Abstract
Background
To quantify alteration of retinal peripapillary microvasculature and visual function within three months follow-up in indirect traumatic optic neuropathy (ITON) after endoscopic trans-ethmosphenoid optic canal decompression (ETOCD).
Methodology
Thirty-seven ITON eyes were included. Radial peripapillary capillary (RPC) density at pre-operation and post-operation within three months follow-up (pre-op, post-op 2 weeks, post-op 1 month and post-op 3 months) was analyzed. The comparisons of RPC density and best corrected visual acuity (BCVA) at different points were analyzed.
Results
In ITON eyes, preoperative global RPC density was reduced compared to unaffected eyes (P ≤ 0.001). Global RPC density of ITON at pre-op, post-op 2 weeks, 1 month and 3 months were 47.71 ± 7.36, 40.56 ± 8.71, 40.75 ± 7.06 and 33.95 ± 8.03, respectively. For ITON eyes, three points' post-op global RPC density significantly differed from pre-op RPC density (All P ≤ 0.006). BCVA of ITON at pre-op, post-op 2 weeks, 1 month and 3 months were 2.41 ± 1.61, 1.84 ± 1.43, 1.54 ± 1.39 and 1.54 ± 1.38, respectively. A significant difference had been found at post-op 1 month and post-op 3 months when compared to pre-op BCVA (P = 0.018 and 0.015, respectively).
Conclusions
The reduced RPC density occurred in ITON with a plateau between post-op 2 weeks and post-op 1 month. The visual improvement might be secondary to the alteration of retinal perfusion after ETOCD for a long time, though discrepancies in structural–functional resilience existed.
Keywords: Retinal peripapillary microvasculature, Indirect traumatic optic neuropathy, Endoscopic trans-ethmosphenoid optic canal decompression, Best-corrected visual acuity, Optical coherence tomography angiography
Introduction
Indirect traumatic optic neuropathy (ITON) was a serious complication after head trauma. The ITON patients were always shown with severe visual impairment, such as reduced best-corrected visual acuity, visual field defect and so on. Though the incidence of ITON was only 5%, serious visual loss was a concern among ophthalmologists and patients themselves [1].
ITON occurred not only with functional damage but also with vascular structural injury [2–5]. We had previously found the retinal microvasculature decreased in ITON eyes [6]. The retinal microvasculature would influence the oxygen supply to the optic nerve, further indicating the ITON's severity. Previously, we gave endoscopic trans-ethmosphenoid optic canal decompression (ETOCD) treatment to the ITON patients and found their visual improvement thereafter. In our predictive model, the pre-operative (pre-op) retinal microvasculature was a crucial factor in predicting the resilience of the visual function of these patients during the post-operative (post-op) 1 month [6]. It might indicate the importance of the vascular structural function for evaluating the severity of the ITON and prognosis of the ETOCD treatment to some extent. However, how the retinal microvasculature altered after the treatment was still unclear. In our mind, ETOCD helped clear up the existing hematoma on the optic nerve, relieved the intra-canalicular pressure and blood stagnation [7–10]. To investigate the alteration of the retinal microvasculature would further help us understand the prognosis and undermining of the ITON with its visual alteration.
Our current study aimed to analyze the longitudinal alteration of the retinal microvasculature with the 3-month follow-up after ETOCD treatment and assess the efficacy of ETOCD in improving visual outcomes after ITON. We would like to further figure out the relation between the retinal microvasculature and visual function in ITON with ETOCD treatment. We hope it will give us more clues to the mechanism of the ITON occurrence and treatment.
Method
Subjects and basic clinical examinations
This was a prospective study. All unilateral ITON patients included were from the Eye Hospital. All patients signed the informed consent and agreed to participate in the current project. This study was by the tenets of the Declaration of Helsinki and was approved by the Ethics Committee of the Eye Hospital (ID: 2021–181-K-156-01).
The unilateral ITON patients were diagnosed and treated with ETOCD by the same ophthalmologist from the Eye Hospital. The clinical examinations, including best-corrected visual acuity (BCVA) with the log (minimum angle of resolution) [logMAR], slit-lamp biomicroscopy, fundus photography, and high-resolution of the head and orbital computed tomography scans were done for all patients. The detailed process of ETOCD had been reported in our previous studies [11, 12].
