The Incidence of Traumatic Optic Neuropathy Associated With Subtypes of Orbital Wall Fracture.

BACKGROUND: Traumatic optic neuropathy (TON) is a rare disease but leaves critical sequelae to patient. Purpose of this study is to evaluate the incidence of TON in each orbital wall fracture. MATERIALS AND METHODS: Retrospective review of 2629 patients with orbital wall fracture was performed in from January 2010 to March 2019, based on diagnostic code, Korean Standard Classification of Diseases, 7th Revision. The orbital wall fractures were divided into 4 subtypes: superior, medial, inferior, and lateral wall. Incidence of TON is analyzed according to subtypes, single and multiple wall fracture. RESULTS: Among 2629 patients with orbital wall fractures, 27 patients were diagnosed with TON with an incidence of 1.02%. In single wall fracture, only lateral wall showed significantly high TON incidence, which only zygomatic fracture was included in single lateral wall fracture. In multiple wall fracture, it was statistically significant in the superior wall. CONCLUSIONS: Fracture on lateral and superior orbital wall showed a tendency to increase the incidence of TON. Based on the above results, radiologic evaluation and physical examination is necessary for patient who has lateral and superior orbital wall fracture.

Traumatic optic neuropathy in orbital wall fractures- diagnostic parameters and treatment outcomes: A prospective observational study.

INTRODUCTION: The aim of the study was to evaluate the associated patterns of orbital wall fractures, diagnostic parameters of Traumatic optic neuropathy and its progress with Mega dose steroid therapy. MATERIALS AND METHODS: 25 patients with unilateral orbital wall fractures of traumatic aetiology were evaluated with ophthalmologic and radiographic parameters. All patients were prescribed Mega Dose Intravenous steroids irrespective of the timing of presentation. Ophthalmic assessment was repeated for same parameters every alternate day upto 2 weeks. RESULTS: Lateral orbital wall was found to be most commonly involved. Visual acuity, Pupillary Reactivity, Visual Field and Visual Evoked Potential showed statistically significant improvement post steroid therapy in early as well as late presenters. DISCUSSION: Highest incidence of Traumatic optic neuropathy was noted in multiple linear orbital wall fractures with highest incidence with lateral orbital wall involvement. Literature regarding Choice and timing of initiation of steroids based on timing of presentation is inadequate to justify skipping steroids to observe or undertake surgical intervention. In the present study marked improvement was noted post steroid therapy regardless of timing of presentation. The authors conclude that Visual evoked potential should be objectively tested and Mega dose steroid therapy should be initiated for all patients with Traumatic optic neuropathy for maximum benefit to the patient.

Surgical Treatment and Visual Outcomes of Adult Orbital Roof Fractures.

BACKGROUND: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis. METHODS: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses. RESULTS: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases. CONCLUSIONS: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Stereotactic radiosurgery in the treatment of parasellar meningiomas: long-term volumetric evaluation.

