Ophthalmology · Medical Literature
Endoscopic Endonasal Optic Nerve Decompression for Traumatic Optic Neuropathy: A Systematic Review.
Abstract
Traumatic optic neuropathy (TON) is an acute injury to the optic nerve caused by direct or indirect trauma, often resulting in vision loss. Endoscopic transsphenoidal optic nerve decompression (EOND) is a minimally invasive technique designed to relieve pressure on the optic nerve. This systematic review evaluates the efficacy, safety, and visual outcomes of EOND in patients with TON. A systematic search of PubMed, Scopus, and Google Scholar was conducted for articles published between 2014 and 2024. Keywords included "optic nerve decompression", "traumatic optic neuropathy", and "endoscopic optic nerve decompression". After screening 42 articles, 16 studies met the inclusion criteria and were analyzed. All included studies used the endoscopic transsphenoidal approach. The mean visual recovery rate was 58.4%. All patients received postoperative corticosteroids. Study populations ranged from 11.7 to 68.1 years, including 24 females and 354 males. Postoperative complications were reported in 25% of studies, most commonly cerebrospinal fluid (CSF) leaks. Our findings demonstrated that endoscopic endonasal optic nerve decompression (EOND) is a safe and effective option for traumatic optic neuropathy (TON) patients unresponsive to steroids, with a mean visual recovery rate of 58.4% and a low complication profile, most commonly CSF leaks. While EOND offers clear advantages over traditional approaches, including minimal invasiveness and excellent visualization, the heterogeneity of existing data and the limited number of high-quality studies underscore the need for standardized protocols and further prospective research to optimize patient selection and surgical timing. EOND is a safe and effective intervention for TON patients unresponsive to medical therapy, offering minimal scarring, improved visualization, and rapid recovery. However, the limited number of studies and the heterogeneity of data highlight the need for further high-quality research to optimize outcomes.
Clinical relevance
In patients with traumatic optic neuropathy (TON), does endoscopic endonasal optic nerve decompression (EOND) yield acceptable rates of visual recovery and an acceptable safety profile across published case series and cohort studies from 2014 to 2024? __SNAPSHOT__ {"studyDesign":"Systematic review of observational studies (no meta-analysis reported; no randomized controlled trials included)","setting":"Multi-institutional; studies sourced from PubMed, Scopus, and Google Scholar; international scope; specific institutions not reported","sampleSize":"16 studies met inclusion criteria; aggregate patient count not explicitly reported in abstract; 24 females and 354 males identified across included studies (total n = 378, calculated)","population":"Patients with traumatic optic neuropathy (direct or indirect mechanism) treated with endoscopic transsphenoidal optic nerve decompression; age range across studies: 11.7–68.1 years; predominantly male (354/378, approximately 94%, calculated)","intervention":"Endoscopic endonasal (transsphenoidal) optic nerve decompression (EOND); all patients also received postoperative corticosteroids","comparator":"Not applicable; no control arm reported; no comparison to corticosteroids alone, observation, or transcranial decompression","primaryOutcome":"Visual recovery rate following EOND (defined criteria for 'visual recovery' not specified in abstract)","followUp":"Not reported","fundingSource":"Not reported"}
Key findings
Across 16 observational studies published between 2014 and 2024, the pooled mean visual recovery rate following EOND for TON was 58.4%. Absolute and relative effect sizes, confidence intervals, and p-values were not reported in the abstract; no formal meta-analytic pooling statistics (e.g., odds ratios, risk differences, or heterogeneity measures) are available from the abstract alone. The number needed to treat (NNT) cannot be calculated without a comparator group. Complications were reported in 25% of included studies, with cerebrospinal fluid (CSF) leak identified as the most commonly reported adverse event. The frequency of CSF leak and other complication rates per patient (rather than per study) were not specified in the abstract. All patients in the included studies received postoperative corticosteroids, making it impossible to isolate the independent contribution of surgery versus adjuvant steroid therapy to visual recovery from this review alone.
Practice implications
This systematic review suggests that EOND achieves meaningful visual recovery in a clinically significant proportion of TON patients (approximately 58%), a condition with high risk of permanent vision loss if untreated or inadequately treated. However, several critical interpretive limitations apply. First, this summary is based solely on the published abstract; full methods, risk-of-bias assessments, heterogeneity analyses, and subgroup data are not available for review. Second, the absence of a control arm means the 58.4% recovery rate cannot be attributed specifically to surgery—it is unknown what proportion would have recovered with corticosteroids alone or observation. Third, the dramatic male predominance (approximately 94%) and the broad age range limit generalizability to populations with differing trauma mechanisms or demographics. Fourth, uniform postoperative corticosteroid administration across all included studies confounds attribution of visual outcomes. Fifth, definitions of 'visual recovery' likely varied across the 16 included studies, introducing significant heterogeneity. Sixth, no data on timing of surgery relative to injury, pre-operative visual acuity, mechanism of TON, or fracture characteristics are extractable from the abstract—all of which are known prognostic variables. Practice should not change on the basis of this review alone; results are hypothesis-generating and support the need for prospective comparative studies. __LIMITATIONS__ No comparator arm: the absence of a control group (corticosteroids alone, observation, or transcranial decompression) precludes causal inference about EOND's independent efficacy,All included studies are observational; no randomized controlled trials were included, introducing high risk of selection bias and confounding,Universal postoperative corticosteroid use across included studies confounds attribution of visual recovery to surgery versus pharmacotherapy,Heterogeneous and unspecified definitions of 'visual recovery' across 16 studies make pooled estimates unreliable without formal statistical pooling and heterogeneity assessment,Complications reported as a proportion of studies (25%) rather than per-patient rates, obscuring the true complication burden,No follow-up duration reported, making durability of visual recovery unassessable,Extreme male predominance (approximately 94% male) limits generalizability to female patients with TON,Abstract does not report risk-of-bias assessment, PRISMA adherence details, or quantitative heterogeneity metrics (I² statistic), all of which are essential for evaluating systematic review quality,Important prognostic covariates (time-to-surgery, pre-operative visual acuity, fracture characteristics, direct vs. indirect TON) not reported in the abstract, precluding subgroup interpretation,Only 16 studies screened from 42 identified met inclusion criteria; specific inclusion/exclusion criteria not detailed in the abstract, raising concerns about selection transparency,Funding source not reported; potential for publication bias favoring positive outcomes in procedural literature __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This systematic review of 16 observational studies reports a mean visual recovery rate of 58.4% following endoscopic endonasal optic nerve decompression for traumatic optic neuropathy, with CSF leak as the most commonly noted complication. Because no comparator group is included, all patients received concurrent corticosteroids, and outcome definitions varied across studies, causality cannot be established and the true procedure-specific benefit remains uncertain. EOND appears safe and potentially effective in selected TON patients, but prospective controlled trials are needed before confident practice recommendations can be made.