Optic Nerve Decompression for Traumatic Optic Neuropathy Workup

  • Author: Erin Kathleen O'Brien, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Nov 17, 2011
 

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
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Imaging Studies

  • Thin-slice CT scan 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.[7]
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Other Tests

  • Visual field perimetry: 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.[8]
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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.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Donald Leopold, MD  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center

Donald Leopold, MD, is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and American Rhinologic Society

Disclosure: NeilMed Corp Consulting fee Consulting; Entellus Medical Inc Consulting fee Consulting; Optinose, Inc Consulting fee Consulting

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.

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.

Specialty Editor Board

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, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, 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 Unrestricted 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; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

References

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  7. 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].

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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.
 
 
 
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