今日の臨床サポート

外傷性視神経損傷

著者: 松脇由典 東京慈恵会医科大学 耳鼻咽喉科

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2016/04/01
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 外傷性視神経管骨折は、顔面や頭部外傷のうちの5%にみられ、頭部および顔面外傷による視力障害を引き起こした状態のことをいう。
  1. もし、そこで異常を認める場合は、ただちに緊急手術を含め対応可能な病院へ転送が必要になる。
  1. 視神経の障害機序としては、視神経の挫滅または離断、骨折による圧迫(頻度は少ない)、管内の出血による圧迫、栄養血管の断裂、瞬間的な骨のたわみによる障害、管内における視神経の浮腫による圧迫が原因に挙げられている。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
松脇由典 : 報酬額(オリンパス株式会社)[2021年]
監修:森山寛 : 特に申告事項無し[2021年]

まとめ

疾患情報(疫学・病態)  
  1. 外傷性視神経損傷は、直接外傷と間接外傷に分類される。
  1. 直接外傷は、「視神経の領域に、直接的に損傷が加わること」であり、穿通性の外傷が多く、視神経の損傷が非常に強いため、予後の悪いものである。
  1. 間接外傷は、「鈍的外傷により、間接的に視神経に何らかの損傷が加わること」である。閉鎖性の頭部外傷の5%に起こるといわれている。視神経管部で生じやすい。
  1. 外傷性視神経損傷の原因としては、以下の6つが挙げられる。
  1. ①視神経の挫滅または離断、②骨折による圧迫、③管内の出血による圧迫、④栄養血管の断裂、⑤瞬間的な骨のたわみによる障害、⑥管内における視神経の浮腫による圧迫[1]
  1. 緊急の治療が必要な疾患であり、治療のオプションとして手術が可能な病院への転送が必要である。
  1. 何も治療をしないよりも、点滴治療や手術治療を合わせて行ったほうが視力や視野の改善がよいというエビデンスがある。
問診・診察のポイント  
問診:
  1. 外傷の評価(頭部外傷)

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文献 

著者: S Shinozuka, M Hayashi, M Nagai, Y Shimada, M Okamoto
雑誌名: Nihon Ganka Gakkai Zasshi. 1967 Oct;71(10):1909-38.
Abstract/Text
PMID 5627127  Nihon Ganka Gakkai Zasshi. 1967 Oct;71(10):1909-38.
著者: S Mine, I Yamakami, A Yamaura, K Hanawa, M Ikejiri, A Mizota, E Adachi-Usami
雑誌名: Acta Neurochir (Wien). 1999;141(1):27-30.
Abstract/Text 34 patients with indirect traumatic optic neuropathy were studied to identify factors affecting outcome and surgical indications. 12 cases (13 eyes = group A) underwent surgery and 24 patients (24 eyes = group B) were managed without surgery. Age, optic canal fracture, visual acuity before treatment (initial visual acuity) and days until surgery (only group A) were employed as variables. Visual acuity improved significantly more in patients with initial visual acuity, hand movement (HM) or better than in those with initial visual acuity for light perception (LP) only or worse. When initial visual acuity was HM or better, vision improved significantly more in patients with surgery than in those without surgery (p = 0.0003 by Mann-Whitney U test). Days until surgery were correlated with visual improvement in patients with visual acuity HM or better. Age and optic canal fracture did not affect visual improvement or influence the decision for or against surgery.

