Ophthalmic Plastic Surgery, Lions Eye Institute, Department of Ophthalmology, Albany Medical Center, Albany (Slingerlands), New York.
Illinois Eye and Ear Infirmary, University of Illinois College of Medicine at Chicago, Chicago, Illinois.
Ophthalmology. 2021 Jun;128(6):928-937. doi: 10.1016/j.ophtha.2020.10.038. Epub 2020 Nov 6.
To review the literature on the efficacy and safety of medical and surgical interventions for indirect traumatic optic neuropathy (TON), defined as injury to the nerve that occurs distal to the optic nerve head.
A literature search was conducted on October 22, 2019, and updated on April 8, 2020, in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis.
No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation. Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage.
Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON.
回顾间接创伤性视神经病变（TON）的医学和手术干预的疗效和安全性的文献，TON 定义为视神经头部远端的神经损伤。
2019 年 10 月 22 日在 PubMed 数据库中进行了英语原始研究的文献检索，并于 2020 年 4 月 8 日进行了更新，以评估各种间接 TON 干预措施的效果。确定了 172 篇文章；41 篇符合概述的纳入标准，选择进行全文审查和摘要。在全文审查中，共有 32 项研究符合所有研究标准，并纳入分析。
没有研究符合 I 级证据标准。有 7 项研究（1 项 II 级研究和 6 项 III 级研究）探讨了皮质类固醇治疗，其结果并不比观察治疗更好。有 20 项研究（3 项 II 级研究和 17 项 III 级研究）评估了视神经管减压和皮质类固醇的使用。尽管减压后视力有所改善，但直接比较手术与药物治疗的研究并未报告减压后结果一致改善。有 4 项研究（1 项 II 级研究和 3 项 III 级研究）评估了促红细胞生成素的使用。尽管最初的研究表明有效，但将其与观察和皮质类固醇的使用进行直接比较未能证实该药物的有用性。有 1 项研究（II 级）记录了左旋多巴加卡比多巴治疗的视力改善。所有这些干预措施的并发症发生率各不相同。药物干预一般与较少的并发症相关，而视神经管减压术存在严重副作用的风险，包括出血和脑脊液漏。
尽管有皮质类固醇、视神经管减压术和间接 TON 药物治疗的视力改善报告，但已发表证据的权重并未证明这些干预措施中的任何一种都有一致的益处。总之，目前发表的研究尚未就 TON 的首选治疗方法达成共识。治疗策略应根据每个患者的具体情况定制。需要更明确的治疗试验来确定间接 TON 的最佳治疗策略。
