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.

Efficacy of Treatments in Nonarteritic Ischemic Optic Neuropathy: A Systematic Review and Meta-Analysis.

BACKGROUND: Nonarteritic Anterior Ischemic Optic Neuropathy (NAION) is the second most common cause of optic nerve-related permanent visual loss in adults. AIM: We aimed to analyze the efficacy of the noninvasive and minimally invasive therapeutic options of NAION. METHODS: We performed a systematic literature search in MEDLINE, EMBASE, and CENTRAL from inception to 10 June 2019 to identify the studies that report on the effect of different therapies on visual acuity (VA) and visual field (VF). Weighted mean difference (WMD) with 95% confidence interval (CI) was calculated for these outcomes. The efficacy of steroids was investigated in quantitative, oxygen, steroid plus erythropoietin (EPO), levodopa/carbidopa, memantine, and heparin-induced extracorporeal LDL/fibrinogen precipitation (HELP) therapies and other therapeutic modalities in qualitative synthesis. RESULTS: Thirty-two studies were found to be eligible. We found that steroid therapy compared to control did not improve VA (p = 0.182, WMD = 0.14, 95% CI: -0.07, 0.35) or VF (p = 0.853, WMD = 0.16, 95% CI: -1.54, 1.86). Qualitative analysis could be performed for oxygen, steroid plus EPO, and HELP as well, however, none of them showed VA and VF benefit. Two individual studies found memantine and levodopa beneficial regarding VA. CONCLUSION: Our systematic review did not reveal any effective treatment. Further investigations are needed to find therapy for NAION.

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.

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 optic 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.

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.

[Temporal arteritis: treatment controversies]. / En la arteritis de la temporal: controversias terapéuticas.

INTRODUCTION: Although giant cell or temporal arteritis represents 5-10% of ischaemic optic neuropathies and is the most common arteritis in people over 60 years old. Currently there is no established treatment with oral glucocorticoids available. BACKGROUND: Glucocorticoid (GC) is still the treatment of choice but has to be started without delay in order to prevent neurological or systemic complications. However, we can resort to intravenous treatment in cases where there is loss of sight or other neurological symptoms. In cases refractory to GC or in those in whom we wish to decrease the dose due to adverse effects, individualised treatment with methotrexate or TNF blockers could be indicated. There is insufficient evidence to recommend other treatments, such as azathioprine, dapsone, cyclosporine, cyclophosphamide or imitinib. In patients with vascular risk factors, anti-platelet therapy with ASA should be assessed. Surgical treatment should be considered in selected cases with symptoms due to arterial stenosis. CONCLUSIONS: The corticoids continue to be the treatment of choice in temporal arteritis, however, given the clinical variability of the disease and the special characteristics of this group of patients, usually elderly and with systemic diseases, we believe that individualised treatment with coherent therapeutic guidelines are essential. Currently there is not only treatment with oral glucocorticoids available, although in our patients we can choose to use intravenous mega-doses, anti-platelet treatment, resort to methotrexate or TNF inhibitors in refractory cases, or even consider surgical approaches.

Radial optic neurotomy for central retinal vein occlusion: long-term retinal perfusion outcome.

BACKGROUND/AIMS: To analyze the long-term changes in retinal perfusion and functional improvement induced by radial optic neurotomy (RON) in central retinal vein occlusion (CRVO). METHODS: Sixty-three eyes of 63 consecutive patients with CRVO were included. Twenty-eight (44.5%) patients underwent RON and 35 (55.5%) were followed as a control group. Time of arteriovenous transit and visual acuity were determined at baseline and after 1-year follow-up. RESULTS: After 1 year, retinal perfusion status improved in 63.1% of operated eyes and 14.3% of controls (p = 0.048). The improvement in arteriovenous retinal transit was statistically significant (p = 0.023) only in the RON group. The visual improvement in the RON group was significantly better (p = 0.043) than in the control group. Moreover, the development of chorioretinal anastomosis was significantly higher (p = 0.036) after RON than in controls and correlated with better functional results. In operated eyes there was a lower incidence of CRVO-related complications. CONCLUSION: RON improved retinal perfusion and achieved a better functional outcome. The measurement of perfusion changes as presented here may be useful for monitoring CRVO and assessing other treatment modalities.

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.