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Show / lll/"", 1 tit 0111/( 111 Nfllro- III'" t/", IIIIII/ t'g'l 12( 3): 142- 148. 1992. Visual Improvement After Transethmoid- Sphenoid Decompression in Optic Nerve Injuries Brigitte Ch. Girard, M. D., Evrydiki A. Bouzas, M. D., Georges Lamas, M. D., and Jean Soudant, M. D. ' 0 1992 Raven Press, Ltd., New York Transethmoid- sphenoid decompression has been performed on 11 patients with indirect optic nerve injury. Visual improvement occurred in 8 patients, including 4 patients with initial total blindness. Optic neuropathy improved even when there was a long interval, up to 92 days, between trauma and decompression. There is still controversy about the treatment of traumatic optic neuropathy. Our results suggest that surgery can be helpful in the management of this condition. Transethmoidsphenoid optic nerve decompression is a minimally invasive procedure that gave, in this series, satisfactory results with low morbidity. Key Words: Optic nerve trauma- Optic nerve decompression- Visual loss. From the Ophthalmology ( B. C. G.) and Otorhinolaryngology ( G. L., J. 5.) Services, Hopital Pitie · Salpetriere; Ophthalmology Service ( E. A. B.), Hopital Saint- Antoine, Paris, France. Address correspondence and reprint requests to Dr. Brigitte Ch. Girard, Service d'Ophthalmologie, Hopital Robert Ballanger, 93602 Au! nay- Sous- Bois, France. 142 Optic nerve injury as a consequence of blunt head trauma can be responsible for severe and permanent loss of vision. The injury can be direct or indirect and many factors interfere in the development of the traumatic optic neuropathy. The exact physiopathological mechanisms remain uncertain. The management of traumatic optic neuropathy is controversial, especially in cases with total and long- standing loss of vision. Spontaneous visual improvement has been noted, but it is considered to be rare. On the other hand, the efficacy of systemic corticosteroids is still under evaluation. Positive results reported after transethmoid- sphenoid decompression are encouraging. The rarity and severity of traumatic optic neuropathy makes the performance of a controlled treatment study difficult. We present the results of surgical decompression in a series of 11 patients with traumatic optic nerve neuropathy, in order to contribute to the definition of the indications and the establishment of the usefulness of this surgical procedure. MATERIALS AND METHODS Eleven patients with optic neuropathy, which occurred after blunt head injury, were referred to the department of otorhinolaryngology of the Pitie- Salpetriere Hospital ( Paris, France). There were 9 men and 2 women, 12 to 61 years of age ( average 32 years) ( Table 1). The cause and violence of the injury was variable; 6 of 11 patients had loss of consciousness. The diagnosis of indirect optic nerve trauma was based on loss of vision, lack of direct pupillary light reflex, and intact consensual response. Par- DECOMPRESSION FOR OPTIC NERVE TRAUMA 143 TABLE 1. Characteristics and visual acuities of patients Initial Final Age Delay visual visual Follow- up No. Sex ( years) ( days) acuity acuity ( months) 1 M 26 1 0 20/ 100 2 2 M 45 1 0 0 6 3 M 61 5 0 CF 3 m 6 4 M 19 7 0 0 6 5 F 12 12 0 0 6 6 F 19 15 0 CF1m 24 7 M 18 17 20/ 40 20/ 30 6 8 M 17 36 0 20/ 25 18 9 M 42 43 HM CF 1 m 24 10 M 57 46 HM 20/ 200 24 11 M 42 92 LP 20170 18 M, male; F, female; CF, count fingers: m, meters: HM, perception of hand motion at 02 m; LP, light perception ticular attention was paid to the latter sign in order to exclude anatomic optic nerve section. Complete interruption of the nerve conduction leads to total pupillary akinesia. Patients with eyeball trauma or other ocular lesions were excluded. All patients underwent a complete neuro- ophthalmic examination before surgery in order to evaluate the initial lesion. Visual acuity measurements are reported in Table 1. Goldmann visual fields were performed, vision permitting. Radiography and computed tomography scan focused on the optic canal contributed to the initial evaluation. The interval between injury and surgery depended on the patient's general health and the delay in consulting an ophthalmologist. This varied from 24 hours to 92 days, with an average of 25 days. Of the 11 patients, 7 were operated on before the end of the third posttraumatic week. The same surgical technique