PMID 10071683  Acta Neurochir (Wien). 1999;141(1):27-30.
著者: H Matsuzaki
雑誌名: Nihon Ganka Gakkai Zasshi. 1981;85(7):824-36.
Abstract/Text
PMID 7304354  Nihon Ganka Gakkai Zasshi. 1981;85(7):824-36.
著者: S E Kountakis, A A Maillard, S M El-Harazi, L Longhini, R G Urso
雑誌名: Otolaryngol Head Neck Surg. 2000 Jul;123(1 Pt 1):34-7. doi: 10.1067/mhn.2000.106007.
Abstract/Text OBJECTIVES: The goal of this study was to compare the outcome of patients with traumatic optic neuropathy (TON) treated with high-dose steroids with the outcome of patients with TON treated with endoscopic optic nerve decompression (EOND) after failing high-dose steroid treatment.
METHODS: During this retrospective review of patients with TON seen from 1994 to 1998, all patients were first treated with megadose methylprednisolone for 48 hours. Patients with no improvement or with worsening visual acuity were offered EOND.
RESULTS: Eleven of 34 (32%) patients treated with high-dose steroids showed improvement, and 23 (68%) did not. Seventeen of the 23 patients without improvement after high-dose steroid treatment underwent EOND. Fourteen of 17 (82%) surgically treated patients had improved visual acuity, and 3 (18%) did not, with an overall improvement in 25 of 34 (74%) patients (chi(2) = 11. 338, P = 0.0007).
CONCLUSION: EOND is an appropriate treatment technique for patients with TON in whom high-dose steroid treatment has failed.

PMID 10889478  Otolaryngol Head Neck Surg. 2000 Jul;123(1 Pt 1):34-7. ・・・
著者: M W Cook, L A Levin, M P Joseph, E F Pinczower
雑誌名: Arch Otolaryngol Head Neck Surg. 1996 Apr;122(4):389-92.
Abstract/Text BACKGROUND: The management of traumatic optic neuropathy remains controversial. Reports of improvement have been published after observation alone, treatment with corticosteroids and surgical decompressions.
OBJECTIVE: To systematically review the published literature about traumatic optic neuropathy using a meta-analysis.
METHODS: We performed a retrospective literature review of case series and case reports of traumatic optic neuropathy. They include all English language cases and selected non-English language cases for which patient data were available. The cases were organized into four grades based on visual acuity and the locations and type of fracture. Grade 1 included patients with visual acuity greater than 20/200 in the affected eye and without a posterior orbit fracture; grade 2, patients with visual acuity between 20/200 and light perception; grade 3, patients without light perception or with a nondisplaced posterior orbital fracture and remaining vision; and grade 4, patients with no light perception and a displaced posterior orbital fracture. A meta-analysis was performed, analyzing for each case the recovery of visual acuity for treatment, fracture pattern, and grade.
RESULTS: The recovery of vision in treated patients was significantly better than the recovery in patients receiving no treatment. No significant difference in improvement was found among patients treated with corticosteroids alone, with surgical decompression alone, or with corticosteroids and surgical decompression. Recovery was related to the severity of initial injury, as reflected in the grading system. A trend was noted for better improvement of visual acuity in patients without orbital fractures than those with orbital fractures, and also in patients with anterior orbital fractures than in patients with posterior fractures.
CONCLUSIONS: Treatment with corticosteroids, extracranial decompression, or both, is better than no treatment of traumatic optic neuropathy. Because the data are insufficient to determine whether corticosteroids, surgery, or the use of both treatments is most effective, the findings of the ongoing International Optic Nerve Trauma Study should prove valuable. The standardized grading system we developed is a useful tool for comparing studies and treatment protocols.

