The Changes in Optic Nerve after Orbital Decompression Surgery for Thyroid Eye Disease and Case Reports of Ischemic Optic Neuropathy.

Purpose: To demonstrate the changes in the retinal nerve fiber layer (RNFL) after orbital decompression for thyroid eye disease (TED). Methods: We retrospectively enrolled 52 surgical TED patients, 30 nonsurgical TED patients, and 30 control subjects. Five surgical TED eyes with disc edema were excluded. The surgical TED patients were classified into the "dysthyroid optic neuropathy (DON)" group (16 eyes) and the "non-DON" group (83 eyes). Optical coherence tomography (OCT) and visual field (VF) examinations were performed preoperatively and 6 months later. The control subjects and nonsurgical TED patients received two OCT examinations at 6-month intervals. The postoperative changes in the RNFL thickness were compared between groups. Three cases with severe postoperative vision loss were presented additionally. Results: The changes in the RNFL thickness of the controls (0.5 ± 3.4 µm) and the nonsurgical TED patients (0.3 ± 2.8 µm) were significantly smaller than the surgical TED patients (P < 0.001). The DON group (-9.2 ± 9.2 µm) had greater RNFL thickness reduction than the non-DON group (-3.9 ± 5.4 µm) (P = 0.002). Bone removal decompression was associated with decreased RNFL in the non-DON (P = 0.025; ß = -2.49) and DON (P = 0.042; ß = -9.43) groups. Three cases who were hard to operate due to extensive fibrosis experienced severe vision loss postoperatively due to anterior ischemic optic neuropathy, posterior ischemic optic neuropathy, and posterior ciliary artery occlusion, respectively. Conclusions: TED patients experienced subclinical optic nerve injury and significant RNFL loss after the orbital decompression surgery. Aggressive manipulation during decompression surgery may lead to dreadful vision loss. Tailored surgical plans and delicate manipulation are warranted.

Surgery for nonarteritic anterior ischemic optic neuropathy.

BACKGROUND: Nonarteritic anterior ischemic optic neuropathy (NAION) is characterized by sudden and painless loss of vision in the eye, accompanied by pallid swelling of the optic disc. Its etiology is unknown and no medical therapy has been proven effective in treating this condition. Optic nerve decompression surgery, a proposed treatment for NAION, involves making two or more slits or a window in the tissue surrounding the optic nerve, thereby allowing cerebrospinal fluid to escape, and theoretically reducing the pressure surrounding the optic nerve. OBJECTIVES: The objective of this review was to assess the safety and efficacy of surgery compared with other treatment or no treatment in people with NAION. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2014), EMBASE (January 1980 to October 2014), PubMed (1948 to October 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 23 October 2014. SELECTION CRITERIA: All randomized trials of surgical treatment of NAION were eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: From full-text copies of all reports from relevant trials, one author extracted data which were verified by another author. No data synthesis was required. MAIN RESULTS: The one included trial, in which 258 participants were randomized, was stopped early for futility. At the time of the 24-month report the follow-up rate was 95.3% for six months and 67.4% for 24 months (174 participants; 89 careful follow-up and 85 surgery). There was no evidence of a benefit of surgery on visual acuity. Measurements of visual acuity and visual fields were performed by a technician masked to the treatment received. At six months 32.0% of the surgery group had improved visual acuity by 3 or more lines compared with 42.6% of the careful follow-up group (unadjusted risk ratio (RR) 0.75, 95% confidence interval (CI) 0.54 to 1.04). At 24 months 29.4% of the surgery group had improved compared with 31.0% of the careful follow-up group (unadjusted RR 0.95, 95% CI 0.60 to 1.49). Participants who underwent surgery more often lost 3 or more lines of visual acuity in the study eye, although the increased risk was not statistically significant. At six months 18.9% in the surgery group had worsened visual acuity in the study eye compared with 14.8% in the careful follow-up group (RR 1.28; 95% CI 0.73 to 2.24). At 24 months 20.0% in the surgery group had worsened visual acuity in the study eye compared with 21.8% in the careful follow-up group (RR 0.92; 95% CI 0.51 to 1.64). Participants who received surgery experienced both intraoperative and postoperative adverse events, including central retinal artery occlusion during surgery and light perception vision at six months (one participant); and immediate loss of light perception following surgery and loss of vision that persisted to the 12-month visit (two participants). In the careful follow-up group, two participants had no light perception at the six-month follow-up visit; one of these had improved to light perception at 12 months. Pain was the most common adverse event in the surgery group (17% in surgery group versus 3% in the careful follow-up group at one week). Diplopia (double vision) was the next most common complication (8% in the surgery group versus 1% in the careful follow-up group at one week); at three months there was no statistically significant difference in proportion of participants with diplopia between the two groups. AUTHORS' CONCLUSIONS: The only eligible trial provided no evidence of a beneficial effect of optic nerve decompression surgery for NAION. Future research should focus on increasing our understanding of the etiology and prognosis of NAION. New treatment options should be examined in the context of randomized clinical trials.

