Endoscopic Optic Nerve Decompression Research Articles

Visual Acuity Recovery in Traumatic Optic Neuropathy Following Endoscopic Optic Nerve Decompression: A Case Report

A 59-year-old Chinese man presented with no light perception in the left eye 1 day following functional endoscopic sinus surgery. The patient underwent endoscopic optic nerve decompression with topical and systemic application of nerve growth factor and steroids after a failed trial of high-dose intravenous corticosteroids. Visual acuity improved to 20/25 at 3 weeks and remained stable at 9 months. Reports of full visual recovery are exceedingly rare following this functional endoscopic sinus surgery complication.

Anatomy of the Optic Canal: A Computed Tomography Study of Endoscopic Nerve Decompression

Objectives: Endoscopic optic nerve decompression has variable success rates for trauma. Little is known of its use in skull base tumors. Our goal is to further delineate the radiographic anatomy of the optic canal to understand if the variable success can be explained on anatomical principles.

Traumatic optic neuropathy — our experience

A great deal of controversy surrounds the physiology and management of traumatic optic neuropathy. Needless to say, it has formed the topic of much debate in the past, especially with regard to its surgical management. With the advances in sinus endoscopic procedures, and their extended applications to the orbit and optic nerve, endoscopic optic nerve decompression offers a very good chance for salvaging vision in patients with traumatic optic neuropathy. However, there is no definite protocol laid down in the world literature for this condition, owing partially to the fact that a majority of such cases are not amenable to surgery within the critical period, due to the coexisting morbidities of head injury. There is also much controversy regarding medical versus surgical management of traumatic optic neuropathy. We present here our experience with this condition, and outline the management protocol followed.

Endoscopic Endonasal Trans-sphenoidal Optic Nerve Decompression for Traumatic Optic Neuropathy -Technical Note-

The endoscopic endonasal trans-sphenoidal approach can decompress the traumatized and swollen optic nerve without brain retraction. Three cases of traumatic optic neuropathy (TON) were treated by this endoscopic approach. We performed 58 endoscopic endonasal trans-sphenoidal approaches in 52 patients between April 2006 and December 2007. Three patients, 2 men and a woman aged 42-66 years, with TON were treated by endoscopic endonasal trans-sphenoidal optic nerve decompression. Adequate decompression of the optic canal was observed in all three patients. Two experienced improved visual function, but the third did not. No surgical complications were observed in any patient. We were able to reach the optic canal above the opticocarotid recess near the orbit. Endoscopic endonasal trans-sphenoidal optic canal decompression using a navigation system may be a safe and effective surgical strategy in carefully selected patients with TON.

Clinical value of endoscopic optic nerve decompression in posttraumatic optic neuropathy patients with no light preception

Objective To investigate the clinical value of endoscopic optic nerve decompression in traumatic optic neuropathy patients with no light perception (NLP). Methods 13 NLP patients with traumatic optic neuropathy were performed endoscopic decompression of optic nerves basing on the Messerklinger technique and the clinical data were retrospective analyzed.Results Seven of 13 patients with NLP improved at least one grade after three to twelve months follow-up period and the total effective ratio was 54% (7/13). Six patients showed no change and one patient was lost during follow-up.Based on the duration from loss of vision to operation after trauma, all 13 patients were divided into 3-7 d group, 8-14 d group,15-21 d group and above 21 d group.In the analysis of the data of different groups, there was no difference in effect among groups (P＞0.05 ). Conclusion Potential benefit could be achieved from endoscopic decompression of optic nerve even for traumatic optic neuropathy patients with no light perception. Key words: Optic nerve trauma; Endoscope; Decompression; Surgery

Anatomy of the Optic Canal: A Computed Tomography Study of Endoscopic Nerve Decompression