The patients who refused to get the treatment of ETOCD were excluded from this study. All unilateral ITON patients were re-examined two weeks, one month and three months after ETOCD (post-op 2 weeks, post-op 1 month and post-op 3 months). The history of the diseases was acquired. The patients with a history of other optic neuropathy, eye surgery, or systemic diseases were also excluded. Patient diagnoses and eligibility determinations were independently assessed by two senior ophthalmologists (YT and WW). Cases with inter-observer disagreement were excluded from the study to ensure diagnostic consistency. Two groups for analysis were as follows: (1) the unaffected eye of unilateral ITON patients; and (2) the ITON eye of unilateral ITON patients.
Optical coherence tomography angiography (OCTA) image
OCTA (Optovue RTVue XR Avanti; Optovue, Inc., Fremont, CA, USA) was used to scan with the angio disc model (4.5 × 4.5 mm). With this scanning model, the information of radial peripapillary capillary (RPC) and peripapillary retinal nerve fiber layer (pRNFL) would be acquired (Fig. 1). The RPC was defined as the perfusion from the internal limiting membrane to the retinal nerve fiber layer (RNFL). The RPC density was calculated as the ratio between the area occupied by the capillary vessels and the whole analyzed area. The analyzed global peripapillary area was a ring with a 4-mm diameter circle centered on the optic disc by ruling out a 2-mm diameter circle with the same center. Based on the Garway-Heath grid map, the global peripapillary area was divided into eight areas, i.e., temporal-superior (TS), superior-temporal (ST), superior-nasal (SN), nasal-superior (NS), nasal-inferior (NI), inferior-nasal (IN), inferior-temporal (IT) and temporal-inferior (TI) (Fig. 1) [13]. The peripapillary RNFL (pRNFL) thickness in the same global and four respective areas were analyzed as well.
Fig. 1.
The presentative OCTA image of the RPC layer, pRNFL layer and its corresponding photography. A The 4.5 × 4.5 mm angio disc scanning area centered on the optic disc with eight areas (TS, ST, SN, NS, NI, IN, IT and TI) for analysis; B OCTA image of the RPC layer and C its corresponding pRNFL layer. OCTA, optical coherence tomography angiography; OCTA, optical coherence tomography angiography; TS, temporal-superior; ST, superior-temporal; SN, superior-nasal; NS, nasal-superior; NI, nasal-inferior; IN, inferior-nasal; IT, inferior-temporal; TI, temporal-inferior; RPC, radial peripapillary capillary; pRNFL, peripapillary retinal nerve fiber layer
One masked reader checked all OCTA images. When the scans with a signal strength index < 40/100, an obvious motion, or artifact RPC/pRNFL layer segmentation error would be excluded.
Statistical analyses
All continuous data were analyzed by SPSS software (version 22.0; SPSS, Inc., Chicago, IL, USA). If the data met normal distribution, then it would be analyzed as means ± standard deviations, otherwise as median with 1st interquartile range (IQR) and 3rd IQR. Differences in the parameters between the ITON eyes and unaffected eyes, and the parameters in the same group with different examining points were analyzed by t-tests. The cut-off value of BCVA improvement was defined as 0.2 (logMAR) [14, 15]. Pearson’s correlation was done to show the correlation between the RPC density and pRNFL thickness at different examining points. P-values less than 0.05 were defined to be statistically significant.
Results
Basic information
A total of 37 unilateral ITON patients were included in this study. The average age was 29.1 ± 20.7 years old. The female-to-male ratio was 11:26. For pre-op BCVA, there was a significant difference between the ITON eye and the unaffected eye (2.41 ± 1.61 vs. 0.01 ± 0.05, P < 0.001). For ITON eyes, there were 24 with orbital fractures and 12 with optic canal fractures. The average time to ETOCD treatment after trauma among the ITON eyes was 4 ± 7 days. For the cause of the injury, 40.5% of patients were due to the car accident, 46.0% of patients resulted from falling, and 13.5% from other causes.
