Traumatic Optic Neuropathy After Head Trauma: Pathophysiology, Interventions, and Evidence From Meta-Analysis

Traumatic optic neuropathy (TON) is a vision-threatening complication of craniofacial trauma that often progresses to optic nerve atrophy and irreversible visual loss. However, the optimal management strategy remains controversial.

This systematic review and meta-analysis aimed to compare the efficacy and safety of surgical optic canal decompression versus corticosteroid therapy in patients with TON.

A comprehensive literature search was conducted in PubMed, Embase, Web of Science, and the Cochrane Library for studies published between January 2005 and July 2025. Both randomized controlled trials and observational studies reporting visual or structural outcomes were included. Data were pooled using a random-effects model, and subgroup analyses were performed according to intervention timing, type of injury, and baseline severity. Risk of bias was assessed with RoB 2.0 and the Newcastle-Ottawa Scale.

Thirty-four studies involving 1046 patients were included. Surgical decompression significantly improved visual outcomes compared with corticosteroids (62% vs. 37%; OR = 2.35, 95% CI: 1.55-3.56). Subgroup analyses indicated superior outcomes with early surgery (≤ 7 days; OR = 2.91, 95% CI: 1.74-4.88) and in indirect TON (OR = 2.62, 95% CI: 1.70-4.04), whereas benefits were less pronounced in direct injuries. Structural outcomes also favored surgery, with greater retinal nerve fiber layer preservation (mean difference = +9.4 μm) and lower incidence of optic atrophy (OR = 0.44, 95% CI: 0.27-0.71). Adverse events were mild and comparable between groups. Funnel plot analysis revealed no significant asymmetry, suggesting minimal publication bias.

This systematic review and meta-analysis provides indicative evidence that early surgical decompression may offer superior outcomes compared with corticosteroid therapy, especially for indirect injuries. Specifically, this meta-analysis suggests that surgical intervention may offer superior outcomes without increasing adverse events. Nevertheless, the evidence base remains limited, and these results should be interpreted with caution. While corticosteroids alone show limited benefit and may be considered adjunctive when surgery is not feasible, high-quality multicenter randomized trials are urgently needed to standardize treatment protocols and optimize patient outcomes.