Indirect traumatic optic neuropathy:modeling optic nerve injury in the context of closed head trauma

Traumatic optic neuropathy:Traumatic brain injury is one of the leading causes of disability and mortality in the United States.It impacts people of all ages and demographics,particularly younger males and members of the military.Vision loss is commonly associated with traumatic brain injuries of all severities and can leave patients permanently disabled.This vision loss can be caused by injury to the visual system at multiple levels,including the eyes,optic nerves,and many different sites in the brain and brainstem(Sen,2017).Despite the far-reaching effects of visual impairment after traumatic brain injury,its incidence after traumatic brain injury is not well measured,and few successful treatments have been identified or implemented.

Prognostic factors of trans-ethmosphenoid optic canal decompression for indirect traumatic optic neuropathy

AIM： To investigate a possible correlation between visual acuity（VA） prognosis and the presence at baseline of various orbital and ocular signs in patients affected by indirect traumatic optic neuropathy（ITON）. METHODS： From July 1 st, 2012 to July 1 st, 2015, 224 adults diagnosed with ITON who underwent endoscopic transethmosphenoid optic canal decompression（ETOCD） were reviewed. Visual outcome before and after treatment were taken into comparison. RESULTS： Accompanied older in age, longer time to medical treatment and existence of optic canal fracture（OCF） were the independent predictors for poor postoperative VA and lower improvement degree of visual acuity（IDVA）, while worse preoperative VA was predictive factor for poor postoperative VA only. Mean value of IDVA in patients with OCF was 0.19±0.30. Mean value of IDVA in patients without OCF was 0.29±0.35. IDVA in cases without OCF was significant higher than those with OCF（t=2.272, P〈0.05）. CONCLUSION： Patients suffered from ITON without OCF before ETOCD have better surgical outcome than those with OCF. Older in age, longer time to medical treatment and existence of OCF are independent factors for poor VA prognosis and lower IDVA. Preoperative VA is independent factor for VA prognosis only.

Newly onset indirect traumatic optic neuropathy-surgical treatment first versus steroid treatment first

AIM: To investigate the efficacy and safety of the treatment of endoscopic trans-ethmosphenoid optic canal decompression(ETOCD) with combination of steroid in patients with newly onset indirect traumatic optic neuropathy(ITON) and compare the outcome between immediate ETOCD treatment and ETOCD with preoperative steroid treatment. METHODS: Patients presented as newly onset ITON(suffered trauma within 3 d) at a tertiary medical center between Mar 1 st, 2016 and Mar 1 st, 2018 were enrolled in this study. All patients were equally and randomly divided into 2 groups. Cases in group A were performed ETOCD immediately after admition while cases in group B were prescribed by methylprednisolone(20 mg/kg · d) for 3 d before ETOCD. Methylprednisolone(20 mg/kg · d) was used after surgery for 6 d in group A and 3 d in group B. Follow-up was up to 3 mo in all cases. Visual acuity(VA) before and after treatment between the two groups were taken into comparison. RESULTS: Complete postoperative data were acquired from 34 patients in group A and from 32 patients in group B. Group A had significantly higher effective rate in VA than group B(χ~2 =4.905, P=0.027).CONCLUSION: For patients with newly onset ITON, combination treatment of ETOCD with high-dose steroid is an effective and safe way. Immediate surgery will lead to better prognosis for these cases.

Traumatic optic neuropathy:a review of 24 patients

AIMTo evaluate the clinical presentations of traumatic optic neuropathy and to assess the visual outcome of three groups of patients managed differently (conservative, intravenous corticosteroids only and combination of intravenous and oral corticosteroids) at an academic tertiary care referral centre.

Traumatic optic neuropathy secondary to acupuncture treatment for glaucoma: A case report

Internal organ injuries have been recognized as a major complication of acupuncture. Reported ocular adverse events include traumatic cataract, oculomotor nerve injury, endophthalmitis and retinal puncture. We report a case of traumatic optic neuropathy and self-sealed globe perforation following acupuncture. A Chinese gentleman with primary open angle glaucoma presented with sudden loss of vision in the right eye after acupuncture therapy. The vision dropped to 2/60 from 6/6 premorbid. Relative afferent pupillary defect was present. Fundus examination showed hemorrhage from the optic disc into the vitreous. It is likely that the optic nerve injury occurred when the acupuncture needle was advanced deep into locations near the optic nerve. Main acupoints used in acupuncture treatment of glaucoma include Tongziliao GB-1, Jingming BL-1 and Chengqi ST-1. It is crucial to have a good understanding of ocular anatomy to avoid potentially blinding complications.