Optic nerve sheath decompression: a surgical technique with minimal operative complications.

BACKGROUND: The purpose of this study was to determine the safety and efficacy of optic nerve sheath decompression (ONSD) with a medial transconjunctival approach for a variety of indications in a larger population of patients than has previously been reported. METHODS: A retrospective chart review was performed on consecutive patients who underwent ONSD between January 1992 and December 2010. Before ONSD, all patients had documented evidence of progressive loss of visual acuity or visual field, or both. Postoperative follow-up visits were scheduled at 1 week, 1 month, and then every 3-6 months. Main outcome measures were visual acuity, visual fields, and surgical complications. RESULTS: Five hundred seventy-eight eyes of 331 patients underwent ONSD for progressive vision loss due to various indications, which included but were not limited to idiopathic intracranial hypertension (IIH), progressive nonarteritic ischemic optic neuropathy, and optic nerve drusen (OND). During a mean follow-up of 18.7 months (range, 1 week to 10 years), postoperative visual acuity remained stable or improved in 536 of 568 eyes (94.4%) and progressively worsened in 32 of 568 eyes (5.6%). Visual fields remained stable or improved in 257 of 268 eyes (95.9%) and progressive visual field loss occurred in 11 of 268 eyes (4.1%). There were no reported intraoperative complications. The most common postoperative complication was diplopia (6.0%). CONCLUSIONS: To our knowledge, this review represents the largest series of patients who have undergone ONSD for any indication. Our data are consistent with current literature supporting ONSD as a safe and effective procedure for IIH. Other indications for ONSD, such as progressive visual field loss associated with OND, warrant further study. Regardless of the indication, complications following ONSD with the technique described in this report are infrequent.

[Uveal effusion syndrome complicated by anterior ischemic optic neuropathy and cystoid macular edema]. / Zespól wysiekowy naczyniówki powiklany przednia niedokrwienna neuropatia nerwu wzrokowego oraz torbielowatym obrzekiem plamki.

The current paper presents a case of unique presentation of idiopathic uveal effusion syndrome. The 28 years old patient with combined bilateral choroidal and retinal detachment, recurrent in the left eye, underwent surgical procedures. He was treated with lamellar sclerectomy under the scleral flap in both eyes and another sclerectomy in the left eye later on. The apposition of the retina was achieved in both eyes and visual acuity improved significantly. Three months later, the patient developed anterior ischemic optic neuropathy in the right eye. In left eye after cataract phacoemulsification, persisted cystoid macular edema appeared.

Surgery for nonarteritic anterior ischemic optic neuropathy.

