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1. Background
Traumatic optic neuropathy (TON) is caused by an acute optic nerve injury from a direct or indirect trauma that results in a reduction of visual acuity. The severity of the optic nerve damage varies from a simple contusion to a complete avulsion of the optic nerve. Indirect damage to the optic nerve can also cause TON which occurs in 0.5%–5% of all closed-head traumas [1, 2]. Although the degree of visual acuity reduction in indirect TON varies, one-half of the cases have visual acuities of light perception or even no light perception [3–5].
No established treatment exists for TON, and its optimal management protocol is under debate [3–7]. The International Optic Nerve Trauma Study (IONTS) group reported that there were no significant differences in the visual outcomes between those treated with surgical decompression and those treated with steroids. Thus, neither corticosteroid therapy nor optic canal decompression is the better treatment of TON [6].
We present a case of TON that underwent steroid pulse therapy, followed by optic canal and nerve sheath decompression surgery. The optic nerve function was assessed by Goldmann visual fields (GVFs). The GVFs were determined multiple times because the defects extended beyond the central 30°. The GVF results were analyzed quantitatively and compared with the best corrected visual acuity (BCVA) and the critical fusion flicker (CFF) frequency during the course of the disease process.
2. Case Presentation
A 70-year-old man fell from a 3 m cliff and landed on the left side of his face. Six days later, he visited an eye clinic complaining of blurred vision, and he was referred to the Saitama Medical University Hospital with a diagnosis of TON. Our examination showed that his decimal BCVA was 0.9 in the right eye and 0.2 in the left eye. A relative afferent pupillary defect was detected in the left eye, and the eye movements were normal bilaterally. Fundoscopy revealed a healthy-looking optic disc with normal retinal circulation bilaterally. The intraocular pressure was 10.0 mmHg in both eyes. The CFF was 37.0 Hz in the right eye and unmeasurable in the left eye.
Computed tomographic examination revealed a fracture in the lateral wall of the left orbit (Figure 1), and the anterior and posterior walls of the left maxillary sinus were fractured and slightly depressed. No obvious optic canal fracture was seen.
[figure(s) omitted; refer to PDF]
Then, 1 g/day of intravenous methylprednisolone was started. Two days later, the visual acuity in the left eye improved to 0.3, but the GVFs had worsened (Figure 2). The GVF examination showed an area of 17.76 deg2 for the I/3e isopter (Figure 3). However, the V/4e area decreased from 539.35 to 359.36 deg2.
[figure(s) omitted; refer to PDF]
The patient then underwent optic nerve decompression by an endoscopic endonasal approach, and a bone fragment was removed from the optic canal. Three days after the surgery, the decimal BCVA improved to 0.6, and the V/4e area and I/3e area enlarged to 1122.52 and 46.88 deg2, respectively. The CFF frequency became measurable at 16.3 Hz in the left eye. Eight weeks after the surgery, the visual acuity was 0.7, although a paracentral relative scotoma was still present. Improvements of the V/4e area to 1955.79 deg2 and the I/3e area to 114.63 deg2 were detected. The CFF frequency was 17.0 Hz in the left eye. Six months after the surgery, the visual acuity further improved to 0.8, and the CFF frequency was 24.7 Hz in the left eye. However, the V/4e area and I/3e area decreased to 1744.14 and 95.36 deg2, which were 0.85 and 0.66, respectively, of the previous values. The changes in the BCVA and the area of each isopter of the GVF are shown in Figures 2 and 3.
2.1. Quantitative Analyses of GVFs
The GVFs were quantified with the ImageJ (https://imagej.nih.gov/ij, accessed on 31 May 2023) software [8–11]. For this, we constructed an ImageJ macro called the Kanno–Saitama Macro (KSM)-GVF program by modifying the already existing KSM program whose details have been reported [12, 13]. In brief, the KSM-GVF program consisted of two macros, one for the extraction and one for the quantification of the size of the visual fields for each isopter. Continuous quantification was also possible by rewriting the macro code. The extraction followed by quantitation is sequentially shown. The procedures are shown as follows:
A. A black magic marker was used to trace each isopter and its scotoma on two copies of papers of the GVF results. One copy was for each isopter, and the other was for the scotoma. The two traced sheets were scanned and imported to ImageJ, and the macro for extraction was started.
B. For isopter extraction, the auto threshold minimum macro [14] in ImageJ was used. When the macro was activated, the size inside the traced black magic marker was calculated and extracted.
C. After each isopter was extracted, the number of pixels in the area surrounded by the isopters was quantified by activating the macro for quantification. Next, the number of pixels within each isopter was divided by the number of pixels in a
The results of the quantification showed that the size of the GVF increased and that of the scotoma decreased with increasing posttreatment times (Figure 2).
3. Discussion
We have presented our findings in a case of TON in which the visual functions were quantitatively monitored during and after steroid pulse therapy combined with optic nerve decompression surgery. Our findings showed that there were improvements in both the BCVA and the GVFs, and the improvements were corresponding.
