【摘要】目的：评估静脉注射甲基强的松龙（IVMP）对外伤性视神经病变患者的疗效。方法：回顾性分析200001至200706我院收治的16例外伤性视神经病变（TON）患者的临床资料。1g甲基强的松龙分3d静脉应用，然后口服泼尼松龙11d，并逐渐减量。记录从损伤开始到治疗开始的时间。视力变化是本研究结果的主要功能评价指标。在入院时，治疗后1，2，3d；1wk和1mo时，分别记录最佳矫正视力(BCVA)。结果：共有16例患者纳入本研究，平均年龄为30岁，其中男性14例、女性2例。引起TON的主要原因有摩托车事故(占69%)，打架斗殴(占19%)和体育运动(占12%)。所有患者都表现有相对传入性瞳孔障碍。在损伤后4d内开始静脉注射甲基强的松龙 ，采用Snellen 视力表检查视力，绝大部分(56%)患者视力提高超过3行或大于等于0.5(6/12)。在损伤后5d以上才开始用类固醇治疗，视力则没有任何进步。结论：治疗TON，静脉注射中等到大剂量甲基强的松龙仍将起到重要作用。静脉注射甲基强的松龙治疗TON可能存在伤后4d的关键时期，超过了这个时期，该治疗可能就毫无效果。但还需要有更多的研究来为我们提供有明显统计学意义的数据。
【关键词】 外伤性视神经病变；甲基强的松龙；类固醇
AbstractAIM: To evaluate the outcome of intravenous methylprednisolone (IVMP) in patients with traumatic optic neuropathy (TON).METHODS: Clinical data of 16 patients with TON who were admitted to our hospital from January 2000 to June 2006 were retrospectively analyzed. 1g of IVMP in divided doses for 3 days followed by a reducing dose of oral prednisolone for 11 days were given. Timing between the onset of injury and the initiation of treatment was noted. A change in visual acuity is the primary functional outcome measure of this study. Best corrected visual acuity (BCVA) was recorded at admission, on day 1, day 2, day 3, 1 week and 1 month after treatment.RESULTS: Sixteen patients were included in this study with a mean age of 30. Fourteen of them were male and 2 were female. Motor vehicle accident (69%), assaults (19%) and sports (12%) were the major causes of TON. All patients had relative afferent pupillary defect at presentation. Majority of the patients (56%) have significant improvement of ≥3 lines or ≥ 6/12 Snellen chart visual acuity when IVMP was started within 4 days of injury. None showed improvement when steroids were started more than 5 days of injury.CONCLUSION: Moderate to high dose of IVMP still plays an important role in treatment of TON. A 4day critical time frame may exist for treatment of TON with IVMP beyond which treatment may be ineffective. More studies are needed to provide us with statistically significant data.
KEYWORDS: traumatic optic neuropathy; methylprednisolone; steroids
INTRODUCTION
Traumatic optic neuropathy (TON) is visual loss caused by trauma to the optic nerve. Although penetrating trauma and orbital fractures can directly injure the optic nerve, in the majority of TON cases the trauma is indirect[1]. This is in the form of a closed injury produced by concussive force to the head and transmitted to the optic nerve[2]. As TON is frequently associated with head injuries, early diagnosis may be difficult[3].
Treatment of TON is still controversial. There is constant debate as for observation or treatment of TON. The International Optic Nerve Trauma Study (IONTS) was aimed to investigate the best treatment for TON[4]. However, it showed no significant difference in results between surgical decompression and the use of corticosteroids.
High dose corticosteroids therapy for TON was introduced by Anderson et al in 1982[5]. The second National Acute Spinal Cord Injury Studies (NASCIS II) in 1990 showed favourable results of corticosteroid treatment for spinal cord injury if administered within 8 hours[6]. This was widely adopted for treatment of TON[7]. However, to date, no study can show conclusive evidence of the benefits of corticosteroids therapy for TON.
TON often affects young patients and the implication from visual loss caused by optic nerve damage in this group of patients is profound. Although there is no statistically significant data to support the use of corticosteroids in treating TON, any potential benefit from any form of treatment of TON should not be overlooked.
We reviewed the medical records of 16 patients in our hospital from January 2000 to June 2007 who received intravenous high dose methylprednisolone (IVMP), 1 g of methylprednisolone in single or divided doses, to study the results of treatment in this group of patients.
PATIENTS AND METHODS
This is a retrospective study. Patients admitted to our ward with TON from January 2000 to June 2007 were included in our study. All the patients enrolled were stable with no serious head injury and had an initial complete eye examination including best corrected visual acuity (BCVA), slit lamp examination, relative afferent pupillary defect (RAPD), fundus examination and CT scan of the orbit. Routine medical examination and investigation including blood tests, electrocardiogram (ECG) and chest X ray were also done to ascertain the suitability of these patients in receiving IVMP.
Moderate to high dose of IVMP were used. Based on each individual consultants preference, patients received 1g of IVMP either as a single dose or divided doses per day for 3 days, followed by 11 days of reducing dose of oral prednisolone. Any adverse effect following IVMP treatment was recorded. The timing between the onset of injury and the initiation of treatment was also noted.
A change in visual acuity is the primary functional outcome measure of this study. Standard BCVA at 6 meters was taken with Snellen chart, during admission, on day 1, day 2, day 3, at 1 week and 1 month after the initiation of IVMP. Improvement of 3 lines or more in Snellen chart visual acuity (VA) or improvement of VA with final VA≥6/12 is considered significant as recorded during one month of followup.
RESULTS
The data of 16 patients were analyzed. There were 14 males and 2 females with the mean age of 30 years, ranging from 17 to 51 years. The major causes of injury were motor vehicle accident (MVA), 69%; assault, 19% and sports related injury 12%. Many of these patients had poor visual acuity on initial presentation, 44% of them (n=7) had vision of CF to NLP. All 16 patients had RAPD and only 2 patients had commotio retinae at presentation. All but one patient had CT of orbit done and majority showed concurrent orbital fractures.
Overall, 9 patients (56%) responded to treatment and showed significant visual improvement following IVMP (Figure 1). Those who did not respond tended to have a poorer vision at presentation.
We observed that besides initial visual acuity, timing of initiating IVMP may play a role in the response to IVMP. The timing of receiving IVMP from the onset of injury ranged from 5 hours to 22 days.
It was noticed that patients who received IVMP later than 4 days from the initial injury did not respond to treatment. Among the 12 patients receiving IVMP within 4 days of injury, ranging from 5 hours to 4 days, 9 (75%) showed improvement of 3 lines or more in VA or achieved VA of ≥6/12 and 6 of these patients had no RAPD at 1 month in the followup. Of the 4 other patients receiving treatment after 4 days from the initial injury, ranging from 5 days to 22 days, nobody showed significant improvement (Table 1).
In subgroup analysis (Table 1), the characteristics of patients in each group were comparable except for the initial vision at presentation. Patients in the delayed group had significantly worse initial vision. The above data suggested that the outcome of a delay of more than 4 days in initiating IVMP was not favourable. However, patients who were in the delayed group had initial VA of 6/60 to NLP. Table 1Subgroup analysis of patients receiving treatment at different timing（略）
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