BACKGROUND: Nonarteritic ischemic optic neuropathy (NAION) is characterized by sudden and painless loss of vision in the eye, accompanied by pallid swelling of the optic disc. Its etiology is unknown and no medical therapy has been proven effective in treating this condition. Optic nerve decompression surgery, a proposed treatment for NAION, involves making two or more slits or a window in the tissue surrounding the optic nerve, thereby allowing cerebrospinal fluid to escape, and theoretically reducing the pressure surrounding the optic nerve. OBJECTIVES: The objective of this review was to assess the safety and efficacy of surgery compared with other treatment or no treatment in people with nonarteritic ischemic optic neuropathy. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 11), MEDLINE (January 1950 to November 2011), EMBASE (January 1980 to November 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (http://clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 19 November 2011. SELECTION CRITERIA: All randomized trials of surgical treatment of NAION were eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: We obtained full copies of all potentially relevant articles. One author extracted data which was verified by another author. No data synthesis was required. MAIN RESULTS: The one included trial randomized 258 participants and was stopped early for futility. At the time of the 24-month report the follow-up rate was 95.3% for six months and 67.4% for 24 months (174 participants; 89 careful follow up and 85 surgery). There was no evidence of a benefit of surgery on visual acuity. Measurements of visual acuity and visual fields were performed by a technician masked to the treatment received. At six months 32.0% of the surgery group had improved visual acuity by three or more lines compared with 42.6% of the careful follow up group (unadjusted relative risk (RR) 0.75, 95% confidence interval (CI) 0.54 to 1.04). At 24 months 29.4% of the surgery group had improved compared with 31.0% of the careful follow up group (unadjusted RR 0.95, 95% CI 0.60 to 1.49). Participants who underwent surgery had a greater risk of losing three or more lines of vision, although the increased risk was not statistically significant. At six months 18.9% in the surgery group had worsened compared with 14.8% in the careful follow up group (RR 1.28; 95% CI 0.73 to 2.24). At 24 months 20.0% in the surgery group had worsened compared with 21.8% in the careful follow up group (RR 0.92; 95% CI 0.51 to 1.64). Participants who received surgery experienced both intraoperative and postoperative adverse events, including central retinal artery occlusion during surgery and light perception vision at six months (one participant); and immediate loss of light perception following surgery and loss of vision that persisted to the 12-month visit (two participants). In the careful follow-up group, two participants had no light perception at the six-month follow-up visit; one of these had improved to light perception at 12 months. Pain was the most common adverse event in the surgery group (17% in surgery group versus 3% in the careful follow-up group at one week). Diplopia (double-vision) was the next most common complication (8% in the surgery group versus 1% in the careful follow-up group at one week); at three months there was no statistically significant difference in proportion of participants with diplopia between the two groups. AUTHORS' CONCLUSIONS: Results from the single trial indicate no evidence of a beneficial effect of optic nerve decompression surgery for NAION. Future research should focus on increasing our understanding of the etiology and prognosis of NAION. New treatment options should be examined in the context of randomized clinical trials.

Bilateral nonarteritic anterior ischemic neuropathy following acute angle-closure glaucoma in a patient with iridoschisis: case report / Neuropatia óptica isquêmica anterior não arterítica bilateral após crise de fechamento angular num paciente com iridosquise: relato de caso

A 55-year-old woman was referred to our clinic because of a one-week history of visual loss and raised intraocular pressure in the left eye followed 4 days later by visual loss in the right eye. Slit-lamp examination showed bilateral conjunctival hyperemia, slight diffuse corneal edema, shallow anterior chamber and fixed and dilated pupil in both eyes. Splitting of the anterior layers of the iris with fibrillar degeneration extending for approximately one quadrant inferiorly was presented in each eye. Fundus examination showed opitc disc edema with no vascular tortuosity and no cup in both eyes. The condition was treated as bilateral acute angle-closure glaucoma in a patient with irisdoschisis. After medical treatment and improvement of visual acuity, perimetry revealed a significant visual field defect especially in left eye; this case represents a rare concurrence of acute angle-closure glaucoma and bilateral nonarteritic ischemic optic neuropathy. Although most cases of elevated intraocular pressure, including acute angle-closure glaucoma, do not result in optic disc edema and irreversible vision loss, variations in the vascular supply of the nerve optic head along with others ocular systemic risk factors, may predispose certain individuals to nonarteritic ischemic optic neuropathy during periods of elevated intraocular pressure.

