High-dose steroid therapy of traumatic optic neuropathy may fail to protect the optic nerve permanently

Abstract

Background: The optimal treatment of traumatic optic neuropathy (TON) is still unresolved due to the poor understanding of the pathology involved and the relatively small number of cases in the published clinical series. It is currently held that the results of conservative treatment with high-dose corticosteroids are similar to those obtained with surgical decompression. Purpose: To assess the late results of conservative treatment for traumatic optic neuropathy. Patients and methods: 15 patients (3 women and 12 men, age 14–64 years) who sustained a direct injury to the optic nerve as a consequence of closed head trauma. All were treated conservatively with high-dose dexamethasone therapy. Ten patients presented for follow-up examination 3–11 years after the injury, on average 5.3±2.4 years (SD). A full ophthalmologic examination and color-coded Doppler (CCD) study of the orbital vessels was performed in all subjects. Results: Full blindness of the affected eye, persisting since the injury, was noted in six patients. Their visual acuity did not improve in spite of vigorous treatment and their eyes remained without sight at the follow-up examination. The finding of an absence of flow in central retinal arteries at follow-up suggests structural damage to the nerve. Moreover, in five of these patients, distinct features of eyeball atrophy had evolved between the time of injury and the follow-up examination. Four patients, who on admission presented only with the ability to perceive light, responded to 2–3 weeks of steroid therapy with improvement of visual acuity to 3/50, 5/50, 5/10, and 5/7. After 4–6 years, however, the visual acuity of all of these patients had deteriorated, resulting in nearly total blindness in one case, light perception in two, and 1/50 in the fourth. Optic nerve atrophy was diagnosed in all of the affected eyes. Conclusion: Conservative treatment of TON, even if giving transient improvement in visual function, may not be reliable in providing permanent relief from the sequelae of traumatic optic neuropathy.