Analysis of retinal vasculature changes in indirect traumatic optic neuropathy using optic coherence tomography angiography

AIM:To assess the retinal vasculature alterations in indirect traumatic optic neuropathy(ITON)patients following craniofacial trauma by optic coherence tomography angiography(OCTA).METHODS:Patients diagnosed of monocular ITON were recruited from August 2016 to May 2020.OCTA was performed using the Angio Vue OCT-A system for two cube scans centered at the optic nerve head and fovea.OCTA data included thicknesses of peripapillary retinal nerve fiber layer(RNFL)and macular ganglion cell complex(GCC),as well as proportion of capillary perfusion and data were analyzed for correlation with post-injury timepoints:within 7,8-30,31-90,and 91-365d.RESULTS:A total of 73 ITON patients were studied.Significant thinning of RNFL and GCC layers and attenuation of microvascular perfusion were observed in ITON eyes as compared to contralateral unaffected eyes(for most of the analyzed sectors and quadrants,P<0.05).Without respect to surgical intervention and vision recovery,the decrease in retinal layer thicknesses and microvascular perfusion was time-dependent,and most significant within three months(P<0.001).CONCLUSION:ITON presents with time-dependent thinning of retinal layers and attenuation of microvasculature,indicating possible degeneration of retinal ganglion cells due to reduced retinal blood supply.

Effect of Wei’s triple nine needling therapy on flash visual evoked potentials in rats with traumatic optic neuropathy

Objective:To investigate the effect of Wei’s triple nine needling therapy on the N2-P2 wave of the flash visual evoked potential(FVEP)in rats of the of the transverse directional pulling model.Methods:Thirty-six Wistar rats were randomly grouped,nine were in normal control group without any treatment,and the remaining 27 were surgically modelled in the right eyes.Eighteen of these rats were randomly divided into a Wei’s triple nine needling therapy group and a model group of nine rats each after the TON model was made using the transverse quantitative retraction method.The other 9 rats were sham-operated,and only the optic nerve was exposed without retraction.On the next day of modelling,the Wei’s triple nine needling therapy group was treated with Wei’s triple nine needling therapy for 20 minutes/1 time/1 day for 14 days.The model group,sham-operated group and normal control group were not intervened.Wei's triple nine acupoints were represented as follows:1st link:"Jingming"(BL1)and"Chengqi"(ST1);2nd link:"Sizhukong"(SJ23)penetrating"Taiyang"(EX-HN5);and the third:"Fengchi"(GB 20)and"Taichong"(LV3).The FVEP of each group was observed on 1d,7d and 14d.The FVEP of each group was observed on 1d,7d and 14d.Results:Compared with the model group,the N2 wave latency and P2 wave latency were shortened in the Wei’s triple nine needling therapy on 1d(P<0.05,P<0.01);on 7d,their N2 wave latency was shortened(P<0.01)and the N2-P2 wave amplitude was increased compared with the model group(P<0.05);on 14d,their P2 wave latency was shortened(P<0.05)and the N2-P2 wave amplitude was increased.There was no statistical difference in N2 wave latency,P2 wave latency and N2-P2 wave amplitude in the sham-operated group on 1d,7d and 14d(P>0.05).The delayed N2 and P2 wave latencies in the model group did not improve from 1d to 14d(P>0.05)and the amplitude decreased throughout,showing a significant difference on 14d compared to 1d(P<0.05).In contrast,the N2 wave latency in Wei’s triple nine needling therapy group was not significantly different until 7d to 14d(P<0.05);its P2 wave latency,although significantly delayed from 1d to 7d(P<0.05),recovered on 14d and reached a level that was not statistically different from 1d and 7d(P>0.05).There was also no significant decrease in N2-P2 wave amplitude between 1d and 14d in Wei’s triple nine needling therapy group(P>0.05).Conclusion:In this experiment,the TON rat model was successfully established by the transverse quantitative retraction method,and the treatment of TON rats with Wei’s triple nine needling therapy reduced the P2 wave delay of the FVEP electrophysiological signal and increased the N2-P2 amplitude,which had a certain positive effect on the repair of optic nerve injury,probably related to its effect of improving the conduction function of the optic nerve and protecting the retinal ganglion cells that had not been degenerated and necrosed.

