Optic nerve decompression in traumatic optic neuropathy: surgery or medical treatment? our experience

Objectives: Post-traumatic optic neuropathy (TON) is a rare contingency to be feared. It is a traumatic injury of the optic nerve at any level along its course (often intra-canal), with partial or total loss of its function, temporarily or permanently. Till now, an univocal treatment strategy does not exist. Methods: The clinical records of 18 patients, treated from 2002 to 2009, were reviewed. The most frequent cause of injury was road traffic accident (63%), followed by iatrogenic damage, work, sport and home accident. All patients underwent pre-operative ophthalmological evaluation, neuroimaging (angio-CT or angio-MR) and systemic corticosteroid therapy (Boston protocol). All patients required a surgical treatment, due to poor response to medical therapy, and it was performed at a maximum distance of 48 hours from the trauma. It consisted of an endonasal endoscopic decompression of the intra-canal tract of the optic nerve, performed by removing the bony wall of the optical channel and cutting the perineural sheath. Results: Improvement of visual functionality was reached in 57% of cases. No minor or major complication occured intra or postoperative, with mean follow up of 41 months. Conclusion: A visual improvement was achieved, although sometimes very slight, when surgery was performed as much as closer to the traumatic event. In the literature there are no evidence based statements considering both the therapeutic options (medical and surgical decompression) as a gold standard treatment for TON. We discuss the pro & cons of our protocol: medical endovenous steroid treatment, within 8 hours by the injury, and endoscopic surgical decompression within 12-24 since the beginning of medical therapy.