Interventions for Indirect Traumatic Optic Neuropathy OTA

A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Oculoplastics and Orbit Panel

Edward J. Wladis, MD,¹ Vinay K. Aakalu, MD, MPH,² Rachel K. Sobel, MD,³ Timothy J. McCulley, MD,⁴ Jill A. Foster, MD,⁵ Jeremiah P. Tao, MD,⁶ Suzanne K. Freitag, MD,⁷ Michael T. Yen, MD⁸ 

Ophthalmology, Volume 128, 928-937, © 2020 by the American Academy of Ophthalmology. Click here for free access to the OTA.

Purpose: To review the literature on the efficacy and safety of medical and surgical interventions for indirect traumatic optic neuropathy (TON), defined as injury to the nerve that occurs distal to the optic nerve head.

Methods: A literature search was conducted on October 22, 2019, and updated on April 8, 2020 in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis. 

Results: No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage.

Conclusions: Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON. 

¹Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York

²Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois

³Vanderbilt Eye Institute, Vanderbilt University Medical Center, Nashville, Tennessee

⁴The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland

⁵Ophthalmic Surgeons and Consultants of Ohio, Columbus, Ohio

⁶Gavin Herbert Eye Institute, University of California, Irvine School of Medicine, Irvine, California

⁷Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts

⁸Cullen Eye Institute, Baylor College of Medicine, Houston, Texas