Paciente de 55 anos, sexo feminino, encaminhada para nosso serviço com história de perda de visão e aumento da pressão intraocular no olho esquerdo há uma semana seguida quatro dias após de perda visual no olho direito. À biomicroscopia hiperemia conjuntival bilateral, edema difuso da córnea, câmara anterior rasa e pupilas fixas e dilatadas em ambos os olhos. Separação do folheto anterior da íris no quadrante inferior estava presente em ambos os olhos. O exame do fundo do olho mostrava edema de disco sem tortuosidade vascular e sem escavação em ambos os olhos. O quadro clínico foi tratado como crise de fechamento angular bilateral num paciente com iridosquise. Após tratamento clínico e iridotomia bilateral com melhora da acuidade visual, a perimetria computadorizada revelou grave perda de campo visual, especialmente no olho esquerdo; este caso representa a rara ocorrência simultânea de crise de fechamento angular e neuropatia óptica isquêmica anterior não-arterítica bilateral. Embora a maioria dos casos com pressão intraocular elevada, incluindo crise de fechamento angular, não resulta em edema de disco e perda visual irreverssível, variações no suprimento vascular da cabeça do nervo óptico associados com outros fatores de risco sistêmicos, podem predispor certos indivíduos à neuropatia óptica isquêmica anterior durante períodos de elevação da pressão intraocular.

Visual fields at follow-up in the Ischemic Optic Neuropathy Decompression Trial: evaluation of change in pattern defect and severity over time.

PURPOSE: To evaluate change from baseline to 12 months follow-up in study and nonstudy (fellow) eye visual fields from the Ischemic Optic Neuropathy Decompression Trial (IONDT). DESIGN: Randomized controlled trial and observational study. PARTICIPANTS: The IONDT enrolled patients >or=50 years with acute nonarteritic ischemic optic neuropathy (NAION). Randomized patients (n = 258) had visual acuity 20/64 or refused randomization. INTERVENTIONS: Optic nerve decompression surgery (n = 127) or careful follow-up (n = 131). MAIN OUTCOME MEASURES: We measured visual fields at baseline and at 6 and 12 months follow-up. Using a computerized system, we classified visual field defects by pattern, location, and severity. We examined changes over time by treatment group, age, baseline comorbidities, and change in visual acuity. In fellow (nonstudy) eyes, we assessed change by whether NAION was present at baseline and also incidence of NAION by whether a visual field defect was present at baseline. RESULTS: We analyzed 245 study eye visual field pairs (179 and 66, randomized and nonrandomized, respectively) for change from baseline to 12 months. We observed significant changes in defect distribution within the central field (P = 0.02) for randomized eyes. Superior and inferior altitudinal defects were less severe at follow-up in both randomized and nonrandomized eyes. We observed an association between change in central field severity and change in visual acuity from baseline (P<0.001 at 6 months; P = 0.01 at 12 months; Kendall's tau-b), but no association between visual field change and treatment group, age, or baseline comorbidities. Superior and inferior visual field defects present at baseline in nonstudy eyes improved at follow-up. Fellow (nonstudy) eyes with normal fields did not have an increased risk of developing NAION compared with eyes with >or=1 defects. CONCLUSIONS: Visual fields of NAION patients enrolled in the IONDT were relatively stable from baseline to follow-up. A visual field defect in the nonstudy eye at baseline was not associated with development of NAION during follow-up compared with eyes with normal fields.

Histopathologic evaluation of optic neurotomy with microvitreoretinal blade or excimer laser in cadaver eyes.