Endoscopic optic nerve decompression has variable success rates. Our goal was to further delineate the radiographic anatomy of the optic canal to determine whether the variable success can be explained on anatomic principles. The optic canal dimensions and the degree of optic canal exposure to the sphenoid sinus were measured on sinus computed tomography images of 96 patients. A total of 191 optic canals were analyzed (111 female subjects and 80 male subjects). The average medial canal wall length was 1.48 cm (range, 0.7 to 2.3 cm). The length in male subjects was 1.61 cm (range, 1.1 to 2.3 cm), as compared to 1.39 cm (range, 0.7 to 2.0 cm) in female subjects (p < 0.001). Onodi cells and pneumatized anterior clinoid processes were present on 14 and 16 images, respectively. The average degree of exposure of the optic canal to the sphenoid sinus in optic canals without Onodi cells or clinoid pneumatization was 99.3 degrees, and in optic canals with both Onodi cells and clinoid pneumatization it was 117.7 degrees. The potential area of canal exposed was 0.66 cm2, or 28% of the total surface area. A wide variation in medial canal wall length and exposure of the optic canal to the sphenoid sinus exists on computed tomography images. Variation in medial canal wall length and optic canal exposure may limit the surface area of nerve available for endoscopic optic nerve decompression.

Endoscopic optic nerve decompression

Endoscopic optic nerve decompression is a safe and reliable approach for surgical decompression. However, the indications and efficacy of surgical decompression remain debatable. Surgical decompression may be performed for numerous lesions that compress the optic nerve in the optic canal leading to problems with vision. However, it is most often most controversially employed for decompression in indirect traumatic injuries to the optic nerve. Advances in endoscopic instrumentation and surgical techniques have made endoscopic optic nerve decompression via an intranasal transethmoidal-transsphenoidal a preferred approach over other extracranial or craniotomy approaches.

Idiopathic intracranial hypertension in otolaryngology

Idiopathic intracranial hypertension (IIH) is defined as increased intracranial pressure in the absence of intracranial mass or obstructive hydrocephalus. Over 80% of patients are overweight women. IIH is usually encountered in the neurology and ophthalmology practise as headaches, visual disturbance and papilloedema are the characteristic features of this syndrome. Patients with IIH also experience tinnitus, hearing loss, balance disturbance, cerebrospinal fluid (CSF) otorrhoea or rhinorrhoea and in some cases these otorhinological symptoms can be presenting features of this syndrome. IIH is also associated with obstructive sleep apnoea. Otolaryngologists should be familiar with this important condition as it can manifest a variety of symptoms that are more frequently seen in their clinics. Sometimes otolaryngologists may be involved in the surgical management of this condition, such as repair of CSF rhinorrhoea or otorrhoea or endoscopic optic nerve decompression. The aim of this review article is to familiarise the otolaryngologists with the important features of this unusual syndrome which may remain unrecognised in the otolaryngology practice.

Timing of operation and therapeutic effect of endoscopic optic nerve decompression for traumatic optic neuropathy

To observe the optimal timing of operation and the therapeutic effect of endoscopic optic nerve decompression for traumatic optic neuropathy (TON). The clinical records of 90 consecutive patients with TON (93 eyes) after head and/or maxillofacial trauma from April 1998 to March 2007 were reviewed and analyzed. All patients were either unresponsive or intolerant to medication before they underwent intranasal endoscopic optic nerve decompression. The time interval between the injury and operation ranged from one day to 97 days (median 5.5 days). Among the 93 eyes, there were 71 eyes with no visual acuity before operation and 22 eyes with residue visual acuity, including light perception in 1 eye, hand movement in 5 eyes, counting fingers in 13 eyes, 0.04 in 1 eye, and 0.1 in 2 eyes. Duration of follow-up ranged from 6 days to two years (median 8 days). After decompression, 35 patients (36/93 eyes, 38.7%) showed improvement of visual acuity, 53 patients (55 eyes, 59.1%) remained the same as before operation, while 2 patients (2 eyes, 2.2%) showed decreased visual acuity. Among patients with visual acuity beyond light perception before decompression, 68.2% of them (15/22 eyes) experienced visual improvement, whereas only 22.9% (8/35 eyes, 0.02 in two eyes) among patients who lost visual acuity immediately after injury, and 36.1% (13/36 eyes, 0.02 in five eyes) among those who lost visual acuity gradually after injury. There was a significant difference in visual improvement between group with visual acuity and group with no visual acuity (chi(2) = 11.864, P < 0.01). Among patients with no visual acuity, 41.2% of those (7/17 eyes) who underwent operation within 3 days of injury, experienced improvement in visual acuity, compared with 25.9% (14/54 eyes) for those who underwent the operation more than 3 days after injury. It was indicated that no significant difference in visual improvement between these two groups (chi(2) = 1.46, P > 0.05). When comparing different sites of fracture, the effect of surgery was the most desirable (55.6%, 10/18 eyes improved) if the fracture occurred simultaneously in both exterior and interior walls of optic canal, followed by the interior wall fracture (45.7%, 21/46 eyes). The operation was less effective if there was no fraction (20%, 4/20 eyes) or if the fracture occurred in exterior wall alone (11.1%, 1/9 eyes). Endoscopic optic nerve decompression is a minimally invasive procedure with no adverse cosmetic effects. Early operation is recommended for saving vision, even though visual acuity is lost immediately after injury. However, the satisfactory clinical effects of endoscopic optic nerve decompression require further study.