PMID 8600923  Arch Otolaryngol Head Neck Surg. 1996 Apr;122(4):389-92・・・
著者: Ian Roberts, David Yates, Peter Sandercock, Barbara Farrell, Jonathan Wasserberg, Gabrielle Lomas, Rowland Cottingham, Petr Svoboda, Nigel Brayley, Guy Mazairac, Véronique Laloë, Angeles Muñoz-Sánchez, Miguel Arango, Bennie Hartzenberg, Hussein Khamis, Surakrant Yutthakasemsunt, Edward Komolafe, Fatos Olldashi, Yadram Yadav, Francisco Murillo-Cabezas, Haleema Shakur, Phil Edwards, CRASH trial collaborators
雑誌名: Lancet. 2004 Oct 9-15;364(9442):1321-8. doi: 10.1016/S0140-6736(04)17188-2.
Abstract/Text BACKGROUND: Corticosteroids have been used to treat head injuries for more than 30 years. In 1997, findings of a systematic review suggested that these drugs reduce risk of death by 1-2%. The CRASH trial--a multicentre international collaboration--aimed to confirm or refute such an effect by recruiting 20000 patients. In May, 2004, the data monitoring committee disclosed the unmasked results to the steering committee, which stopped recruitment.
METHODS: 10008 adults with head injury and a Glasgow coma score (GCS) of 14 or less within 8 h of injury were randomly allocated 48 h infusion of corticosteroids (methylprednisolone) or placebo. Primary outcomes were death within 2 weeks of injury and death or disability at 6 months. Prespecified subgroup analyses were based on injury severity (GCS) at randomisation and on time from injury to randomisation. Analysis was by intention to treat. Effects on outcomes within 2 weeks of randomisation are presented in this report. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN74459797.
FINDINGS: Compared with placebo, the risk of death from all causes within 2 weeks was higher in the group allocated corticosteroids (1052 [21.1%] vs 893 [17.9%] deaths; relative risk 1.18 [95% CI 1.09-1.27]; p=0.0001). The relative increase in deaths due to corticosteroids did not differ by injury severity (p=0.22) or time since injury (p=0.05).
INTERPRETATION: Our results show there is no reduction in mortality with methylprednisolone in the 2 weeks after head injury. The cause of the rise in risk of death within 2 weeks is unclear.

PMID 15474134  Lancet. 2004 Oct 9-15;364(9442):1321-8. doi: 10.1016/S0・・・
著者: B Katz, J Herschler, D C Brick
雑誌名: Br J Ophthalmol. 1983 Aug;67(8):549-53.
Abstract/Text Two patients developed traumatic orbital haemorrhage resulting in prolonged blindness. Orbital decompression successfully reversed the visual loss, though both eyes had no light perception for at least 3 1/2 hours. The clinical findings suggest damage to the posterior optic nerve as cause of the visual loss. The optic nerve tolerance time to ischaemic injury may be longer than previously thought.

PMID 6871148  Br J Ophthalmol. 1983 Aug;67(8):549-53.
著者: Qin-Tai Yang, Ge-Hua Zhang, Xian Liu, Jin Ye, Yuan Li
雑誌名: J Trauma Acute Care Surg. 2012 May;72(5):1350-5. doi: 10.1097/TA.0b013e3182493c70.
Abstract/Text BACKGROUND: Traumatic optic neuropathy (TON) is an important cause of severe loss of vision due to blunt or penetrating head trauma. The pathogenesis of TON remains unclear, and there are several potential causes for the observed loss in vision. Endoscopic optic nerve decompression (EOND) has been reported to improve the visual prognosis in TON cases, but its efficacy remains controversial. It is important to investigate the therapeutic efficacy of EOND in the treatment of TON and to evaluate the relevant prognostic factors.
METHODS: A retrospective study was conducted to analyze the clinical characteristics and prognoses of 96 TON cases. The χ(2) test and multiple logistic regression analyses were used to evaluate potential prognostic factors.
RESULTS: : The overall rate of EOND effectiveness was 40.6% (39 of 96). A significantly higher effective rate (83.3%) was observed for patients with light perception compared with those without light perception (26.4%, p < 0.05). Univariate and multiple logistic regression analyses identified three variables (no light perception, undergoing EOND 3 days after trauma, and hemorrhage within the ethmoid and/or sphenoid sinus) that were significantly associated with unrecovered visual acuity. Age, loss of consciousness, optic canal fracture, preoperative steroid megadose treatment, and optic nerve sheath incision were all factors that showed no significant correlation with therapeutic efficacy. However, patients with fractures in a single medial wall of the optic canal appeared to have better prognoses than patients with multiple fractures or those with a single fracture in a lateral wall.
CONCLUSIONS: The overall therapeutic efficacy of EOND for the treatment of TON is far from satisfactory, especially for patients without light perception. The factors that impact TON prognoses are complex and may be interrelated. The indication for EOND must be individualized.
LEVEL OF EVIDENCE: III, epidemiological study.

