeneration with loss of myelin
  • Ischemic necrosis

The time-dependent histopathologic changes of the optic nerve following indirect trauma have not been adequately described.

Previous
 
 
Contributor Information and Disclosures
Author

Christie Anne Barnes, MD Chief Resident in Otolaryngology-Head and Neck Surgery, Fletcher Allen Healthcare

Christie Anne Barnes, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Rhinologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

James W Gigantelli, MD, FACS Professor, Department of Ophthalmology and Visual Sciences, Assistant Dean of Governmental Affairs, University of Nebraska Medical Center

James W Gigantelli, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Donald Leopold, MD Professor of Otorhinolaryngology, University of Vermont College of Medicine

Donald Leopold, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Rhinologic Society

Disclosure: Received consulting fee from Optinose, Inc for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Université de Sherbrooke, Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

M Abraham Kuriakose, MD, DDS, FRCS Chairman, Head and Neck Institute, Amrita Institute of Medical Sciences

M Abraham Kuriakose, MD, DDS, FRCS is a member of the following medical societies: American Association for Cancer Research, American Head and Neck Society, British Association of Oral and Maxillofacial Surgeons, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Acknowledgements

Erin Kathleen O'Brien, MD Assistant Professor, Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics

Erin Kathleen O'Brien, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Rhinologic Society

Disclosure: Nothing to disclose.

Michel Siegel, MD Staff Physician, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center

Michel Siegel, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and American Rhinologic Society

Disclosure: Nothing to disclose.

References
  1. Yu-Wai-Man P. Traumatic optic neuropathy-clinical features and management issues. Taiwan J Ophthalmol. 2015 Mar 1. 5 (1):3-8. [Medline].

  2. Wu N, Yin ZQ, Wang Y. Traumatic optic neuropathy therapy: an update of clinical and experimental studies. J Int Med Res. 2008 Sep-Oct. 36(5):883-9. [Medline].

  3. Ford RL, Lee V, Xing W, Bunce C. A 2-year prospective surveillance of pediatric traumatic optic neuropathy in the United Kingdom. J AAPOS. 2012 Oct. 16(5):413-7. [Medline].

  4. Lee V, Ford RL, Xing W, Bunce C, Foot B. Surveillance of traumatic optic neuropathy in the UK. Eye (Lond). 2010 Feb. 24(2):240-50. [Medline].

  5. Pirouzmand F. Epidemiological trends of traumatic optic nerve injuries in the largest Canadian adult trauma center. J Craniofac Surg. 2012 Mar. 23(2):516-20. [Medline].

  6. Yu Wai Man P, Griffiths PG. Surgery for traumatic optic neuropathy. Cochrane Database Syst Rev. 2005. (4):CD005024. [Medline].

  7. Yu-Wai-Man P, Griffiths P. Steroids for traumatic optic neuropathy. Cochrane Database Syst Rev. 2007. (4):CD006032. [Medline].

  8. Levin LA, Beck RW, Joseph MP, Seiff S, Kraker R. The treatment of traumatic optic neuropathy: the International Optic Nerve Trauma Study. Ophthalmology. 1999 Jul. 106(7):1268-77. [Medline].

  9. Entezari M, Rajavi Z, Sedighi N, Daftarian N, Sanagoo M. High-dose intravenous methylprednisolone in recent traumatic optic neuropathy; a randomized double-masked placebo-controlled clinical trial. Graefes Arch Clin Exp Ophthalmol. 2007 Sep. 245(9):1267-71. [Medline].

  10. Edwards P, Arango M, Balica L, Cottingham R, El-Sayed H, Farrell B, et al. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005 Jun 4-10. 365(9475):1957-9. [Medline].

  11. Kountakis SE, Maillard AA, El-Harazi SM, Longhini L, Urso RG. Endoscopic optic nerve decompression for traumatic blindness. Otolaryngol Head Neck Surg. 2000 Jul. 123(1 Pt 1):34-7. [Medline].

  12. Yang QT, Fan YP, Zou Y, Kang Z, Hu B, Liu X, et al. Evaluation of traumatic optic neuropathy in patients with optic canal fracture using diffusion tensor magnetic resonance imaging: a preliminary report. ORL J Otorhinolaryngol Relat Spec. 2011. 73(6):301-7. [Medline].

  13. Li J, Shi W, Li M, et al. Time-dependent diffusion tensor changes of optic nerve in patients with indirect traumatic optic neuropathy. Acta Radiol. 2013 Oct 6. [Medline].

  14. Holmes MD, Sires BS. Flash visual evoked potentials predict visual outcome in traumatic optic neuropathy. Ophthal Plast Reconstr Surg. 2004 Sep. 20(5):342-6. [Medline].

  15. Steinsapir KD. Treatment of traumatic optic neuropathy with high-dose corticosteroid. J Neuroophthalmol. 2006 Mar. 26(1):65-7. [Medline].