Transnasal endoscopic optic nerve decompression for traumatic optic neuropathy: analysis of 155 cases

To explore the outcome of transnasal endoscopic optic nerve decompression (TEOND) for traumatic optic neuropathy (TON). The clinical data of 155 consecutive patients with TON treated with TEOND after failure of mega-dose steroid therapy were retrospectively analyzed, their outcomes were summarized after follow-up, and then Logistic regression was used to analyze the prognosis-related information to explore the factors influencing prognosis. Patients were followed up for 3 - 60 months. The total effective rate of the 155 patients was 44.5%. The effective rate of the patients with light perception or better vision was 87.5%, much higher than that of the patients without light perception (29.6%). Eyesight was improved, mostly occurring 1 - 5 days after operation and lasting for 1 - 3 months, in 69 patients. Residual vision degree after trauma (OR = 0.04) and the interval between injury and surgery (OR = 4.62) were significant prognostic factors of the general effect (P < 0.01), and the gradual or immediate visual loss history (OR = 0.22) and the interval between injury and surgery (OR = 6.34) were significant to the outcomes of the patients with no light perception (P < 0.05). Sex, age, duration of coma after trauma, pre- and post-operative duration of steroid treatment, operators, fracture site of optic canal, and nerve sheath incision were not correlated to the outcomes of patients (all P > 0.05). Intraoperative cerebrospinal fluid rhinorrhea and postoperative transient visual loss occurred in one and the other two cases, respectively, but these conditions were resolved successfully. TEOND is effective and safe for TON patients, but the visual outcome is poor for the immediate blindness cases. The surgery is indicated for the patients with some residual vision or with a gradual visual loss and is suggested to perform early within seven days after injury.

内視鏡下視神経管開放術が奏効した外傷性盲の２例

We treated 2 patients with traumatic optic neuropathy showing complete loss of vision. The optic nerve was decompressed by the endoscopic endonasal approach. Visual improvement was achieved in both patients. Endoscopic optic nerve decompression is a minimally invasive procedure that has no adverse cosmetic effects. This endoscopic technique offers several advantages over other surgical approaches. Immediate surgery is preferable for traumatic optic neuropathy, but the improvement of vision is possible even in cases with delayed surgery or with indefinite optic canal fracture. In surgery, frontal sinus seekers are useful for the removal of a thin bony wall, and a diamond drill burr for dacryocystorhinostomy is useful for the removal of a thick bony wall.

Treatment of traumatic optic neuropathy: our experience of endoscopic optic nerve decompression

Treatment of traumatic optic neuropathy: our experience of endoscopic optic nerve decompression

Transsphenoidal Optic Nerve Decompression

The objective was to study the relationships among the optic nerve, posterior paranasal sinuses, and ophthalmic artery. The identification of reliable anatomic landmarks would provide an endoscopic anatomic basis for optic nerve localization and effective prevention of ophthalmic artery injury during transsphenoidal optic nerve decompression surgery. The Messerklinger technique was performed to open the posterior ethmoid sinus and sphenoid sinus in 8 adult-head specimens. The opticocarotid recess and optic canal were identified under endoscopy, and the relationships between the optic nerve and posterior paranasal sinuses were observed. The relationship between the optic nerve and ophthalmic artery was examined. In all specimens, the opticocarotid recess could be identified; however, the optic nerve protuberance was present in only 10 sides (62%). Three types of relationships were found to exist among the optic nerve, sphenoid sinus, and posterior ethmoid sinus. The posterior ethmoid sinus was anterior and the sphenoid sinus was posterior in 8 sides (50%), the sphenoid sinus was both anterior and posterior in 5 sides (31%), and the ethmoid sinus was both anterior and posterior in 3 sides (19%). At the intracranial opening of the optic canal, the ophthalmic artery was inferomedial to the optic nerve in 9 sides (56%), inferior to the optic nerve in 4 sides (25%), and inferolateral to the optic nerve in 3 sides (19%). The ophthalmic artery coursed laterally from inferior to the optic nerve, and at the intraorbital opening of the optic canal, the ophthalmic artery was inferolateral to the optic nerve in 13 sides (81%) and inferior to the optic nerve in 3 sides (19%). The opticocarotid recess is always present; the imaging characteristics of endoscopy allow this recess to be more reliably identified than the optic nerve protuberance. It can be used as the anatomic landmark of choice in endoscopic optic nerve decompression. The origin of the ophthalmic artery is inferomedial to the optic nerve, and thereafter, it courses inferolaterally. An intersecting relationship exists along its course, a factor that must be taken into account during surgery to avoid injuring the ophthalmic artery.