Differences of preoperative RPC and pRNFL between the ITON eyes and unaffected eyes
The RPC density of the ITON eye was significantly decreased in global and all respective peripapillary areas when compared to the unaffected eye before the ETOCD treatment (P ≤ 0.005, Figs. 2, 3).
Fig. 2.
The Alteration of the global RPC density and pRNFL thickness during the 3 months follow-up in ITON eyes and unaffected eyes with ETOCD treatment. The Alteration of the global A RPC density and B pRNFL thickness during the 3 months follow-up in ITON eyes and unaffected eyes with ETOCD treatment. The Alteration of the global C RPC density and D pRNFL thickness during the 3 months follow-up in ITON eyes with and without final visual improvement. ETOCD, endoscopic trans-ethmosphenoid optic canal decompression; RPC, radial peripapillary capillary; pRNFL, peripapillary retinal nerve fiber layer
Fig. 3.
The Alteration of the global RPC density and its RPC density in corresponding eight respective area during the 3 months follow-up in ITON eyes and unaffected eyes with ETOCD treatment. The global RPC density and its RPC density in corresponding eight respective area at A pre-op, B post-op 2 weeks, C post-op 1 month and D post-op 3 months in ITON eyes and unaffected eyes with ETOCD treatment. ETOCD, endoscopic trans-ethmosphenoid optic canal decompression; RPC, radial peripapillary capillary; TS, temporal-superior; ST, superior-temporal; SN, superior-nasal; NS, nasal-superior; NI, nasal-inferior; IN, inferior-nasal; IT, inferior-temporal; TI, temporal-inferior; pre-op, pre-operative; post-op, post-operative
For the pre-op pRNFL, the ITON eye didn’t show significant thinning pRNFL in the global area compared to the unaffected eye (P = 0.375, Fig. 2). However, there were significant differences between the unaffected eye and the ITON eye in TS, ST, SN, IN and IT areas (P = 0.004 ~ 0.026, Fig. 4). There wasn’t a significant difference between the unaffected eye and the ITON eye in the other three areas (NS, NI and TI areas, P = 0.386 ~ 0.966, Fig. 4).
Fig. 4.
The Alteration of the global pRNFL thickness and its pRNFL thickness in corresponding eight respective area during the 3 months follow-up in ITON eyes and unaffected eyes with ETOCD treatment. The global pRNFL thickness and its pRNFL thickness in corresponding eight respective area at A pre-op, B post-op 2 weeks, C post-op 1 month and D post-op 3 months in ITON eyes and unaffected eyes with ETOCD treatment. ETOCD, endoscopic trans-ethmosphenoid optic canal decompression; pRNFL, peripapillary retinal nerve fiber layer; TS, temporal-superior; ST, superior-temporal; SN, superior-nasal; NS, nasal-superior; NI, nasal-inferior; IN, inferior-nasal; IT, inferior-temporal; TI, temporal-inferior; pre-op, pre-operative; post-op, post-operative
The alteration of the RPC during the post-op 3 months in ITON eyes
The global RPC density of all ITON eyes at the pre-op, post-op 2 weeks, 1 month and 3 months were 47.71 ± 7.36, 40.56 ± 8.71, 40.75 ± 7.06 and 33.95 ± 8.03%, respectively. For all ITON eyes, the post-op global RPC density at three points was significantly different from the pre-op RPC density (All P ≤ 0.006). There wasn’t a significant difference between the global RPC density at post-op 2 weeks and post-op 1 month (P = 0.947). The significant difference between the global RPC density at the post-op 1 month and post-op 3 months was still found (P = 0.008).
When we separated all ITON eyes into two groups depending on whether their final visual acuity improved or not at post-op 3 months (compared to the pre-op), there were 28 ITON eyes with final visual improvement and 9 without final visual improvement (3 with deteriorated visual acuity and 6 with stable visual acuity). The global RPC density of the ITON eyes with final visual improvement at the pre-op, post-op 2 weeks, 1 month and 3 months were 48.95 ± 5.83, 42.32 ± 7.41, 43.06 ± 5.22 and 35.14 ± 8.53%, respectively (Fig. 2). However, the global RPC density of the ITON eyes without final visual improvement at the pre-op, post-op 2 weeks, 1 month and 3 months were 44.74 (IQR, 35.13–53.16), 34.67 (IQR, 24.17–44.43), 36.51 (IQR, 26.85–43.32) and 29.03 (IQR, 25.78–35.39) %, respectively (Fig. 2).