OBJECTIVE Parasellar meningiomas tend to invade the suprasellar, cavernous sinus, and petroclival regions, encroaching on adjacent neurovascular structures. As such, they prove difficult to safely and completely resect. Stereotactic radiosurgery (SRS) has played a central role in the treatment of parasellar meningiomas. Evaluation of tumor control rates at this location using simplified single-dimension measurements may prove misleading. The authors report the influence of SRS treatment parameters and the timing and volumetric changes of benign WHO Grade I parasellar meningiomas after SRS on long-term outcome. METHODS Patients with WHO Grade I parasellar meningiomas treated with single-session SRS and a minimum of 6 months of follow-up were selected. A total of 189 patients (22.2% males, n = 42) form the cohort. The median patient age was 54 years (range 19-88 years). SRS was performed as a primary upfront treatment for 44.4% (n = 84) of patients. Most (41.8%, n = 79) patients had undergone 1 resection prior to SRS. The median tumor volume at the time of SRS was 5.6 cm3 (0.2-54.8 cm3). The median margin dose was 14 Gy (range 5-35 Gy). The volumes of the parasellar meningioma were determined on follow-up scans, computed by segmenting the meningioma on a slice-by-slice basis with numerical integration using the trapezoidal rule. RESULTS The median follow-up was 71 months (range 6-298 months). Tumor volume control was achieved in 91.5% (n = 173). Tumor progression was documented in 8.5% (n = 16), equally divided among infield recurrences (4.2%, n = 8) and out-of-field recurrences (4.2%, n = 8). Post-SRS, new or worsening CN deficits were observed in 54 instances, of which 19 involved trigeminal nerve dysfunction and were 18 related to optic nerve dysfunction. Of these, 90.7% (n = 49) were due to tumor progression and only 9.3% (n = 5) were attributable to SRS. Overall, this translates to a 2.64% (n = 5/189) incidence of direct SRS-related complications. These patients were treated with repeat SRS (6.3%, n = 12), repeat resection (2.1%, n = 4), or both (3.2%, n = 6). For patients treated with a margin dose ≥ 16 Gy, the 2-, 4-, 6-, 8-, 10-, 12-, and 15-year actuarial progression-free survival rates are 100%, 100%, 95.7%, 95.7%, 95.7%, 95.7%, and 95.7%, respectively. Patients treated with a margin dose < 16 Gy, had 2-, 4-, 6-, 8-, 10-, 12-, and 15-year actuarial progression-free survival rates of 99.4%, 97.7%, 95.1%, 88.1%, 82.1%, 79.4%, and 79.4%, respectively. This difference was deemed statistically significant (p = 0.043). Reviewing the volumetric patient-specific measurements, the early follow-up volumetric measurements (at the 3-year follow-up) reliably predicted long-term volume changes and tumor volume control (at the 10-year follow-up) (p = 0.029). CONCLUSIONS SRS is a durable and minimally invasive treatment modality for benign parasellar meningiomas. SRS offers high rates of growth control with a low incidence of neurological deficits compared with other treatment modalities for meningiomas in this region. Volumetric regression or stability during short-term follow-up of 3 years after SRS was shown to be predictive of long-term tumor control.

Incidence of optic canal fracture in the traumatic optic neuropathy and its effect on the visual outcome.

OBJECTIVE: To correlate the intraoperative endoscopic findings with high-resolution CT (HRCT) for the diagnosis of optic canal fractures (OCF). To compare the visual outcome of patients with different types of OCF and without. DESIGN: A retrospective, comparative case series. PARTICIPANTS: 1275 consecutive patients (1275 eyes) with indirect traumatic optic neuropathy (TON). METHODS: Altogether, 1275 patients who underwent endoscopic transethmoid optic canal decompression (ETOCD) for unilateral indirect TON were reviewed from 1 October 2006 to 30 September 2014. HRCT performed prior to surgery were compared with findings during surgery. The visual outcomes before and after surgery were also compared. MAIN OUTCOME MEASURES: The presence and type of OCF detected by HRCT and during surgery; visual acuity prior to surgery and at 3 months after surgery. RESULTS: A total of 1275 patients (1275 eyes) were included, with 708 patients that had OCF visible on HRCT image. During surgery, an additional 187 (20.9%) patients with OCF were noticed. Among these, 136 had undisplaced fractures, most of which were linear intracanalicular fractures. The initial visual acuity of patients with OCF was worse than that of patients without OCF (p<0.01). However, no statistical difference existed in the final visual acuity at 3 months after surgery (>0.05). Significant statistical difference of surgical efficacy existed between all the patients with OCF and without OCF (p<0.001). CONCLUSIONS: Among patients with OCF, 20.9% were not detected by HRCT. Patients with OCF had a worse initial visual acuity than those without OCF. There was no significant difference in final visual acuity after ETOCD.

Epidemiological trends of traumatic optic nerve injuries in the largest Canadian adult trauma center.