Computed Tomography Anatomy of the Optic Canal

Objective (1) Analyze the radiographic anatomy of the optic canal in relationship to the sphenoid sinus. (2) Understand the role variation in optic canal anatomy may have in the variability of outcomes in optic nerve decompression. Methods Fine cut computed tomography images of the sinuses were obtained with an IRB waiver. Optic canal dimensions were measured on sinus computed tomography images of 96 patients. 191 optic canals were analyzed (111 females, 80 males). Student T-test calculations were performed for statistical analysis on computer software. Results The average medial canal wall length was 1.48 centimeters (range 0.7–2.3). The length in males was 1.61 centimeters (1.1–2.3) as compared to 1.39 centimeters (0.7–2.0) in females (p=8.0–7). The average degree of exposure of the optic canal exposed to the sphenoid sinus was 101.3 degrees (56–176). The degree of exposure was 105.6 in males versus 98.2 in females (p=.01). The potential area of canal exposed to the sphenoid sinus was 0.66 centimeters squared or 28% of the total surface area. The potential area exposed to the sphenoid sinus in males was 0.76cm2 (28%) and 0.58 centimeters squared (27%) in females. Conclusions A wide range in medial canal wall length and exposure of the bony optic canal to the sphenoid sinus exists on CT images. The variation in medial canal wall length and in optic canal exposure to the sphenoid sinus may contribute to the variability in success rates of endoscopic optic nerve decompression for optic neuropathy.

Treatment of traumatic optic neuropathy: our experience of endoscopic optic nerve decompression

Traumatic optic neuropathy can be treated by various methods including steroids and surgical decompression. Endoscopic optic nerve decompression has been suggested to be effective in treating this condition. The aim of this study was to assess the outcome of treating traumatic optic neuropathy with steroids and endoscopic surgical decompression. Two hundred and thirty-seven patients with traumatic optic neuropathy were treated with steroids; 176 also consented to endoscopic optic nerve decompression. The total vision improvement rate was 55 per cent in the 176 patients treated with both steroids and endoscopic optic nerve decompression, compared with 51 per cent in the 61 patients treated with steroids alone; this difference was not statistically significant (p > 0.05). Treatment with steroids plus endoscopic optic nerve decompression resulted in a significantly greater vision improvement in patients with gradual vision loss, compared with those with immediate blindness (68 vs 42 per cent, respectively). Early surgery (within one week) was an important prognostic factor for vision recovery, compared with more delayed surgical treatment (associated vision improvement rates were 60 and 31 per cent, respectively). Endoscopic optic nerve decompression is a minimally invasive, safe and efficient treatment for traumatic optic neuropathy. Used in combination with steroids, it provides effective rescue for some patients suffering visual loss. It should be undertaken as soon as possible.

Endoscopic Optic Nerve Decompression for Idiopathic Intracranial Hypertension in Two Cases: Case Report

Pseudotumor cerebri is a syndrome with headaches and visual loss that sometimes cannot be treated with medication. In spite of medical treatment, the clinical course in some patients can approach extreme dysfunction with severe impairment in visual field and acuity as well as incapacitating headache. Patients with progressive or persistent symptoms require surgical treatment and decompression of the optic nerve is the preferred surgical procedure. We report on two cases of bilateral decompression of the optic nerves performed through an endonasal endoscopic approach.