Clinical interventions for TON include observation only, megadose steroid administration, and/or optic canal decompression with or without steroids. The best treatment has still not been definitively determined. A review of the earlier studies showed that the visual acuity of patients with TON can be significantly improved after optic canal decompression surgery, independent of steroid use [7]. The rationale for surgical decompression is that it can remove the structures compressing the optic canal and thus remove the detrimental effects of compression. The decompression lowers the intracanalicular pressure and enables the removal of any impinging bone fragments, allowing nerve function to be restored. Systematic steroids have a similar effect, leading to a medical decompression [15].
Static perimetry is used more widely than kinetic perimetry today in ophthalmic practice. However, kinetic perimetry remains helpful in evaluating the progression of inherited, autoimmune retinal degenerations, and severe optic neuropathy, where the visual field defects or scotomas lie beyond the central 30° of the visual field [16]. Descriptive methods for assessing the GVFs have been used in clinical settings. In contrast, several methods have been proposed to quantify the GVFs such as the use of planimetry [17–19], the use of the American Medical Association (AMA) score [20], and digital quantification using Adobe Photoshop [21, 22].
In our case, we have used the KSM macro with ImageJ to obtain quantitative values of the size of the GVFs. Thus, the course of the disease process can be easily determined by the changes in the quantified data. We found that the BCVA improved slightly, but the GVFs improved markedly after the steroid pulse therapy, especially after the decompression surgery. The quantification of the size of the VDs showed that the size of the GFVs I/3e isopter had the greatest increase from the earlier value, suggesting that there is a correlation between the recovery of central visual fields and the improvements of visual acuity. At 6 months after the surgery, the BCVA was still improving, but the GVF values started to decrease. Although the influence of fluctuations inherent in subjective tests cannot be denied, it is possible that the improvements in the BCVA and the GVF had passed their peak. This clearly indicated that functional decline can occur even after a significant recovery due to the treatments. This suggests the importance of obtaining quantitative indices of the visual field function in clinical practice.
The KSM-GVF can measure the area of each isopter and scotomata in a time-saving, reproducible, and reliable manner. It can follow the longitudinal changes in the GVF quantitatively and accurately. This will then allow clinicians to monitor the progress of the disease process and determine the effectiveness of the therapy being administered.
There are several limitations in this study. First, because we have reviewed the patients’ medical records, there was a lack of structural parameters such as retinal nerve fiber layer thickness or retinal capillary density in the superficial retinal layer. Both findings are important because they have been reported to reflect the retinal ganglion cell damage [23, 24]. Second, the KSM-GVF program calculates only the area of each isopter and does not consider differences of sensitivity within the VF; for example, the central part of the isopter is more sensitive than the peripheral part. Therefore, it may be better to sum the KSM-GVF indices on a weighted scale to measure the volume corresponding to each isopter. This would consider the sensitivity and area into account. For this limitation, Odaka et al. proposed a system that can digitize the isopters to calculate the area, volume, and shape factors [25]. Third, the findings are from a single case and cannot be generalized. However, no new equipment is required, and analysis can be performed on the results already obtained using the widely used GFVs. New quantitative metrics may be useful in the interpretation of the visual fields.
4. Conclusion
We have presented the functional changes caused by a unilateral TON in a 70-year-old Japanese man using quantitative analyses of the GVFs. Although the data were from a single case and cannot be generalized, the findings showed a significant improvement of the GVFs that corresponded with the improvements of the BCVA after the optic canal decompression. Additional cases and further quantitative analyses of the GVFs should provide new insights into the usefulness of multimodal functional evaluations of optic nerve disorders.
Author Contributions
M.T., M.H., Y.H., M.S., and T.I. cared for the patient including assessment and treatment throughout the follow-up period. M.T., J.K., Y.N.-O., S.K., R.A., S.I., J.M., and K.S. collected data, analyzed the ophthalmological findings, and gave critical suggestions. J.K. developed the KSM-GVF program and performed a quantitative assessment of the kinetic visual field with it. M.T. and J.K. prepared the figures. K.S. prepared a draft, and M.T., J.K., Y.H., M.S., Y.N.-O., S.K., R.A., S.I., J.M., and T.I. revised and finalized it. All authors agree to be accountable for all aspects of their work. All authors attest that they meet the current ICMJE criteria for authorship.
Funding
This study was supported in part by the Japan Society for the Promotion of Science (JSPS; KAKENHI grant number 22K09838).
Acknowledgments
The authors thank emeritus Professor Duco Hamasaki for the English language review. The patient’s anonymity is preserved.
[1] L. B. Kline, R. B. Morawetz, S. N. Swaid, "Indirect injury of the optic nerve," Neurosurgery, vol. 14 no. 6, pp. 756-764, DOI: 10.1227/00006123-198406000-00021, 1984.
[2] I. Kallela, T. Hyrkäs, P. Paukku, T. Iizuka, C. Lindqvist, "Blindness after maxillofacial blunt trauma," Journal of Cranio-Maxillofacial Surgery, vol. 22 no. 4, pp. 220-225, DOI: 10.1016/S1010-5182(05)80561-X, 1994.
[3] S. Lessell, "Indirect optic nerve trauma," Archives of Ophthalmology, vol. 107 no. 3, pp. 382-386, DOI: 10.1001/archopht.1989.01070010392031, 1989.