BACKGROUND: There has been a paucity of information on the epidemiology of traumatic optic neuropathy (TON). This study documents epidemiology of TON over 2 decades in the largest level I adult trauma center in Canada. METHODS: Data on all the trauma patients admitted to Sunnybrook Health Sciences Centre from 1986 to 2007 were collected in a prospective database. The aggregate data on optic nerve injuries including demographic data, etiology, Injury Severity Score (ISS), and associated head and facial injuries were recorded. These were analyzed using univariate and multivariate techniques to summarize the association of different variables with TON. RESULTS: During the study period, 0.4% of all trauma patients had TON. The respective demographics for TON group were as follows: male, 76%; median for age, 33.5 years; length of hospital stay, 14 days; ISS, 32; and case fatality, 14%. About two thirds of patients with TON had associated significant head injuries. Conversely, 2.3% of patients with head injury had TON. The relative incidence of TON per year has remained variable from 0% to 1.2%. Motorized vehicle accidents remained the main etiology of TON (63%), but fall had the highest relative frequency leading to TON. In univariate analysis, both ISS and significant head injury were associated with TON. In multivariate analysis, TON was associated with only nasoethmoid complex fractures and significant head injury. CONCLUSIONS: These data provide useful information on the frequency and etiologies of TON. It also highlights the importance of studies on better diagnostic tools for TON.

Surveillance of traumatic optic neuropathy in the UK.

AIMS: The aim of this study is to provide epidemiological data on the incidence, aetiology, management, and visual outcome in traumatic optic neuropathy (TON) in the UK. METHODS: Patients with TON were identified prospectively by population-based active surveillance through the British Ophthalmic Surveillance Unit over a 2-year period with data obtained from an incident questionnaire and follow-up questionnaire sent to positive reporters. RESULTS: Incident and follow-up data were available on 121 and 97 (80%) patients, respectively. The minimum estimated incidence was 1.005 per million. Leading causes included falls (25.6%), road traffic accidents (RTAs) (21.5%), and assaults (20.7%). The median age was 31 years. There were 95 (78.5%) men. Presenting visual acuity (VA) was 6/60 or worse in 85 (70%) patients, with 43 patients (36%) with no perception of light. Associated injuries included 47 (39%) orbital wall fractures, 37 (31%) closed globe injuries, 23 (19%) ocular adnexal injuries, 23 (19%) skull fractures, and 18 (16%) intracranial bleeding. Sixty-five percent (75/116) received no acute treatment and 35% (41/116) received steroids and/or surgery. Of the treated group, 24% (8/33) and of the untreated group 20% (11/56) improved three lines or more of VA (P=0.61). Prompt ophthalmic examination (P=0.002), orbital fracture (P=0.046), high Glasgow Coma Scale (GCS) score (P=0.023), and poor initial VA (P=0.009) were associated with increased likelihood of treatment. Poor initial VA (P<0.001), orbital fracture (P=0.004), and significant head injury (P=0.038) were associated with poor visual outcome. CONCLUSIONS: This study suggested that young men were at greatest risk of TON. We detected a trend towards conservative management of this condition in the UK. TON was associated with significant ocular, orbital, and head injuries that highlighted the need for multidisciplinary management.

Giant olfactory groove meningioma: ophthalmological and cognitive outcome after bifrontal microsurgical approach.

OBJECT: Olfactory groove meningiomas arise in the midline along the dura of the cribriform plate and may reach a large size before producing symptoms. We conducted a retrospective study of patients with these lesions focused on pre- and post-operative investigations for ophthalmological, personality and cognitive disturbances. METHODS: The authors reviewed 36 patients with giant olfactory groove meningiomas surgically treated via a bifrontal approach. Ophthalmological evaluation included visual acuity, fundoscopy and visual fields while psychological evaluation included a Mini-Mental State Examination. Data was collected before, 1 and 12 months after surgery. Formal pre- and post-operative ophthalmological examinations discovered visual deficits in 55.5% of the patients. Within the first month after surgery, improvement of visual acuity and of visual field deficits was observed. In post-operative neuropsychological testing, higher mental functions showed improvement. The most frequent post-operative complication was persistent rhinorrhoea in two patients. CONCLUSIONS: Results at longest follow up indicate that cognitive changes and visual deficits will improve in patients with giant olfactory groove meningiomas after a bifrontal approach, without additional neurological deficits.