BACKGROUND AND OBJECTIVE: To evaluate histopathologic features of optic neurotomy with microvitreoretinal (MVR) blade or excimer laser. MATERIALS AND METHODS: Optic neurotomy was performed in 11 cadaver eyes using a 20-gauge MVR blade and 3 cadaver eyes with pulsed xenon chloride excimer laser. Hematoxylin-eosin stained slides were used to evaluate the posterior segments of the globes, including the optic nerve head. RESULTS: No eyes in the MVR group had scleral macroscopic or microscopic perforation and there was no injury to the central retinal vein or artery. The distance between the neurotomy site and the central retinal vessels ranged from 50 to 500 microm at all histologic levels in 10 eyes and was approximately 10 microm in two histologic sections and 200 microm in a third section in 1 eye. Intraneural hemorrhage was found in 11% of eyes. Neurotomy was successful in 2 of 3 eyes with the excimer laser and no neurotomy was evident on sectioning in the third eye due to cloudy media. CONCLUSIONS: Optic neurotomy with an MVR blade was an effective procedure for scleral outlet relaxation in cadaver eyes, with no significant surgical complications. This preliminary study also demonstrates that the excimer laser can make non-mechanical cuts with relative ease and reliability.

[Radial optic neurotomy for ischemic central retinal vein occlusion]. / Therapie des Zentralvenenverschlusses durch radiäre Optikusneurotomie (RON). Funktionelle und morphologische Langzeitbeobachtungen.

INTRODUCTION: Occlusion of the central retinal vein (CRVO) is the second most frequent cause for blindness in the course of pathological changes of the vascular system. Vitreous haemorrhages and neovascular glaucoma are known as serious complications. Clinically accepted guidelines for treating CRVO do not exist up to now. In this report our results after radial optic neurotomy (RON) of patients suffering from CRVO associated with visual deterioration are summarised. PATIENTS AND METHOD: 78 patients (mean age 68 year, gender: 41 male, 37 female) with visual acuity of 0.2 or worse were treated with RON. Mean follow-up was 13 months. 35 patients underwent previously haemodilution treatment without success. Visual acuity tests, fluorescein angiographic appearance, OCT and postoperative complications were analysed, in 47 % additionally VEP, ERG and the visual field were evaluated. RON was carried out by conventional pars plana vitrectomy. Neurotomy was performed at the nasal side of the optic disc in all cases. Neither ILM peeling nor gas tamponade was used. Follow-up examinations were carried out after 2 and 4 weeks, after 3 and 6 months and after 3 years. RESULTS: Improvement of morphological parameters could be registered in 95 % of our patients by means of fluorescein angiography or OCT. Visual acuity improved in 81 % and worsened in 10 %. After 6 months patients with non-ischaemic CRVO had a significantly better visual acuity compared to patients with ischaemic CRVO. A retino-choroidal anastomosis could be observed in 38 (48 %) eyes, all these patients experienced visual improvement. The results of VEP and ERG showed partial recovery in all cases. A temporal visual field defect occurred postoperatively in 95 % of our patients. CONCLUSION: Visual acuity of patients suffering from non-ischaemic CRVO with low preoperative visual acuity and short history may improve after RON. Frequent complications were temporal field defects and vitreous haemorrhage. Further randomised studies are necessary to compare these results after RON with other alternative therapeutic procedures, for example, intravitreal injection of VEGF inhibitors.

Vitrectomy and release of presumed epipapillary vitreous traction for treatment of nonarteritic anterior ischemic optic neuropathy associated with partial posterior vitreous detachment.