The alteration of the pRNFL during the post-op 3 months in ITON eyes
The global pRNFL thickness of all ITON eyes at the pre-op, post-op 2 weeks, 1 month and 3 months were 112.76 ± 27.76, 92.50 ± 22.73, 88.36 ± 18.96 and 68.30 ± 17.61 μm, respectively. The post-op global pRNFL thickness of all ITON eyes at three points was significantly different from the pre-op pRNFL thickness (All P ≤ 0.006). There wasn’t a significant difference between the global pRNFL thickness at post-op 2 weeks and post-op 1 month (P = 0.585). The significant difference between the global pRNFL thickness at the post-op 1 month and post-op 3 months was still found (P = 0.003).
Then, we separated all ITON eyes into two groups depending on whether their final visual acuity improved or not at post-op 3 months as well. The global pRNFL thickness of the ITON eyes with final visual improvement at the pre-op, post-op 2 weeks, 1 month and 3 months were 117.87 ± 26.70, 97.81 ± 21.98, 94.40 ± 18.14 and 69.79 ± 19.35 μm, respectively (Fig. 2). However, the global pRNFL thickness of the ITON eyes without final visual improvement at the pre-op, post-op 2 weeks, 1 month and 3 months were 112.95 (IQR, 66.78–118.13), 71.87 (IQR, 60.23–89.73), 77.49 (IQR, 60.20–86.64) and 62.11 (IQR, 58.15–71.77) μm, respectively (Fig. 2).
The alteration of the BCVA during the post-op 3 months in ITON eyes
The BCVA of all ITON eyes at the pre-op, post-op 2 weeks, 1 month and 3 months were 2.41 ± 1.61, 1.84 ± 1.43, 1.54 ± 1.39 and 1.54 ± 1.38, respectively. In all ITON eyes, the BCVA at post-op 2 weeks didn’t show any significant difference from the pre-op BCVA (P = 0.107). A significant difference had been found at post-op 1 month and post-op 3 months when compared to the pre-op BCVA (P = 0.018 and 0.015, respectively). The insignificant difference between the BCVA at the post-op 1 month and post-op 3 months was shown (P = 0.995).
Separating all ITON eyes into two groups depending on whether their final visual acuity improved or not at post-op 3 months, the BCVA of the ITON eyes with final visual improvement at the pre-op, post-op 2 weeks, 1 month and 3 months were 2.36 ± 1.54, 1.58 ± 1.16, 1.15 ± 0.87 and 1.16 ± 0.89, respectively. Differently, the BCVA of the ITON eyes without final visual improvement at the pre-op, post-op 2 weeks, 1 month and 3 months were 2.59 ± 1.89, 2.62 ± 1.94, 2.78 ± 2.00 and 2.89 ± 1.94, respectively.
The association between RPC density and pRNFL thickness
For RPC density, the pre-op RPC density was correlated with the post-op 2 weeks and post-op 1 month RPC density (Both P ≤ 0.001, Fig. 5), but wasn’t correlated with the post-op 3 months RPC density (P = 0.071, Fig. 5). The RPC density at the post-op 2 weeks and post-op 1 month were both correlated with the post-op 3 months RPC density (P = 0.004 and < 0.001, respectively, Fig. 5).
Fig. 5.
The Association between RPC density and pRNFL thickness in ITON eyes. RPC, radial peripapillary capillary; pRNFL, peripapillary retinal nerve fiber layer. The color bar indicated the value of relative coefficient between the two parameters
For the pRNFL thickness, the pre-op pRNFL thickness was correlated with the pRNFL thickness at post-op 2 weeks and post-op 1 month (Both P ≤ 0.008, Fig. 5), but wasn’t correlated with the post-op 3 months’ RPC density (P = 0.065).
