Surgical outcomes and prognostic factors in traumatic optic neuropathy: a systematic review and meta-analysis of the endoscopic optic nerve decompression.

BACKGROUND AND

aimTraumatic optic neuropathy (TON) is a vision-threatening condition with no consensus on optimal management. Corticosteroids and surgical decompression of the optic canal are widely used, but their relative efficacy remains debated. This meta-analysis aimed to evaluate the effectiveness of Endoscopic transnasal optic canal decompression (ETOCD) and compared with or alongside medical therapy, with a focus on visual acuity (VA) outcomes and the influence of timing of intervention.

methodsA systematic literature search was conducted across PubMed, Embase, Scopus, and Web of Science, for relevant studies. Eligible studies included randomized controlled trials, prospective and retrospective cohorts, case series, and case reports that reported baseline and postoperative VA in TON patients undergoing ETOCD. Data extracted included study design, sample size, baseline VA, postoperative VA, intervention type, and interval between injury and operation. Statistical analyses were performed using random-effects models for pooled estimates with R software. Heterogeneity across studies was assessed using the I² statistic and chi-square tests. The quality of the included studies was evaluated using tools appropriate for their study designs.

resultsForty-two studies involving 2,859 cases were included. The majority of patients were young adult males, consistent with the epidemiology of TON. The overall pooled visual improvement rate was 26% (95% CI: 18-34%). No statistically significant difference in improvement rates was found between ETOCD combined with steroid pulse therapy (SPT) (26%) and ETOCD alone (26%; p = 0.9297). However, surgery significantly improved functional outcomes overall (SMD = 0.32, p < 0.0001). Regarding timing, surgery within 7 days showed a trend toward greater recovery (SMD = 0.37) compared to delayed intervention (SMD = 0.25). The strongest clinical improvement was observed in the 3-7 day window (SMD = 0.45, p = 0.0179).

conclusionETOCD and related surgical techniques provide a valuable treatment option for TON, particularly in patients with residual vision and when performed early after injury. However, the evidence is primarily derived from observational studies with some heterogeneity in reported improvement rates, which limits the overall certainty of these findings. While pooled data supports surgical decompression as an effective intervention, future multicenter randomized controlled trials are essential to refine patient selection criteria, clarify the role of adjunctive steroids, and establish standardized protocols.