Endoscopic optic nerve decompression in traumatic optic neuropathy: our experience in a tertiary care centre

<p><strong>Background: </strong>Traumatic optic neuropathy (TON) a vision threatening disorder requires early diagnosis and prompt treatment. High dose steroid injections, optic nerve decompression or combined therapy are the available current treatment options. This study aims to determine the visual outcome with transnasal endoscopic optic nerve decompression in patients with TON having no improvement in vision despite high dose steroids.</p><p><strong>Methods:</strong> A prospective study was conducted at the department of ENT, government medical college Kozhikode; on patients who presented with loss of vision following history of trauma. All patients suspected of compressive optic neuropathy received injection methyl prednisolone (30 mg/kg/day) with assessment of vision and HRCT scan. Patients with deterioration or no improvement in vision despite high steroid therapy were taken up for trans-nasal endoscopic optic nerve decompression.</p><p><strong>Results:</strong> In our study 19 patients with TON underwent trans-nasal endoscopic optic nerve decompression. 11(57.9%) patients had improvement of vision, 7 (36.8%) patients had no improvement of vision and 1 (5.3%) patient had worsening of vision. The visual improvement was seen in 8 (80%) patients when treatment was initiated within 7 days and in only 3(33.3%) patients when treatment was initiated after 7 days. The visual acuity at presentation and time interval between trauma and intervention are factors that determine better visual outcomes.</p><p><strong>Conclusions:</strong> The decreased visual acuity in TON requires prompt treatment. High dose steroid must be started at once when it is suspected or diagnosed. The timely surgical intervention with trans-nasal endoscopic optic nerve decompression is a relatively safe and effective technique enabling better visual prognosis.</p>

Traumatic Optic Neuropathy Our Experience with Combined Therapy

Objective Traumatic optic neuropathy (TON) is an important cause of severe vision impairment after sustaining a closed head injury. This study describes the safety and efficacy of combined therapy in the management of TON. Methods A retrospective analysis of 23 consecutive cases of unilateral TON managed with combined therapy (steroid and surgery) were performed. Statistical analysis of patient characteristic, timing of vision loss, radiological and intraoperative findings, and pre- and post-treatment vision were compared to assess the prognostic factors. Results Seventeen patients (85%) had vision improvement with combined therapy. Three patients (15%), who recorded no improvement, initially presented with no perception of light, and loss was sudden and immediate. With steroids, 9 patients improved, all of them presented with perception of light (PL) or better and vision improved to (6/6 in five, 6/9 in one, 6/18 in 3). Eleven patients (6 PL–ve and 5 PL + ve after failed steroid therapy) underwent endoscopic optic nerve decompression and eight had improvement in vision. The status of vision at presentation was only statically significant prognostic factor (p < 0.02). Others prognostic factors, for example, time of starting treatment, surgery, and presence of fracture in optic canal, were not found statistically significant (p > 0.05). There were no significant intra- and postoperative complications. Conclusion Combined therapy is safe and effective in management of TON. Mild form injury with some preserved vision at presentation respond well to steroids, while endoscopic nerve decompression should be reserved in cases with failed steroid therapy.

Right radial nerve decompression for refractory radial tunnel syndrome

Background: Radial tunnel syndrome arises due to compression of the radial nerve through the radial tunnel.[1,5] The radial nerve divides into superficial and deep branches in the forearm. The deep branch travels posteriorly through the heads of the supinator where compression commonly occurs.[3,9,7] This syndrome results in pain in the hand and forearm with no motor weakness.[8] This condition can be treated conservatively with splinting and anti-inflammatory medication.[2,4,6] For cases of refractory radial tunnel syndrome, surgical management can be considered. Herein, we have presented a step-by-step video guide on how to perform a radial nerve decompression with a review of the relevant anatomy and surgical considerations. Case Description: A 68-year-old right-handed woman presented to the Mayo Clinic (Scottsdale, AZ) with the right elbow pain which radiated to the forearm causing significant difficulties with daily tasks. She had been dealing with worsening symptoms for 4 months. The patient’s history of gardening and clinical presentation allowed for diagnosis of radial tunnel syndrome. After conservative measures failed and other differential diagnoses were excluded, surgical decompression was recommended to treat her symptoms. The patient’s right arm was marked preoperatively between the brachioradialis and extensor carpi radialis longus (ECRL) muscles. The posterior cutaneous nerve of the forearm was identified which allowed for the determination of the interval between the brachioradialis and ECRL. Separation of the two muscles allowed for the identification of the radial sensory nerve. A nerve stimulator was used to confirm the sensory nature of this nerve. The nerve to the extensor carpi radialis brevis (ECRB) was identified and retracted with a vessel loop. Dorsal to the nerve to the ECRB is the posterior interosseous nerve (PIN), which was identified and retracted with a vessel loop. The fascia of the ECRB was divided both longitudinally and transversely and the supinator below was identified. The supinator muscle was carefully divided to further decompress the PIN. Informed consent for publication of this material was obtained from the patient. Conclusion: The patient tolerated the procedure well and reported significantly reduced pain at 7-month follow-up. To the best of our knowledge, video tutorials on this procedure have not been published. This video can serve as an educational guide for peripheral nerve specialists dealing with similar lesions.