Salvage optic nerve decompression for traumatic blindness under nasal endoscopy: risk and benefit analysis

Transnasal endoscopic optic nerve decompression was recommended to treat traumatic optic neuropathy as an effectively adjunctive procedure. The aim of this study was to assess the risks and benefits of salvage surgical decompression for complete vision loss (no light detection) after failure of mega-dose steroid therapy. Retrospective study. Two hospitals in Guangzhou and Nanjing, China. Forty-two patients of traumatic optic neuropathy with complete vision loss and failed to improve after steroid therapy for at least 3 days. All patients were treated by transnasal endoscopic optic nerve decompression and received follow-up for at least 6 month. Vision improvement and complications were evaluated. Transnasal endoscopic optic nerve decompression was performed successfully in 40 patients and was incomplete in two patients due to bleeding. Vision improved in four of 42 patients (9.5%) of traumatic optic neuropathy with complete vision loss and failed steroid therapy. Complications and sequelae included severe bleeding (two cases), cerebrospinal fluid rhinorrhea (one case), nasal polyps (seven cases), chronic sinusitis (four cases) and nasal synechia (17 cases). Transnasal endoscopic optic nerve decompression was recommended as a minimally invasive, safe procedure, but complications and sequelae of the surgery should not be neglected. Based on the risk and benefit analysis, we conclude that the very poor surgical outcomes of this series do not support endoscopic optic nerve decompression for traumatic blindness.

Endoscopic Optic Nerve Decompression for Nontraumatic Optic Neuropathy

To determine the efficacy of endoscopic optic nerve decompression for the treatment of patients with nontraumatic optic neuropathy. Retrospective case series. Academic medical center. Ten optic nerve decompressions were performed on 7 patients with nontraumatic optic neuropathy caused by various pathologic entities, including meningioma, lymphangioma, fibro-osseous lesions (fibrous dysplasia and osteoma), mucopyocele, and Graves orbitopathy. Endoscopic instrumentation was used in a transnasal fashion to decompress the optic nerve. Visual acuity and complication rates. Mean visual acuity improved from 20/300 preoperatively to 20/30 after surgery. Visual acuity improved by at least 2 lines on the Snellen chart following 7 of the 10 decompressions. Median operative time was 133 minutes, and median length of stay was less than 24 hours. Complications were limited to postoperative hyponatremia and corneal abrasions, both of which resolved with conservative therapy. Mean follow-up time was 6.1 months. Endoscopic optic nerve decompression appears to be an effective treatment for restoring visual acuity in select patients who present with compressive optic neuropathy.

Endoscopic approach to traumatic visual loss.

To review our experience with the use of endoscopic optic nerve decompression in traumatic blindness. We did a retrospective analysis of patients with traumatic blindness that underwent endoscopic decompression of the optic canal to determine postoperative visual acuity and correlate it to preoperative visual loss and intraoperative findings. The setting was a Level I university trauma center. We identified 8 patients treated with both surgery and steroids over a 10-month period beginning in 1993 (Seven males, one female). Four of six patients with total blindness (no light perception) had improvements in visual acuity. In three patients, visual acuity returned to preinjury levels. One patients with total blindness was operated on 6 weeks after injury and had a visual acuity of 20/800 at 1-year follow-up. Two patients with hand motion preoperatively had improvement in visual acuity. In one patient, vision returned to normal (20/20), and in the other it improved to 20/200). Five patients were operated on after megadose steroid treatment for at least 48 hours failed; four of five noted dramatic improvements in visual acuity. The endoscopic approach may be used to successfully decompress the optic nerve in traumatic blindness.

Traumatic optic neuropathy: visual outcome following combined therapy protocol.

To assess the visual outcome in cases of traumatic optic neuropathy treated with a combined therapy protocol of methylprednisolone injections and endoscopic optic nerve decompression. Prospective, nonrandomized study. Academic tertiary care referral center. The study included 44 patients with posttraumatic indirect optic nerve injury. Visual acuity. Visual improvement was achieved in 31 patients (70%) when treatment was initiated within 7 days of injury, whereas only 10 patients (24%) showed improvement when the treatment was started after more than 7 days. The time lapse after injury and treatment, degree of visual loss, and computed tomographic evidence of canalicular and pericanalicular fractures were found to be significant prognostic factors. Endoscopic optic nerve decompression is a minimally invasive procedure that does not cause any adverse cosmetic effects. The risk-benefit ratio suggests that the combined therapy protocol of methylprednisolone injections and endoscopic optic nerve decompression results in a better visual outcome, without any major risks.