  16. Ropposch T, Steger B, Meço C, Emesz M, Reitsamer H, Rasp G, et al. The effect of steroids in combination with optic nerve decompression surgery in traumatic optic neuropathy. Laryngoscope. 2013 May. 123(5):1082-6. [Medline].

  17. Yu-Wai-Man P, Griffiths PG. Steroids for traumatic optic neuropathy. Cochrane Database Syst Rev. 2013 Jun 17. 6:CD006032. [Medline].

  18. Yu-Wai-Man P, Griffiths PG. Surgery for traumatic optic neuropathy. Cochrane Database Syst Rev. 2013 Jun 18. 6:CD005024. [Medline].

  19. Kong DS, Shin HJ, Kim HY, Chung SK, Nam DH, Lee JI, et al. Endoscopic optic canal decompression for compressive optic neuropathy. J Clin Neurosci. 2011 Nov. 18(11):1541-5. [Medline].

  20. Peng A, Li Y, Hu P, Wang Q. Endoscopic optic nerve decompression for traumatic optic neuropathy in children. Int J Pediatr Otorhinolaryngol. 2011 Aug. 75(8):992-8. [Medline].

  21. Yang QT, Zhang GH, Liu X, Ye J, Li Y. The therapeutic efficacy of endoscopic optic nerve decompression and its effects on the prognoses of 96 cases of traumatic optic neuropathy. J Trauma Acute Care Surg. 2012 May. 72(5):1350-5. [Medline].

  22. Chen F, Zuo K, Feng S, et al. A modified surgical procedure for endoscopic optic nerve decompression for the treatment of traumatic optic neuropathy. N Am J Med Sci. 2014 Jun. 6 (6):270-3. [Medline].

  23. Emanuelli E, Bignami M, Digilio E, Fusetti S, Volo T, Castelnuovo P. Post-traumatic optic neuropathy: our surgical and medical protocol. Eur Arch Otorhinolaryngol. 2015 Nov. 272 (11):3301-9. [Medline].

  24. Onofrey CB, Tse DT, Johnson TE, Neff AG, Dubovy S, Buck BE, et al. Optic canal decompression: a cadaveric study of the effects of surgery. Ophthal Plast Reconstr Surg. 2007 Jul-Aug. 23(4):261-6. [Medline].

  25. Levin LA, Joseph MP, Rizzo JF 3rd, Lessell S. Optic canal decompression in indirect optic nerve trauma. Ophthalmology. 1994 Mar. 101(3):566-9. [Medline].

  26. Cook MW, Levin LA, Joseph MP, Pinczower EF. Traumatic optic neuropathy. A meta-analysis. Arch Otolaryngol Head Neck Surg. 1996 Apr. 122(4):389-92. [Medline].

  27. Ahmad S, Fatteh N, El-Sherbiny NM, et al. Potential role of A2A adenosine receptor in traumatic optic neuropathy. J Neuroimmunol. 2013 Nov 15. 264(1-2):54-64. [Medline].

  28. Henrich-Noack P, Voigt N, Prilloff S, Fedorov A, Sabel BA. Transcorneal electrical stimulation alters morphology and survival of retinal ganglion cells after optic nerve damage. Neurosci Lett. 2013 May 24. 543:1-6. [Medline].

  29. Jacobs SM, Van Stavern GP. Neuro-ophthalmic deficits after head trauma. Curr Neurol Neurosci Rep. 2013 Nov. 13(11):389. [Medline].

  30. Manjunath YC. Traumatic Optic Nerve Compression. Radiodiagnosis-Imaging is Interesting-Amazing Cases. Available at http://manju-imagingxpert.blogspot.com/2011/09/traumatic-optic-nerve-compression-ct.html. Accessed: October 15, 2013.

  31. Pletcher SD, Sindwani R, Metson R. Endoscopic orbital and optic nerve decompression. Otolaryngol Clin North Am. 2006 Oct. 39(5):943-58, vi. [Medline].

  32. Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004 Oct 9-15. 364(9442):1321-8. [Medline].

 
Previous
Next
 
Endoscopic view of the intranasal anatomy: (1) lateral nasal wall, (2) middle turbinate, and (3) nasal septum.
Endoscopic view after intranasal ethmoidectomy. The ethmoid air cells have been removed, exposing the orbit. The black line delineates an intact orbit prior to decompression.
The first step in orbital decompression is depicted in this endoscopic view of the right eye. A curette can be observed. The surgeon is removing the thin bone covering the orbit (the lamina papyracea of the right orbit).
This image depicts exposure of the orbital contents as the lamina papyracea is removed. The arrow points to the orbit without its bony coverage.
The next step in orbital decompression is depicted. After the lamina papyracea is removed, a sickle knife is used to incise the orbital periosteum to allow the orbit to herniate into the sinuses, thus reducing orbital pressure. The black line highlights the limits of the orbit.
empty para to satisfy content model
This image represents the successful decompression of the orbit. The periorbital fat that encases the orbit can be seen herniating into the intranasal cavity (1). This procedure reduces the intraorbital pressure.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.