OBJECTIVE: To study the results of vitrectomy and release of epipapillary vitreous adhesions for the treatment of nonarteritic anterior ischemic optic neuropathy (NAION) associated with partial posterior vitreous detachment (PVD). DESIGN: Prospective noncomparative interventional case series. PARTICIPANTS: A series of 16 patients with clinical picture of NAION and small discs associated with partial PVD, diagnosed clinically and confirmed by optical coherence tomography and B-scan ultrasonography. INTERVENTION: All patients underwent standard pars plana vitrectomy with meticulous removal of epipapillary vitreous adhesions within 1 month from the onset of visual symptoms. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), mean deviation of visual fields, and color vision testing. RESULTS: In 15 patients BCVA improved (93.7%), mean preoperative BCVA was 6/38 (0.82+/-0.53 logarithm of the minimum angle of resolution [logMAR]), which improved to 6/18 (0.49+/-0.37 logMAR) postoperatively at 3 months. Nine eyes (56%) had > or =3 lines of visual improvement. Visual fields improved in 4 patients and color vision improved in 1 patient. CONCLUSION: Vitreous traction from partial PVD may have a causative role in some cases of NAION associated with small discs. In these cases, vitrectomy and removal of epipapillary vitreous may result in improvement of visual acuity.

[Morphological rationale for autografting of musculus rectus ocularis fibers at revascular optic nerve decompression surgery].

The authors made a morphological study of the early proposed and clinically tested revascular optic nerve decompression operation developed to improve blood supply to the initial portion of the optic nerve in glaucoma-induced optic neuropathy. An experiment was carried out on 11 rabbits. The operated and control eyes were enucleated 1, 4, and 6 months after surgery. The experiment has established that muscle autografting into the retroscleral and paraneural space of the optic nerve is followed by a number of cellular reactions with the active participation of satellite cells, some of which may be associated with regenerative processes and presumably regarded as one of the cell autotherapy modalities.

Endoscopic transnasal orbital decompression for visual failure due to sphenoid wing meningioma.

AIM: To review a group of patients with sphenoid wing meningioma and visual impairment. The technique and results for endoscopic transnasal decompression of the orbital apex is presented. PATIENTS AND METHODS: Patients presenting between 1993 and 2004 with visual impairment due to sphenoid wing meningioma were identified. All patients had full ophthalmic assessment, automated visual field testing, and appropriate orbital imaging. Patients with clinical evidence of significant progression in visual impairment (loss of acuity, reduced colour discrimination, or field deterioration) underwent endoscopic transnasal orbital decompression. OUTCOME MEASURES: Assessment of visual function (Snellen acuity, Ishihara colour perception, and visual field testing), together with other measures of orbital structure and function (ocular balance, ductions, and exophthalmometry). RESULTS: Twelve patients (all women) presented to the Orbital Clinic between the ages of 38 and 71 years (mean 42.6; median 48.5 years) and with symptoms for an average of 32 months (3-102 months; median 22). The most common symptom was swelling and proptosis, in 11 (91%) patients, and subjective deterioration of vision had been noted in six cases (50%). Eight right orbits (67%) were affected and the preoperative acuity varied between Snellen 6/5 and counting fingers, with visual field impairment in all cases. There was an average of 5.0 mm of axial proptosis (range 5-9 mm; median 5). Endoscopic decompression was without complication in all cases. With a follow-up interval of 33.9 months (range 5-80; median 26 months), there was a subjective and objective improvement in visual functions-with Snellen acuity improving between 1 and 4 lines in seven patients, reduction in relative afferent pupillary defect in 10/12 patients, and improved visual field testing. There was a 2.3 mm reduction in proptosis (1-4 mm; median 3 mm) with less lid swelling, improved ocular balance and motility in four patients, and slightly worse diplopia in one patient. Three patients required further procedures: one had ipsilateral middle meatal antrostomy for retained secretions at 18 months and two had strabismus surgery. Three patients underwent fractionated radiotherapy for large tumours, or for late tumour growth and recurrent visual impairment. CONCLUSION: Orbital decompression by transnasal endoscopic ethmoidectomy appears to alleviate optic nerve compression due to sphenoid wing meningioma, with a reasonable relief of the condition for some years. Some patients will require later radiotherapy for progressive tumour growth or visual failure.

Surgery for nonarteritic anterior ischemic optic neuropathy.

