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LP Frohman, PR D'Amato; Management of Traumatic Optic Neuropathy in the Comatose/Confused Patient . Invest. Ophthalmol. Vis. Sci. 2002;43(13):2635.
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Purpose: Detection of traumatic optic neuropathy (TON) in the comatose/confused patient is a management problem for which no theraputic guideline exist. The patient is diagnosed by the discovery of a relative afferent pupillary defect. Unlike in the alert patient where the treatment can be tailored to the severity of the visual loss, this study reviews the aggressiveness/risk of therapy for the best possible visual outcome after the extent of the visual function cannot be assessed. Methods:Retrospective study involving the records of 95/127 patients seen by one of us (LF)with traumatic optic neuropathy from 1989 - 2000. Of these we identified 6 patients with unilateral TON who were comatose or confused at the time of initial ophthalmic exam, precluding visual assessment. Results: All had amaurotic pupil or just a questionable trace of reaction to light, one had a reactive pupil with a sphincter tear. None had optic nerve avulsion or circulatory disruption. We performed flash VEP's on three cases, all were flat. All received IV solumedrol one gram for 3 - 5 days at time of diagnosis, the two with canal fracture/sheath hematoma underwent canal decompression. Conclusion: With a mean follow up of 79.5 weeks (range 1 - 312), the final visual outcome was NLP in 3, CF </= 1 foot in 2, and 20/25 in one. The case with a good visual outcome was the case with a reactive pupil. All three with flat VEP's had poor outcomes. This study, albeit with a small sample size, suggests that regardless of therapy, an amaurotic pupil at onset or a flat VEP prognosticates poor visual outcome.
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