外伤性视神经病变的诊断和治疗进展

外伤性视神经病变(TON)是导致严重视功能障碍的急性视神经损伤,为颅面外伤的一种常见并发症,病因分为直接损伤或间接损伤,后者更常见。近年来,TON的发病率呈逐渐上升趋势,一旦发生可能会严重影响患者生活质量,故需早期诊断并及时治疗。TON的诊断除了眼科常规检查外,还需结合神经眼科及电生理、影像学辅助检查。由于缺乏明确的临床指南,其治疗尚无统一的标准。TON的临床治疗包括仅观察及保守治疗、单独使用皮质类固醇治疗或不同方式的视神经减压(使用或不使用类固醇)。本文总结近年文献的主流观点,就TON的病因、损伤机制、诊断、治疗及一些尚处于实验阶段但具备治疗前景的方法等进行综述。

阻断DLK/MKK4/JNK/c-JUN通路对ITON小鼠视网膜神经节细胞存活的影响

目的研究阻断DLK/MKK4/JNK/c-JUN通路的表达能否促进间接性创伤性视神经病变(ITON)小鼠视网膜神经节细胞(RGCs)的存活并比较阻断不同位点产生的阻断效果。方法使用能够产生创伤性轴突损伤(TAI)的撞击加速(IA)模型对6~8周龄的小鼠进行处理模拟间接性创伤性视神经病变,筛选出符合条件的小鼠分为4组:空白对照组,IA组,IA+sunitinib组,IA+SP600125组。在实验要求的各个时间点留取标本,进行γ-synuclein或p-c-JUN免疫荧光染色、TUNEL染色和Western blot检测,并进行统计学分析。结果免疫荧光染色结果显示,与IA组相比,IA+sunitinib组和IA+SP600125组存活的RGCs密度显著升高、p-c-JUN(+)RGCs密度显著降低(P<0.05);TUNEL检测结果显示,与IA组相比,IA+sunitinib组和IA+SP600125组凋亡的RGCs密度显著降低(P<0.05);Western blot检测结果显示,与IA组相比,IA+sunitinib组和IA+SP600125组DLK/MKK4/JNK/c-JUN通路中的相应下游蛋白表达水平均降低(P<0.05)。结论DLK/MKK4/JNK/c-JUN通路的激活与ITON小鼠中RGCs的存活率相关,应用DLK抑制剂或JNK抑制剂可有效阻断该通路的蛋白表达,并促进RGC的存活,且后者效果更佳。

视神经减压术治疗外伤性视神经病变有效率的Meta分析

目的系统评价视神经减压术(Optic nerve decompression,OND)治疗外伤性视神经病变(Traumatic optic neuropathy,TON)的有效率。方法计算机检索PubMed、EMbase、The Cochrane Library和Web of Science等网站中,从建库到2023年2月7日的,关于OND治疗TON的回顾性研究。由两位研究人员按照纳入与排除标准对所获文献独立进行筛选、提取,使用纽卡斯尔-渥太华量表(Newcastle-Ottawa Scale,NOS)评定所有纳入研究的质量。结局指标为视神经减压术治疗外伤性视神经病的有效率,区间估计使用95%置信区间(Confidence interval,CI)表示,采用Stata 16.0软件对收集的数据进行Meta分析。结果最终纳入42篇文献,共3579例患者。Meta分析结果显示,OND治疗TON的总体有效率为54.2%(95%CI 49.2%~59.2%)。以不同手术入路进行亚组分析,结果显示:经眶、神经内镜经鼻和经颅入路治疗的有效率分别为56.0%(95%CI 46.2%~65.7%)、52.8%(95%CI 45.1%~60.5%)和50.0%(95%CI 36.1%~63.9%)。伤后≤7 d和>7 d手术减压有效率分别为69.5%(95%CI 55.0%~82.5%)、28.6%(95%CI 21.4%~36.2%);伤后1~2 d手术和3~7 d手术减压有效率分别为71.5%(95%CI 45.2%~92.3%)、51.2%(95%CI 65.3%~100.0%)。术前有、无光感患者的有效率分别为79.2%(95%CI 84.6%~100.0%)、36.3%(95%CI 30.2%~42.6%)。切开视神经鞘联合OND的总体有效率为40.7%(95%CI 27.0%~55.1%)。结论OND是改善TON患者视力的有效方法,不同手术方式相差不大,经眶手术减压有效率最高;手术时机应尽早,术前有光感患者预后较好,术中切开视神经鞘可能对患者的视力恢复有帮助。

