Early transethmoidal optic nerve decompression for indirect traumatic optic neuropathy

Background: Indirect traumatic optic neuropathy represents a severe, potential vision-threatening disease process that requires close interdisciplinary cooperation for treatment. In general, any therapy has been discussed controversially in the literature. Based upon experiences with spinal cord trauma, high-dose steroid therapy is recommended initially to minimize secondary consequences following orbital trauma. The usefulness of surgical decompression of the optic nerve has been confirmed in several studies but is still not recommended in principle. Patients and method: In nine consecutive patients with known indirect traumatic optic neuropathy and marked losses of vision, transsphenoidal optic decompressions were carried out with simultaneous systemic megadose steroid therapy. Results: A postoperative increase in visual acuity from 1/35 to 10/20 occurred in five patients, while no improvement in visual acuity could be achieved in the other four patients. Discussion and conclusion: Previous reports have indicated that some authors will not recommend surgical decompressions if a loss of sight or no light perception occurs directly after an accident. This situation was seen in seven of our patients. The visual acuity of four patients remained no light perception in spite of surgical treatment. In three other patients, an increase in visual acuity from amaurosis improved to 1/35, 4/20 and 8/20, respectively,following early decompression combined with steroids. This experience together with the positive results of other studies supports carrying out decompressions of the optic nerve, even when an amaurosis occurs directly after trauma.