PMID 22673265  J Trauma Acute Care Surg. 2012 May;72(5):1350-5. doi: 1・・・
著者: M G Rajiniganth, Ashok K Gupta, Amod Gupta, Jayapalli Rajiv Bapuraj
雑誌名: Arch Otolaryngol Head Neck Surg. 2003 Nov;129(11):1203-6. doi: 10.1001/archotol.129.11.1203.
Abstract/Text OBJECTIVE: To assess the visual outcome in cases of traumatic optic neuropathy treated with a combined therapy protocol of methylprednisolone injections and endoscopic optic nerve decompression.
DESIGN: Prospective, nonrandomized study.
SETTING: Academic tertiary care referral center.
PATIENTS: The study included 44 patients with posttraumatic indirect optic nerve injury.
MAIN OUTCOME MEASURES: Visual acuity.
RESULTS: Visual improvement was achieved in 31 patients (70%) when treatment was initiated within 7 days of injury, whereas only 10 patients (24%) showed improvement when the treatment was started after more than 7 days. The time lapse after injury and treatment, degree of visual loss, and computed tomographic evidence of canalicular and pericanalicular fractures were found to be significant prognostic factors.
CONCLUSIONS: Endoscopic optic nerve decompression is a minimally invasive procedure that does not cause any adverse cosmetic effects. The risk-benefit ratio suggests that the combined therapy protocol of methylprednisolone injections and endoscopic optic nerve decompression results in a better visual outcome, without any major risks.

PMID 14623751  Arch Otolaryngol Head Neck Surg. 2003 Nov;129(11):1203-・・・
著者: Nicholas J Volpe, Leonard A Levin
雑誌名: J Neuroophthalmol. 2011 Jun;31(2):169-74. doi: 10.1097/WNO.0b013e31821c9b11.
Abstract/Text
PMID 21593629  J Neuroophthalmol. 2011 Jun;31(2):169-74. doi: 10.1097/・・・
著者: Ying-An Chen, Dhruv Singhal, Yu-Ray Chen, Chien-Tzung Chen
雑誌名: J Plast Reconstr Aesthet Surg. 2012 Oct;65(10):1325-30. doi: 10.1016/j.bjps.2012.04.037. Epub 2012 Jun 19.
Abstract/Text BACKGROUND: Retrobulbar haematoma formation is a known complication following facial trauma involving the orbits. This is an important clinical entity as it can lead to permanent vision loss if not appropriately managed in the acute setting.
METHODS: From 1999 to 2009, 2586 patients presented to the Chang Gung Memorial Hospital with orbital fractures. Eight patients presented with nine retrobulbar haematomas. A retrospective review of the patient's medical records was performed. Analysis of visual outcomes was performed based on the improvement degree (ID) formula.
RESULTS: The average age of our patients is 24.5 years with the most common cause of trauma being motor vehicle (motorcycle) collisions. Visual acuity and the light reflex were abnormal in all patients. Five patients (case #1-5) demonstrated an absent relative afferent pupillary defect (RAPD). Computed tomography imaging confirmed the presence of a retrobulbar haematoma in all patients. The average follow-up was 14.5 months (range: 6-20 months). Management was divided into three cohorts: observation alone, medical therapy alone or a combined surgical and medical therapy. The best visual outcomes (ID=82%) were achieved in the combined treatment group. The worst outcomes (ID=42%) were in the medical therapy alone group.
CONCLUSION: In review of our experience, we have found that the presence or absence of an RAPD is the most sensitive indicator of optic nerve compromise and necessity for intervention. An algorithm was also developed based on this study. Once a decision is made to intervene on a retrobulbar haematoma, both medical and surgical therapies should be instituted with a priority given to timely decompression of the orbit.

Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
PMID 22717974  J Plast Reconstr Aesthet Surg. 2012 Oct;65(10):1325-30.・・・

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