Steroids in the treatment of traumatic optic neuropathy

The optic nerve transmits visual information from the eye to the brain and traumatic optic neuropathy (TON) refers to any injury to the optic nerve secondary to trauma. After the optic nerve has been injured, it becomes more swollen and this can lead to further damage. Traumatic optic neuropathy often results in severe visual loss and the vast majority of affected people are young males in their thirties. Since the early 1980s, steroids have been used in an attempt to reduce the abnormal swelling that follows an injury to the optic nerve and improve visual recovery. However, the role of steroids in TON is controversial and clinicians remain divided over the best management strategy. The recommendations in this review are based on a critical analysis of the available evidence in the medical literature. We found only one, relatively small, randomised controlled trial of steroids in TON, which included 31 participants within seven days of their initial injury. These participants received either high dose intravenous steroids (n = 16) or placebo (n = 15). At three months follow-up, no significant difference in best corrected visual acuity was found between these two groups. There is a relatively high rate of spontaneous visual recovery in TON and no convincing data that steroids provide any additional benefit over observation alone. Each case needs to be assessed on an individual basis and the patient needs to be made fully aware of the possibility of a serious adverse reaction, although rare, to steroids. Furthermore, recent studies have highlighted possible detrimental effects of steroids when used in brain and spinal cord injuries and these new lines of evidence need to be considered seriously.