of transethmoidal- sphenoidal decompression of the optic nerve was used for all patients, as described ( 1,2). Surgery was performed under general anesthesia, with the use of the operating microscope. Follow- up neuroophthalmological examinations were done 1 day, 1 week, 1, 2, 3, and 6 months after the operation, and then every 6 months whenever possible ( Table 1). RESULTS No intraoperative complications were noticed. The only postoperative complication observed was a transient abducens paralysis ( patient 7), which left no oculomotor sequela. Visual recovery of these 11 patients was variable. Evolution of visual acuities and visual fields are summarized in Table 1 and Figs. 1 and 2. Ex-cellent results were noticed in one case ( patient 8) whose visual acuity improved from " no light perception" to 20/ 25, despite 5 weeks interval between trauma and surgery. During the operation a bone fragment was found close to the optic nerve and was removed. Good results were noted in five patients ( 1, 7, 8, 10, and 11). They showed expansion of their visual fields and recovery of a numbered visual acuity. Moderate improvement was noted in three patients ( 3, 6, and 9), whose vision increased from total blindness without light perception or hand movement perception to " counting fingers," accompanied by an improvement in visual fields. No functional improvement was noticed in three cases ( patients 2, 4, and 5). In this group, severe lesions were found during the operation: multiple fractures of the optic canal associated with fractures of other bones. In most of the patients responding to the treatment the improvement of the visual function was obvious on the first postoperative day. However, an additional delayed improvement was not unusual during the first months of the follow- up period. DISCUSSION Indirect optic nerve Injury is a severe consequence of blunt head trauma, often resulting in blindness ( 3- 6). The optic nerve is very sensitive to ischemia and compression in the optic canal. Edema secondary to ischemia increases mechanical compression ( 7- 9). The demonstration of nerve infarction in the intracanalicular portion of the nerve on pathology specimens supports the theory of vascular participation in the pathophysiology of traumatic neuropathy ( 7,8). Those observations provide theoretical support to the surgical decompression of the optic nerve in the canal after indirect optic nerve injury. Spontaneous visual improvement has been reported either anecdotally ( 10,11) either in small series of patients with a frequency of 20- 380/ 0 ( 12- 14). Hughes reported 9 cases of recovery in a series of 56 consecutive patients with traumatic optic neuropathy ( 3). Different therapeutic approaches have been proposed in order to increase the chances of functional recovery. Medical treatment consists in intravenous high- dose or megadose of corticosteroids and led to the improvement of visual function in 45- 70% of the patients in different reports ( 12, 1~ 21). Surgical treatment became more popular after the development of extracranial ap- JClIII NClIro- oplithalmol. Vol. 12. No. 3. 1992 144 B. C. GIRARD ET AL. 00_" PATIENT No 1 ,/.~ 0.'..'" ..........,........ /' B ( 0.': 1 J ... • 0.10 '"' I' M • 0.. 0 " t '" tlO. 1e J I' I C O. U 2111 .. • 0.10 1 N 11 • 1.00 0 V .. I I I I \. \ \ ,. \ -- _ ...... P. A. T.. IE.. N. T.. N.. o.. 3... FIG. 1. Visual fields after optic nerve decompression of patients 1 ( A), 3 ( 8), 6 ( C), and 8 ( D). None of these patients could perceive the stimulus V/ 4e preoperatively. proaches of optic nerve decompression, as by Niho et al. ( 22) and Fukado ( 23). These techniques replaced the more morbid and less efficient neurosurgical route ( 3,24,25). In our study, 11 patients with traumatic optic neuropathy underwent surgical decompression by transethmoid- sphenoid route; 8 patients showed visual recovery based on visual acuity and visual field testing. Good results of extracranial optic nerve decompression after indirect injury have previously been reported by several authors ( 1, 13,15,18,22,23,26- 28). Recently visual improvement has been reported by Joseph et al. ( 2) in 11 of 14 patients with traumatic optic neuropathy after transethmoid- sphenoid decompression. None of the above- mentioned studies is controlled. However, the comparison of the results presented herein and previously reported in the