Traumatic

Optic
Neuropath
y

Khairun Nisa
 Traumatic Optic Neuropathy (TON)
Traumatic Optic Neuropathy (TON) is a
condition in which acute injury to the optic
nerve from direct or indirect trauma results
in vision loss.

The severity of optic nerve damage may

range from simple contusion to complete
avulsion of the optic nerve.

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NERVUS OPTIK

INTRAOKULAR

INTRAORBITAL

INTRAKANALIKULAR

INTRAKRANIAL
 EPIDEMIOLOGY

• Traumatic optic neuropathy occurs in 0.5-5 % of patients

presenting with closed head trauma and in 2.5 % of patients
presenting with midfacial fracture
• Young > Old
• Males > Females

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 CLASSIFICATION
 TRADITIONALLY
 Direct
 Indirect
 ANATOMICALLY
 Anterior optic neuropathy
 Posterior optic neuropathy
 SITE OF INJURIES
 Intraocular
 Intraorbital
 Intracanalicular
 Intracranial
 Etiology
‐ The most common cause of TON is
‐ Indirect injury to the optic nerve

‐ Direct TON
‐ penetrating injury
‐ Orbital hemorrhage ( orbital compartment syndrome)

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MECANISM : DIRECT INJURIES
 MECANISM : INDIRECT INJURIES

• Indirect trauma to the optic nerve is more common than direct optic nerve injury.
Indirect TON may occur even with relatively minor head injury.

• The trauma involves the frontal or maxillary bone, and the transmitted forces damage
the optic nerve at the orbital apex.

• The pathophysiology presumably involves shear forces on the nerve and possibly its
vascular supply in the optic canal.

American Academy of Ophthalmology. BCSC section 4. Neuro-Ophthalmology. Bhatti. ed. San Francisco: American Academy of Ophthalmology; 2019–2020.
 MECANISM :
INDIRECT INJURIES
 Signs
• Decreased Vision. Vision loss is typically immediate and often severe (24%–86% of patients have no
light perception at presentation).
• Decreased color vision (Dyschromatopsia)
• Afferent pupillary defect
• Visual field deficits

Symptom
• Blurry Vision
• Scotoma
• Decreased color sensation

American Academy of Ophthalmology. BCSC section 4. Neuro-Ophthalmology. Bhatti. ed. San Francisco: American Academy of Ophthalmology; 2019–2020.
 Physical examination
• The initial external eye exam may show signs of
orbital trauma or fracture (soft tissue edema,
hematoma, step-off on palpation of orbital rim).
• Decreased visual acuity and an afferent pupillary
defect (in unilateral cases) are also seen.
• On funduscopy, the initial optic nerve head
assessment will be normal. Optic atrophy may be
seen 3-6 weeks after trauma.
 Differential diagnosis
‐ Posterior ischemic optic neuropathy
‐ Optic neuritis
‐ Optic nerve avulsion
‐ Non-organic vision loss
‐ Pre-/intra-/subretinal hemorrhage
‐ Choroidal Rupture
‐ Commotio retinae

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 INVESTIGATIONS
• History: Mechanism of injury Loss of consciousness, nausea and/or
vomiting, headache, clear nasal discharge

• Visual acuity testing may be difficult depending on the patient's mental

status, use of sedatives, narcotics

• Pupillary evaluation : Relative afferent papillary defect (RAPD) is in

cases of unilateral TON. In the absence of RAPD either there is no TON
or there is bilateral TON
 INVESTIGATIONS
• EOM motility
• Color vision : Checking red desaturation is a useful alternative if color
plates are not available.
• Visual fields : Any type of field defects may be seen in optic nerve trauma
e.g. altitudinal, central, paracentral, hemianopic,etc.
• Fundus examination : The optic nerve head will appear normal initially, but
optic atrophy can be seen 3-6 weeks after the initial traumatic event.
• Neuro-imaging : Globe rupture , IOFB, fracture
• Humphrey (HVF)
 INVESTIGATIONS
VISUAL EVOKED POTENTIALS (VEP)

Visual evoked potentials (VEP) are used to assess the visual pathways through the optic nerves
and brain. VEP is an important procedure for evaluating visual function and is highly sensitive to
lesions of the optic nerve and anterior chiasm. VEP may be affected by variety of physiological
factors including age, sex, visual acuity and pupillary size.

