Role of Surgery Versus Medical Treatment for Traumatic Optic Nerve Compression: A Systematic Review and Meta-Analysis

BACKGROUND: Traumatic optic neuropathy (TON) can result in irreversible blindness. A consensus is not currently available on the superior treatment modality for TON. This study evaluates the literature to determine the superior treatment modality and the impact of time to treatment on outcomes. METHODS: A systematic search was conducted following Preferred Reporting for Systematic Reviews and Meta-Analysis guidelines. Random effects models were used to pool relative risk from RCTs, Peto odds ratios from sparse controlled nonrandomized studies, and arcsine transformed crude rates of the outcomes from uncontrolled case series and case reports. RESULTS: There were 51 studies were included in our quantitative synthesis. Low-quality evidence suggests systemic corticosteroids increase the rates of improved visual acuity when compared with observation alone in adolescents and adults (Peto OR 2.7 (1.5; 4.9); NNT 4 (2;9)). Early (< 24 hours from trauma) versus delayed (within 7 days) prednisolone administration does not result in greater rates of improved visual acuity in children (Peto OR 2.8 (0.3; 29.0)). When surgery is performed, early surgery results in greater rates of improvement in visual acuity than later surgery in adults and children (Peto OR 6.0 (1.9; 19.4) NNT 2 (5;1)). CONCLUSIONS: Systemic corticosteroids were superior to observation alone, but surgical decompression did not significantly improve visual acuity when compared to systemic therapy. The results of this review suggest that medical management and surgical intervention have therapeutic value in the resolution of TON; however, in the instance of neuropathy that is refractory to medical management in the setting of injuries with deformities that warrant surgical repair, the pursuit of intervention within a week from injury may prove useful. Further contributions of high-level evidence are required to substantiate case-by-case treatment algorithms.