No matter at the pre-op or post-op points, the RPC density was correlated with the corresponding pRNFL thickness (All P < 0.001, Fig. 5).
Discussion
In the current study, we reported the alteration of the RPC density and pRNFL thickness in ITON eyes after ETOCD treatment. To our knowledge, this was the first study to investigate the alteration of RPC density with a long follow-up after the ETOCD treatment. Surprisingly, the visual acuity showed continuous and mild improvement in most patients, whereas RPC density continued to deteriorate (Fig. 6).
Fig. 6.
Diagram showing the alteration in ITON eyes with ETOCD treatment. RPC, radial peripapillary capillary; pRNFL, peripapillary retinal nerve fiber layer; BCVA, best corrected visual acuity
At the pre-op, we found a significantly decreased RPC density but not the thinning pRNFL in ITON compared to the unaffected eyes in our current study. In our mind, the blood stagnation occurred in ITON due to the elevated intra-canalicular pressure [16, 17]. The blood stagnation would lead to insufficient blood supply and oxygen, then resulting in the degeneration of pRNFL [17, 18]. On the one hand, it might indicate that the alteration of RPC might occur before the pRNFL. The average time to ETOCD treatment after trauma among the ITON eyes was 4 ± 7 days in the current study. The pRNFL might be a secondary injury. In our previous study, we also found that RPC density was more significantly degenerated in ITON than pRNFL as well. The ITON might be an ischemic optic neuropathy to some extent. On the other hand, we supposed that though blood stagnation occurred, it might only involve some part of the pRNFL but not the entire optic nerve head. Then, some parts of pRNFL might have deteriorated at this time with thinning thickness, and the other part of pRNFL might be thicker due to the inflammatory response [19, 20]. In this way, insignificant changes in global pRNFL were found.
At the post-op 2 weeks, the RPC density was decreased significantly when compared to the pre-op RPC density. It was widely accepted that ETOCD helped remove the existing bony fragment and clear up the hematoma in the optic canal [21, 22]. ETOCD would relieve the intra-canalicular pressure [12, 23, 24]. When the intra-canalicular pressure was relieved after ETOCD, the blood stagnation was addressed. However, the RPC density still decreased but not increased after ETOCD in our current study. This was different from the traditional hypothesis. We supposed that the part of pRNFL that was still with the recovery function would get more oxygen with the improved visual function after ETOCD. However, the other part of pRNFL had already been destroyed before the treatment would be with further less oxygen demand. The decreased global RPC density might indicate that the destroyed part of pRNFL might be more than the part that with the resilience function to some extent.
The structural–functional discrepancy after treatment had been observed here as well. The resolution of conduction block by mechanisms of repair and decompression might result in improved visual function, while the neuroaxonal loss didn’t recover and continued slowly. On the other hand, the contradiction between the global RPC/pRNFL progressive decrease and visual acuity improvement might be due to the function of the entire optic nerve being only shown with the visual field [25]. The eyes with the massive visual field loss could still show normal visual acuity. The visual acuity might more rely on the papillomacular nerve fibers [25, 26]. It was believed that blunt force on the head caused the shearing of the posterior optic nerve with more significant degeneration of the superior macular ganglion cell layer. [27, 28] Similarly, we found that the degeneration of the pRNFL in temporal and nasal parts were less than the other two parts. It would explain that the papillomacular nerve fibers may not be degenerated seriously at all, with a higher resilience function. As we had known, an intracranial portion of the optic nerve was fixed within the optic nerve canal and was stretched when the trauma occurred. With ETOCD, the existing bony fragment and hematoma in the optic canal were cleared up. That would be one of the reasons for the visual improvement after ETOCD. The structural–functional discrepancy during the follow-up after treatment had also been reported in other optic neuropathies previously [29, 30].
With relived intra-canalicular pressure after ETOCD, the RPC density and pRNFL thickness would be stable for around 1 month. The visual function was improved progressively during the post-op 1 month. It would indicate more oxygen supply to the “resilience” pRNFL for recovery of its function and less oxygen supply to the “total degeneration” pRNFL for its un-functionality. The observable visual recovery would also be secondary to the resilience of the pRNFL and RPC. Post-op 1 month would be an important point as a plateau. In our current study, the visual acuity was improved at post-op 2 weeks and post-op 1 month, but not improved anymore thereafter. Furthermore, the plateau in both RPC density and pRNFL thickness observed between postoperative 2 weeks and 1 month may suggest a delayed treatment response to ETOCD. Future studies with extended follow-up periods would be valuable to provide further insights into this phenomenon.
