Compressive Optic Neuropathy Treatment & Management

Updated: May 21, 2019
  • Author: Amritha Kanakamedala; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Approach Considerations

Treatment of compressive optic neuropathy should be aimed at the underlying cause. Treatment can be separated into medical management and surgery.

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, surgery may be considered with or without embolization of feeder vessels to the tumor.

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 may be useful in compressive optic neuropathy caused by inflammation (e.g. sarcoid) and thyroid ophthalmopathy. Radiation can also be considered for thyroid eye disease or some anterior visual pathway tumors (eg, meningioma). [22, 23]

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Surgical Care

Treatment of compressive optic neuropathy is aimed at managing the underlying cause. Consider surgical excision or decompression as a treatment option when visual failure results from optic nerve compression by a tumor. [4] Apical optic nerve tumors (eg, cavernous hemangioma) may require an orbitocranial approach. [24]

Surgical orbital decompression may be necessary for compressive optic neuropathy of thyroid eye disease.

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.

If the cause of CON is trauma (eg, sheath or retrobulbar hematoma), surgical decompression may be necessary. Steroids can be used preoperative, intraoperatively, or postoperatively. [6]

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Consultations

Patients with compressive optic neuropathy should be managed in consultation with a neuro-ophthalmologist and/or a neurosurgeon, if necessary.

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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 may improve disease and may slow the development of CON, diplopia, and proptosis. [25]

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Complications

Surgery to remove orbital tumors compressing the optic nerve is frequently associated with injury to the surrounding structures, including third, fourth, and/or sixth cranial nerves, which may result in paralytic strabismus and ptosis.

Surgery to remove lesions that are intimately involved with the nerve sheath (eg, meningiomas, schwannomas) often results in further loss of vision or blindness, and primary radiation therapy may be indicated.

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Prevention

Preventive measures vary by etiology.

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Long-Term Monitoring

Long-term monitoring is indicated for patients who are found to have chronic CON. Patients should seek regular care with their ophthalmologist, as well as the appropriate specialist.

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