BACKGROUND: Nonarteritic ischemic optic neuropathy is characterized by sudden and painless loss of vision in the eye, accompanied by pallid swelling of the optic disc. No medical therapy has been proven effective in treating this condition. OBJECTIVES: The objective of this review is to assess the safety and efficacy of surgery compared with other treatment or usual care in people with nonarteritic ischemic optic neuropathy. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Group Trials Register, in The Cochrane Library, MEDLINE, EMBASE and the UK National Research Register (NRR). The last search was on 13 July 2005. SELECTION CRITERIA: We included randomized controlled trials. DATA COLLECTION AND ANALYSIS: We obtained full copies of all potentially relevant articles. One randomized trial was eligible for inclusion. One author extracted data which was verified by another author. No synthesis was required. MAIN RESULTS: The one included trial randomized 258 participants and was stopped early. At the time of the 24-month report the follow-up rate was 95.3% for six months and 67.4% for 24 months (174 participants, 89 careful follow up and 85 surgery). There was no evidence of a benefit of surgery on visual acuity. At six months 32.0% of the surgery group had improved visual acuity by three or more lines compared with 42.6% of the careful follow up group (unadjusted risk ratio (RR) 0.75, 95% confidence interval (CI) 0.54 to 1.04). At 24 months 29.4% of the surgery group had improved compared with 31.0% of the careful follow up group (unadjusted RR 0.95, 95% CI 0.60 to 1.49). Participants who underwent surgery had a greater risk of losing three or more lines of vision. At six months 18.9% in the surgery group had worsened compared with 14.8% in the careful follow up group (RR 1.28; 95% CI 0.73 to 2.24). At 24 months 20.0% in the surgery group had worsened compared with 21.8% in the careful follow up group (RR 0.92; 95% CI 0.51 to 1.64). AUTHORS' CONCLUSIONS: Results from the single trial indicate no evidence of a beneficial effect of optic nerve decompression surgery for nonarteritic ischemic optic neuropathy.

Surgical or medical decompression as a first-line treatment of optic neuropathy in Graves' ophthalmopathy? A randomized controlled trial.

OBJECTIVE: Only a small percentage of Graves' ophthalmopathy (GO) patients develop optic neuropathy with impending loss of visual acuity. Therapy with methylprednisolone pulses is the treatment of first choice in severe and active GO patients. When the effect is insufficient, patients are usually treated with surgical decompression. We investigated whether surgery could become the first-line treatment, thus preventing treatment with steroids. DESIGN AND SUBJECTS: We performed a randomized trial in 15 patients with very active GO and optic neuropathy. Six patients were treated with surgical decompression, and nine with methylprednisolone i.v. pulses for 2 weeks, followed by oral prednisone for 4 months. The primary outcome was determined by changes in visual acuity. If the eye disease deteriorated despite treatment or did not improve sufficiently, patients were switched to the other treatment arm. RESULTS: The severity and activity of GO in both groups were similar at baseline. The Clinical Activity Score (CAS) was 6.3+/- 0.8 in the surgical group vs. 6.0+/- 0.5 in the steroids group and the Total Eye Score was 24+/- 6 vs. 25+/- 6. In the surgery group, 5/6 patients (82%) did not respond because of insufficient improvement in vision (n=3) or persistent chemosis (n=2), and all needed further immunosuppression. In the steroids group, 4/9 patients (45%) did not improve in visual acuity (P=0.132 vs. surgery group), and these needed decompressive surgery. All patients in whom therapy failed were switched to the other treatment arm and visual acuity improved in almost all patients. Visual acuity improved from 0.36 (0.02--0.40) to 0.90 (0.63--1.0) in the surgery group and from 0.50 (0.32--0.63) to 0.75 (0.32--1.0) in the steroids group at 52 weeks. At long-term follow-up in the surgery group 3/6 patients required squint surgery and 5/9 patients in the steroids group. Eyelid surgery was performed in 5/6 patients in the surgery group and in 4/9 patients in the steroids group. CONCLUSION: Immediate surgery does not result in a better outcome and therefore methylprednisolone pulse therapy appears to be the first-choice therapy.