鼻内镜下手术与糖皮质激素药物治疗对外伤性视神经病变疗效比较的Meta分析

目的系统分析鼻内镜下经蝶筛入路减压手术治疗和糖皮质激素冲击治疗对外伤性视神经病变(TON)的疗效。方法检索PubMed、Web of Science、Cochrane Library、ClinicalTrial.gov、中国知网(CNKI)、万方以及中国生物医学等数据库从建库起至2020年11月1日发表的关于内镜手术和激素治疗TON的临床研究。由2名研究人员独立对文献进行筛选,并对纳入文献进行质量评价。以治疗前后视力是否提高作为有效判定指标。应用RevMan 5.3统计学软件进行Meta分析。采用排除文献法对结果进行敏感性分析。采用漏斗图和Begg检验对各研究的发表偏倚进行双重检验。结果纳入了8项研究,其中7项为队列研究,1项为随机对照试验。鼻内镜减压手术组与糖皮质激素药物组对TON治疗视力提高有效率无明显差异[比值比(OR)=1.65,95%置信区间(CI)∶0.75~3.66,P=0.22]。对于术前有残余视力的患者,鼻内镜减压手术组与糖皮质激素药物治疗组的治疗视力提高有效率也无明显差异(OR=2.17,95%CI:0.94~4.98,P=0.07)。对于鼻内镜减压手术治疗而言,早期(病程小于7 d)手术治疗比晚期(病程大于7 d)接受治疗的视力提高有效率更高(OR=4.73,95%CI:2.55~8.78,P<0.01)。敏感性分析提示此次文献分析结果稍欠稳键。Begg检验表明此次分析没有文献发表偏倚。结论鼻内镜手术与糖皮质激素药物治疗方式对TON的疗效没有显著差异,对于有残余视力的患者早期接受内镜手术治疗可能有助视力提高。

神经内镜下经筛蝶行视神经减压治疗创伤性视神经损伤的疗效及其预后的影响因素分析

目的观察神经内镜下经筛蝶行视神经减压治疗创伤性视神经损伤(TON)的疗效,以及分析预后的影响因素。方法回顾性分析该院2017年1月-2020年1月收治的21例24眼TON患者的临床资料,所有患眼均经筛蝶行视神经减压术。比较分析术后视力改善状况,以评估手术疗效,并对预后的影响因素进行分析。结果术后未发生严重不良事件,有效率为54.17%。经单因素分析发现,术前视力是否存在光感和实施手术的及时性是影响预后的因素(P=0.002,P=0.013)。而年龄、视神经管骨折、意识状况、创伤类型、手术路径和是否存在脑脊液漏均与预后无明显相关性。结论神经内镜下经筛蝶行视神经管减压术是治疗TON的有效手段,实施手术的及时性和术前是否存在光感是预后的影响因素。

外伤性视神经损伤的研究进展

外伤性视神经损伤(Traumatic optic neuropathy,TON)常发生在颅脑损伤后,发病人群以青年为主。视神经损伤可致视力下降,甚至视力丧失,严重影响患者身心健康。目前关于TON的治疗意见不一,手术与非手术治疗共存,但治疗效果均不尽如人意。本文对近年来视神经损伤的研究进展进行综述,以期为临床治疗提供新的思路。