literature with reports of spontaneous recovery show better results after optic nerve decompression. A double- blind study evaluating efficacy of medical treatment and surgical decompression has never been performed. Comparison of different series reporting results of medical and surgical treatment reveal better results after surgical decompression, but the fact that some of the patients operated on in these series had also had corticotherapy makes the interpretation of the results difficult. However, surgical decompression is reported to be rapidly successful even in patients DECOMPRESSION FOR OPTIC NERVE TRAUMA 145 FIG. 1. Continued. -- I '<> ." . ' 0 a....: ............... _, N_.... N.. m" n PAnENT No • att. r dec: Omp,..., on , . , .. c ••••••••• c, ••• "' It. II · ' "' 1"" •• -;- Q -.~~."';- ." c.... oo., __ 00 ~ ... 0 I I I I ___ < 110 IO~-. ,' 0.100" 111", )' 0.11'-' ....... .,... _, 0..- 0 • I '" tOM J n 1 C llAo) ' J." .. CO. · I'" 11 • UIO 0 Y ... \, .. 1.00 ~ .0,110 226 ''''', bO. 1loO J II I ( G. I. J l III oil _:.~~~:.~ o c who fail to respond to steroid therapy ( 12,18,20, 21,28). In our series none of the patients had corticotherapy before or after surgery. The results reported can thus be attributed to the effect of the surgical treatment. Spontaneous recovery seems improbable but cannot be excluded, although most of the functional recovery became manifest soon after the operation. Most of our patients have been operated on during the first 3 weeks after trauma. However in Cases 8- 11, delayed surgical decompression up to 92 days after the trauma did not exclude the possibility of improvement in visual function. Positive results after delayed surgery have rarely been reported ( 18,23), but surgery performed later than 7 days after the injury is considered to be nonefficient by other authors ( 2,20). Permanent loss of vision had been considered a contraindication for any therapeutic attempt ( 4,15, 20,25,27). However, 4 of 7 of our patients presenting with total blindness regained some visual function after surgical decompression, as in some cases previously reported ( 2,11,18). As it has frequently been mentioned ( 2,14,25,29) a large, randomized, prospective, multicentric study would be useful for the evaluation of the management of traumatic optic neuropathy, but its rarity and severity make this very difficult. The results reported by our series are in favor of the transethmoid- sphenoid decompression, which ap- J Clin Neuro- ophthalmol. Vol. 12, No. 3, 1992 146 B. C. GIRARD ET AL. ---- _.' - J~-~'---•- .......'•• ' 1.:•• , '. -.--;-,.~ ,.. ,.',. ..~;;'''., . """'-""' 01 _=:=_ 0= ... =. I I to. IOOMl_ ) 0,", 1' •, , " .. cO.'" : I III ' 0_ 1 rY 1. " .. / 16~ t..- I I -....- I ' T-.. , I -~ l- ! I ! i :" 1"-. - ' 80H',_. 1" _. 1--- 4-,:,. J,. " , t ! I \ \ \ \ ..\.---- ...\~ S-'\\--.-,\" /\ ' y \ \ /' C ~. A; , 210 \ A B ...... J' .. o. a , I • ..... 1 IV " .. 1.00 0 V · I I NOm4n PATIEHT No 8 ." ., I.... OI'~ puoIl_ FIG. 2. Visual fields before ( A) and after ( 8) optic nerve decompression ( aND) of patient 9. visual field's before ( e) and after aND ( D) of patient 10, visual field before ( E) and after aND ( F) of patient 11. PATIENT No 10 .... II • I! I [ .. \ . . •• ( C ••• , IIC •••• ( II. -: 1 I • I ., . ~~ ." I I , " ;!:~~ c o DECOMPRESSION FOR OPTIC NERVE TRAUMA Hom... PATIENT No 10 -- I I 147 E lUIlIIIf1_"" 30 ............ ., L0l'_ .~ ..... .,....... I I OD ~ o,- n PATIENT No 11 .45 ~~ II II It • .,. 0 FIG. 2. Continued. Nom... PATIENT No 11 Del"'" _ fter deCOmpr... IOn F ., " 100.- 0 ) II I e O, IJ : _ • 110.10 ,. M I I ." . JO ,'. "~,~~ ~ II o N, . ! I F J Clin Neuro- ophthalmoC Vol. 12. No. 3, 1992 148 B. C. GIRARD ET AL. peared safe and efficient even in cases with total blindness and, sometimes, despite a delayed treatment. However, as there is no proof that the recovery is directly related to the interval between trauma and surgery, a trial period of corticotherapy might be suggested. REFERENCES I. Soudant L Peytral C, Peynegre R, Freyss G, Narey P, Saraux H, Pialoux P. Voie transethmoido- sphenoidale et decompression du nerf optique. Bull Soc Ophtalmol Fr 1975; 75: 523- 6. 2 joseph MP, Lessell S, Rizzo j, Momose j. Extracranial optic nerve decompression for traumatic optic neuropathy. Arch O/ Jht/ lalmol 1990; 108: 1091- 3 3. Hughes B. 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