Controversial issues in the treatment of traumatic optic neuropathy: A journey through historical course

Traumatic optic neuropathy (TON) can occur by either direct injury or an indirect way which can develop secondary to transfer forces occurring due to trauma in frontal and maxillary bones to optic canal. The involvement of productive individuals at younger age groups makes it more important. Since TON is accompanied by multiple traumas, the diagnosis of TON is generally challenging and delayed in these patients usually requiring ICU follow-up. The treatment in patients diagnosed as TON is one of the most controversial issues in neuro-ophthalmology. The clinical experiences on treatment of TON have been built on 'National Spinal Cord Injury Study II and III2 trials rather than small cases series and the results had been found satisfactory. On the other hand, the concerns about translation of results from studies on spinal cord injury treatment to optic nerve injuries have been increased with the results of 'International Optic Nerve Trauma Study' showing no difference between groups underwent observation, steroid treatment or optic canal decompression. Additionally, the results from 'Medical Research Council-Corticosteroid Randomisation After Signifi cant Head Injury' study, which showed statistically signifi cantly higher mortality rates within fi rst two weeks of mega-dose steroid treatments compared to placebo groups, have promoted us to review our treatment protocols. As similar to stroke and degenerative neurological disorders, the effi ciency of neuroprotective agents have been investigated and molecules like erythropoietin are promising. The major challenges in the treatment of TON are high spontaneous recovery rates due to the nature of the disorder and lacking of class I evidence from multi-center, randomized, prospective, double-blind studies comparing different treatment modalities. This review aimed to summarize different studies which form our preferences in treatment of TON.