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Abstract：
To review the literature on the efficacy and safety of medical and surgical interventions for indirect traumatic optic neuropathy (TON), defined as injury to the nerve that occurs distal to the optic nerve head.
A literature search was conducted on October 22, 2019, and updated on April 8, 2020, in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis.
No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation. Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage.
Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON.
A literature search was conducted on October 22, 2019, and updated on April 8, 2020, in the PubMed database for English language original research that assessed the effect of various interventions for indirect TON. One hundred seventy-two articles were identified; 41 met the inclusion criteria outlined for assessment and were selected for full-text review and abstraction. On full-text review, a total of 32 studies met all of the study criteria and were included in the analysis.
No study met criteria for level I evidence. Seven studies (1 level II study and 6 level III studies) explored corticosteroid therapy that did not have uniformly better outcomes than observation. Twenty studies (3 level II studies and 17 level III studies) assessed optic canal decompression and the use of corticosteroids. Although visual improvement was noted after decompression, studies that directly compared surgery with medical therapy did not report uniformly improved outcomes after decompression. Four studies (1 level II study and 3 level III studies) evaluated the use of erythropoietin. Although initial studies demonstrated benefit, a direct comparison of its use with observation and corticosteroids failed to confirm the usefulness of this medication. One study (level II) documented visual improvement with levodopa plus carbidopa. Complication rates were variable with all of these interventions. Pharmacologic interventions generally were associated with few complications, whereas optical canal decompression carried risks of serious side effects, including hemorrhages and cerebrospinal fluid leakage.
Despite reports of visual improvement with corticosteroids, optic canal decompression, and medical therapy for indirect TON, the weight of published evidence does not demonstrate a consistent benefit for any of these interventions. In summary, no consensus exists from studies published to date on a preferred treatment for TON. Treatment strategies should be customized for each individual patient. More definitive treatment trials will be needed to identify optimal treatment strategies for indirect TON.
摘要：
回顾关于间接外伤性视神经病变（TON）的内科和外科治疗的疗效和安全性的文献，定义为视神经头远端发生的神经损伤。
于2019年10月22日进行了文献检索，并于2020年4月8日在PubMed数据库中进行了更新，用于评估各种干预措施对间接TON的影响。确定了一百七十二篇文章；41篇符合评估概述的纳入标准，并被选中进行全文审查和抽象。关于全文审查，共有32项研究符合所有研究标准,并被纳入分析.
没有研究符合I级证据的标准。7项研究（1项II级研究和6项III级研究）探索了皮质类固醇治疗，其结果均未优于观察。20项研究（3项II级研究和17项III级研究）评估了视神经管减压和皮质类固醇的使用。尽管在减压后观察到视觉改善，直接比较手术与药物治疗的研究未报告减压后结局的统一改善.四项研究（1项II级研究和3项III级研究）评估了促红细胞生成素的使用。尽管最初的研究证明了益处，将其使用与观察和皮质类固醇的直接比较未能证实该药物的有效性。一项研究（II级）记录了左旋多巴加卡比多巴的视力改善。所有这些干预措施的并发症发生率都是可变的。药物干预通常与很少的并发症相关，而光学管减压有严重副作用的风险，包括出血和脑脊液漏.
尽管有皮质类固醇的视力改善的报道，视神经管减压术,和间接TON的药物治疗，已发表的证据的权重未证明这些干预措施中的任何一项都具有一致的获益.总之,迄今为止发表的关于TON首选治疗的研究尚未达成共识.应针对每个患者定制治疗策略。需要更明确的治疗试验来确定间接TON的最佳治疗策略。
于2019年10月22日进行了文献检索，并于2020年4月8日在PubMed数据库中进行了更新，用于评估各种干预措施对间接TON的影响。确定了一百七十二篇文章；41篇符合评估概述的纳入标准，并被选中进行全文审查和抽象。关于全文审查，共有32项研究符合所有研究标准,并被纳入分析.
没有研究符合I级证据的标准。7项研究（1项II级研究和6项III级研究）探索了皮质类固醇治疗，其结果均未优于观察。20项研究（3项II级研究和17项III级研究）评估了视神经管减压和皮质类固醇的使用。尽管在减压后观察到视觉改善，直接比较手术与药物治疗的研究未报告减压后结局的统一改善.四项研究（1项II级研究和3项III级研究）评估了促红细胞生成素的使用。尽管最初的研究证明了益处，将其使用与观察和皮质类固醇的直接比较未能证实该药物的有效性。一项研究（II级）记录了左旋多巴加卡比多巴的视力改善。所有这些干预措施的并发症发生率都是可变的。药物干预通常与很少的并发症相关，而光学管减压有严重副作用的风险，包括出血和脑脊液漏.
尽管有皮质类固醇的视力改善的报道，视神经管减压术,和间接TON的药物治疗，已发表的证据的权重未证明这些干预措施中的任何一项都具有一致的获益.总之,迄今为止发表的关于TON首选治疗的研究尚未达成共识.应针对每个患者定制治疗策略。需要更明确的治疗试验来确定间接TON的最佳治疗策略。