自噬在外伤性视神经病变中作用的研究进展

外伤性视神经病变是因外力损伤视神经,进而严重损害视力的致盲性眼病。自噬是一种细胞内降解途径,有助于维持细胞正常组分合成与受损细胞器及有毒细胞成分的分解之间的平衡。视神经受创后,视神经和视网膜中自噬标志物增加。自噬在外伤性视神经病变的不同阶段对视网膜神经节细胞可能起不同作用。多数研究表明,上调自噬可以减轻外伤性视神经病变中视网膜神经节细胞的死亡;也有研究提示在视神经损伤后极早的时期抑制自噬可以抑制视网膜神经节细胞轴突变性。该文对自噬的定义及功能、自噬的发生机制、视神经创伤后自噬水平改变、自噬在视神经创伤后对视网膜神经节细胞的作用的研究结果进行综述。

基于数据挖掘分析中医药治疗外伤性视神经病变用药规律

目的运用数据挖掘方法探讨中医药治疗外伤性视神经病变(TON)的用药规律,以期为临床用药提供参考。方法收集并整理中国期刊全文数据库(CNKI)、中国学术期刊数据库(万方数据)、中文科技期刊数据库(VIP)和中国生物医学文献服务系统(SinoMed)自建库至2021年11月3日有关TON的文献,严格按纳入与排除标准抽取方剂,建立中医药治疗TON的处方数据库,并对高频药物及其性味归经进行频次统计,采用SPSS Modeler 18.0软件和R4.0.5软件对高频药物进行关联规则分析,使用SPSS Statistics 26.0对高频药物进行聚类分析。结果共纳入116首方剂,涉及药物149味,其中使用频率>10%的药物有31味,包括当归、川芎、赤芍、桃仁、柴胡、丹参、红花等;药物以活血化瘀药、补虚药和清热药为主;药性以微寒、温、平为主,药味以甘、苦、辛为主,归经以肝经为主。药物关联规则分析得出常用药物组合有川芎-当归、赤芍-川芎、赤芍-当归等;高频药物聚类分析归为4大类。结论中医药治疗TON的药物配伍原则和治疗方法明确,多采用活血化瘀、益气补血、疏肝清热和通络明目法。

Axonal loss and blood flow disturbances in the natural course of indirect traumatic optic neuropathy

Background Indirect traumatic optic neuropathy （TON） is an acute injury of the optic nerve associated with severe visual dysfunction, which may be a result of secondary mechanical injury and vascular disorder of the optic nerve due to trauma. We analyzed the natural course of axonal loss and blood flow disturbances in patients with indirect TON to find a possible therapeutic window. Methods A cohort of 54 patients with indirect TON recruited between October 2008 and October 2010 at Beijing Tongren Hospital was retrospectively analyzed. The patients were divided into no light perception group （NLP） and better than NLP （btNLP） group. Specifically, the thickness of the retinal nerve fiber layer （RNFL） measured by spectral domain optical coherence tomography （SD-OCT）, and hemodynamic parameters of the ophthalmic artery （OA）, central retinal artery （CRA） and posterior ciliary artery （PCA） were determined. Results Two weeks after injury, there was a statistically significant decrease in the thickness of RNFL in the btNLP group as compared with the fellow control eyes （P 〈0.05）. In contrast, in the NLP group, RNFL thickness slightly increased for 2 weeks following injury, then overtly reduced after 4 weeks （P 〈0.05）. Peak systolic velocity （PSV） of CRA was significantly decreased 4 weeks after injury （P 〈0.05） in both the NLP group and btNLP group （P 〈0.05）. The thickness of RNFL in the NLP group was negatively correlated with PSV of CRA after 1 week of injury （P 〈0.05, r=-0.962）. Conclusions SD-OCT is a useful supplement in detecting the axonal loss in TON. The dynamic change of the thickness of RNFL appears to correlate with the hemodynamic disturbances in the natural course of TON. The first 2 weeks following an injury is critical and should be considered as the therapeutic window for TON patients.

