Diagnosis and management of traumatic optic neuropathies

If a patient has vision immediately following trauma, with subsequent deterioration of visual acuity and/or field, and the presence of a relative afferent pupillary defect, compression of the optic nerve or its vascular supply is very likely. We currently lack a proven optimal treatment, but in the otherwise healthy patient, we suggest an intravenous (IV) loading dose of methylprednisolone 30 mg/kg, and a second 15-mg/kg dose 2 hours after the initial dose, followed by 15 mg/kg every 6 hours. Optic nerve decompression is indicated in this situation when corticosteroids have only a temporary effect, a diminishing one, or none at all. It may also be indicated when there is evidence of a traumatic optic neuropathy with a fractured or narrowed optic foramen or with dislocated bone fragments that directly impinge on the nerve. Optic nerve sheath decompression is indicated in progressive traumatic optic neuropathy when an enlarged fluid-filled sheath has been demonstrated sonographically.