NORMAL REVERSAL VEP

Sharma R, Joshi S, Singh KD, Kumar A. Visual Evoked Potentials: Normative Values and Gender Differences. J Clin Diagn Res. 2015;9(7):CC12-CC15. doi:10.7860/JCDR/2015/12764.61
CLINICAL APPLICATION
DELAYED
LATENCY REDUCED AMPLITUDE

• Demyelinating optic • Optic atrophy

neuritis • Toxic
• Neurotransmitter • Compressive
disorders • Uncorrected refractive
• Glaucoma error
• Uncorrected refractive • Ambylopia
error
• Ageing
 MANAGEMENT
• The injury to optic nerve function results from raised pressure in the orbit and may be
relieved by elevating the head and administering Diamox to lower the intraocular
pressure. If conservative measures fail, then a lateral canthotomy and drainage of orbital
haemorrhage or drainage of the air (Orbital emphysema) by a retrobulbar needle may
restore function.
• Therapy for indirect TON is controversial. Although the prognosis for vision recovery
has generally been regarded as poor, numerous reports describe occasional spontaneous
recovery of some visual function.

Sarkies, N. Traumatic optic neuropathy. Eye 18, 1122–1125 (2004). https://doi.org/10.1038/sj.eye.6701571

 management
‐ The management of TON is controversial, however, the
data in the literature to date has not shown any treatment
to be superior to observation
‐ Medical therapy
‐ Surgery

https://eyewiki.aao.org/Traumatic_Optic_Neuropathy
18
 Medical therapy
‐ Some authors have supported the use of high or “mega” dose
corticosteroids in TON. This therapeutic regimen has been
extrapolated from the National Acute Spinal Cord Injury Study
II, which showed a statistically significant improvement in
neurologic outcome (motor and sensory) in a subgroup analysis
of acute spinal cord injury patients receiving a
methyprednisolone 30 mg/kg bolus within eight hours of injury,
followed by 5.4 mg/kg/hr for 23 hours,.[3] Subsequently
however,the CRASH (Corticosteroid Randomization After
Significant Head injury) study showed an increased relative risk
of death in patients given this regimen after significant head
injury.[4] The International Optic
19 Nerve Trauma Study also did
not show a difference in final visual acuity between patients
 Surgery
‐ Surgical intervention for TON was shown to not be
beneficial in The International Optic Nerve Trauma Study.
Some have supported the use of surgery in certain
scenarios such as when a bony fragment is abutting to
optic nerve or in the case of an optic nerve sheath
hematoma but there is no good data supporting surgery for
indirect TON.

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 CORTICOSTEROID STUDY

National Acute Spinal Cord The CRASH The International Optic

Injury Study 2 [NASCIS II], a (Corticosteroid Nerve Trauma Study also
multicenter clinical trial that
Randomization After did not show a difference in
evaluated patients with acute
Significant Head injury) final visual acuity between
spinal cord injury.
study showed an increased patients with TON that
Methylprednisolone was
associated with a significant relative risk of death in were observed compared
improvement in both motor and patients given this regimen with those given steroids or
sensory function compared to after significant head optic canal decomprossion.
patients treated with a placebo injury.

Sarkies, N. Traumatic optic neuropathy. Eye 18, 1122–1125 (2004). https://doi.org/10.1038/sj.eye.6701571

 PROGNOSIS

• In the International Optic Nerve Trauma Study, visual acuity improvement

of >3 lines was seen in 57% of the untreated group, 52% of the group that
received steroids alone, and 32% of the group that underwent surgery.

• This was not a statistically significant result.

Sarkies, N. Traumatic optic neuropathy. Eye 18, 1122–1125 (2004). https://doi.org/10.1038/sj.eye.6701571

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gold, butter and ripe and fresh snow clear sky and the deep sea and courage and of outer space gold, butter and ripe
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