认知行为干预对外伤性视神经病变手术患者心理状态及自我护理能力的影响

目的探讨认知行为干预在外伤性视神经病变手术中的应用效果。方法选择本院2020年3月至2021年3月救治的80例外伤性视神经病变患者(均为单眼患病),按照随机数字表法将其分为对照组和观察组,各40例。对照组给予常规护理,观察组给予常规护理+认知行为干预。比较两组的干预效果。结果干预后,两组的抑郁自评量表(SDS)、焦虑自评量表(SAS)评分均明显降低,视力与视野平均缺损(MD)均明显升高,且观察组优于对照组(P<0.05)。干预后,两组的自我护理能力测量量表(ESCA)各项评分均升高,且观察组高于对照组(P<0.05)。干预后,两组的屈服、回避评分均降低,面对评分均升高,且观察组优于对照组(P<0.05)。结论认知行为干预可显著提高外伤性视神经病变手术患者视力水平,改善不良情绪,提高自护能力。

外伤性视神经病变致伤原因及视力预后的多因素分析

目的分析外伤性视神经病变的致伤原因,探讨视力预后的影响因素。方法回顾性收集2007年1月至2012年12月在三峡大学仁和医院眼科住院的外伤性视神经病变患者104例(108眼)的临床资料,分析患者的致伤原因,采用多因素Logistic回归分析筛选影响外伤性视神经病变预后的危险因素。结果本组病例平均年龄(33.6±12.8)岁,男95例,占91.3%。致伤原因主要以非机动车、机动车事故为主(84例,占80.8%)。绝大多数患者在伤后3d内就诊(81例,占77.9%)。总体疗效有效率为45.4%(49/108),伤后视力为无光感患眼的有效率为29.9%(20/67),伤后视力为光感及以上患眼的有效率为70.7%(29/41)。多因素Logistic回归分析显示,就诊时间≥伤后24h、眶内出血或眶骨骨折、筛窦/蝶窦出血、伤后无光感是外伤性视神经病变视力预后的独立危险因素。结论就诊时间长和病情严重是影响外伤性视神经病变视力预后的独立危险因素,控制好上述危险因素,对外伤性视神经病变的治疗和预后有重要临床意义。

鼻内镜下视神经管减压术治疗视神经外伤10例

目的探讨鼻内镜下视神经管减压术疗效可能的影响因素。方法对本科2003年4月至2004年2月10例鼻内镜下视神经管减压术患者的临床资料进行回顾性分析。结果本组10例患者,6例患者视力有不同程度的恢复,4例无效。结论鼻内镜下视神经管减压术是治疗外伤性视神经损伤的有效方法,术前术后配合予改善微循环、神经营养、糖皮质激素等药物及高压氧治疗,可能有助于提高其疗效。

影响外伤性视神经病变视力好转的临床因素分析

目的分析影响间接性外伤性视神经病变(indirect traumatic optic neuropathy,ITON)视力好转的临床因素。方法采用回顾性病例系列研究。对111例(118眼)ITON患者的临床资料进行回顾分析,通过单因素分析(χ2检验)和多因素分析(Logistic回归分析),筛选出影响ITON视力预后的危险因素。结果经过激素或激素联合手术治疗后,51眼(43.22%)视力得到提高。单因素分析显示:伤后有无光感、伤后距离治疗的时间(<2d:≥2d)、是否有手术治疗、有无眼眶骨折或血肿、有无蝶窦/筛窦积血、有无视神经管骨折、F-VEP改变(F-VEP异常:F-VEP正常,F-VEP熄灭:F-VEP正常)差异均有统计学意义(均为P<0.05)。多因素分析显示:伤后残留光感(OR=0.23)、伤后2d内接受糖皮质激素治疗(OR=0.13)是ITON患者视力改善的保护因素(P<0.05);而合并蝶/筛窦积血(OR=9.57)、合并视神经管骨折(OR=4.09)、F-VEP异常(OR=3.73)或熄灭(OR=20.48)是ITON患者视力无提高的危险因素。结论 ITON视力预后与多种临床因素有关,明确影响视力预后的危险因素和保护因素,有利于临床医师制定合理的临床策略,指导治疗。