However, we found that the RPC density and pRNFL thickness were still reduced at the post-op 3 months with stable visual acuity compared to the post-op 1 month. Similarly, it had also been reported that significant pRNFL loss in other ischemic optic neuropathies, even before the observable visual function impairment [31–33]. As an ischemic optic neuropathy, though the intra-canalicular pressure had been relieved, the deterioration of the optic nerve might still exist. It had been reported that the primary pRNFL damage due to the optic nerve injury would be related to the further surrounding pRNFL degeneration [34]. It would give us clues that the long follow-up for these patients was important and the visual function would not be the only thing we should focus on during the clinic.
When separating all ITON eyes into two groups depending on whether the final visual acuity improved or not at post-op 3 months, the pre-op global RPC density in ITON eyes with final visual improvement showed a little higher than ITON eyes without final visual improvement, which met our previous conclusion that the pre-op RPC was a great indicator for the visual prognosis after ETOCD [6]. What’s more, the global RPC density and the global pRNFL thickness in ITON eyes without final visual improvement showed sharper alteration after ETOCD at post-op 2 weeks compared to the ITON eyes with final visual improvement. However, RPC density and pRNFL thickness during further follow-up showed a similar tendency between the two groups. It might indicate the first two weeks after ETOCD would be the most important timing for final visual prediction. ETOCD helped relieve the intra-canalicular pressure and tried to reduce the degree of ischemia. The visual alteration at the post-op two weeks was also more significant in the ITON eyes with final visual improvement. As an ischemic optic neuropathy, if the effect of ETOCD during the first two weeks was great, a better visual prognosis could be found. Based on that, we supposed that the post-op 2 weeks would be an important timing for structural–functional prognosis in ITON eyes.
We still acknowledged some limitations in the current study. First, the small sample size of the current study. In the future, including a larger sample size with a longer follow-up would be essential. Then, we didn’t analyze the visual field alteration in our current study. For most of ITON's eyes with visual acuity of less the 1.3, it would be unmeaningful to do the visual field examination among them. Moreover, for these patients, the visual acuity alteration would be more important in their daily lives.
In conclusion, we demonstrated the progressive decreasing RPC density and pRNFL thickness in ITON eyes after ETOCD though with a plateau between post-op 2 weeks and post-op 1 month (Fig. 6). For ITON eyes, the deterioration might occur in only some parts of the optic nerve while other parts do not (e.g. the papillomacular nerve fibers might not be impaired seriously and still with resilience function in some cases). As an ischemic optic neuropathy, the alteration of the RPC would be paid attention to carefully, especially for the pre-op and post-op 2 weeks. What’s more, the visual improvement might be secondary to the alteration of retinal perfusion after ETOCD for a long time, though discrepancies in structural–functional resilience existed.
Acknowledgements
Thanks for the support from Qucheng Hong.
Author contributions
JY and WW conceived and designed the study; YT, WY, and XH performed the experiments; JY and WW wrote and modified the manuscript. All authors read and approved the manuscript.
Funding
This study is supported by research grants from Wenzhou basic scientific research project (Grant No. Y2023815) and the Natural Science Foundation of Zhejiang Province (Grant No. LQ21H120007).
Data availability
The data would be supplied if required.
Declarations
Ethics approval and consent to participate
The study adhered to the tenets of the Declaration of Helsinki and was approved by the Ethics Committee of the Eye Hospital of Wenzhou Medical University. Written informed consent was obtained from all subjects.
Consent for publication
All authors agree to publish this manuscript and all patients included consent to publish this manuscript using their clinic information.
Competing interests
No conflicting relationship exists for any author.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Wencan Wu, Email: wuwencan@wmu.edu.cn.
Jie Ye, Email: jieyeah8651@wmu.edu.cn.
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