[4] K. D. Steinsapir, R. A. Goldberg, "Traumatic optic neuropathy," Survey of Ophthalmology, vol. 38 no. 6, pp. 487-518, DOI: 10.1016/0039-6257(94)90145-7, 1994.
[5] P. I. Chou, A. A. Sadun, C. Y. Chen, W. Y. Su, S. Z. Lin, C. C. Lee, "Clinical experiences in the management of traumatic optic neuropathy," Neuro-ophthalmology, vol. 16 no. 6, pp. 325-336, DOI: 10.3109/01658109609044636, 1996.
[6] L. A. Levin, R. W. Beck, M. P. Joseph, S. Seiff, R. Kraker, "The treatment of traumatic optic neuropathy," Ophthalmology, vol. 106 no. 7, pp. 1268-1277, DOI: 10.1016/S0161-6420(99)00707-1, 1999.
[7] B. Chen, H. Zhang, Q. Zhai, H. Li, C. Wang, Y. Wang, "Traumatic optic neuropathy: a review of current studies," Neurosurgical Review, vol. 45 no. 3, pp. 1895-1913, DOI: 10.1007/s10143-021-01717-9, 2022.
[8] M. Díaz, J. Novo, P. Cutrín, F. Gómez-Ulla, M. G. Penedo, M. Ortega, "Automatic segmentation of the foveal avascular zone in ophthalmological OCT-A images," PLoS One, vol. 14 no. 2, article e0212364,DOI: 10.1371/journal.pone.0212364, 2019.
[9] Y. Lu, J. M. Simonett, J. Wang, M. Zhang, T. Hwang, A. M. Hagag, D. Huang, D. Li, Y. Jia, "Evaluation of automatically quan-tified foveal avascular zone metrics for diagnosis of diabetic retinopathy using optical coherence tomography angi-ography," Investigative Ophthalmology & Visual Science, vol. 59 no. 6, pp. 2212-2221, DOI: 10.1167/iovs.17-23498, 2018.
[10] F. Y. Tang, D. S. Ng, A. Lam, F. Luk, R. Wong, C. Chan, S. Mohamed, A. Fong, J. Lok, T. Tso, F. Lai, M. Brelen, T. Y. Wong, C. C. Tham, C. Y. Cheung, "Determinants of quantitative optical coherence tomography angiography metrics in patients with diabetes," Scientific Reports, vol. 7 no. 1,DOI: 10.1038/s41598-017-02767-0, 2017.
[11] A. Lin, D. Fang, C. Li, C. Y. Cheung, H. Chen, "Improved automated foveal avascular zone measurement in cirrus optical coherence tomography angiography using the level sets macro," Translational Vision Science & Technology, vol. 9 no. 12,DOI: 10.1167/tvst.9.12.20, 2020.
[12] H. Ishii, T. Shoji, Y. Yoshikawa, J. Kanno, H. Ibuki, K. Shinoda, "Automated measurement of the foveal avascular zone in swept-source optical coherence tomography angiography images," Translational Vision Science & Technology, vol. 8 no. 3, pp. 28-28, DOI: 10.1167/tvst.8.3.28, 2019.
[13] J. Kanno, T. Shoji, H. Ishii, H. Ibuki, Y. Yoshikawa, T. Sasaki, K. Shinoda, "Deep learning with a dataset created using Kanno Saitama macro, a self-made automatic foveal avascular zone extraction program," Journal of Clinical Medicine, vol. 12 no. 1,DOI: 10.3390/jcm12010183, 2023.
[14] J. M. Prewitt, M. L. Mendelsohn, "The analysis of cell images," Annals of the New York Academy of Sciences, vol. 128 no. 3, pp. 1035-1053, DOI: 10.1111/j.1749-6632.1965.tb11715.x, 1966.
[15] F. Chen, K. Zuo, S. Feng, J. Guo, Y. Fan, J. Shi, H. Li, "A modified surgical procedure for endoscopic optic nerve decompression for the treatment of traumatic optic neuropathy," North American Journal of Medical Sciences, vol. 6 no. 6,DOI: 10.4103/1947-2714.134372, 2014.
[16] J. J. S. Barton, M. Benatar, Field of Vision: A Manual and Atlas of Perimetry,DOI: 10.1385/1592593550, 2003.
[17] F. A. Linstone, J. R. Heckenlively, A. M. Solish, "The use of planimetry in the quantitative analysis of visual fields," Glaucoma, vol. 4 no. 17, 1982.
[18] H. A. Ferreyra, T. Jayasundera, N. W. Khan, S. He, Y. Lu, J. R. Heckenlively, "Management of autoimmune retinopathies with immunosuppression," Archives of Ophthalmology, vol. 127 no. 4,DOI: 10.1001/archophthalmol.2009.24, 2009.
[19] J. R. Heckenlively, H. A. Ferreyra, "Autoimmune retinopathy: a review and summary," Seminars in Immunopathology, vol. 30 no. 2, pp. 127-134, DOI: 10.1007/s00281-008-0114-7, 2008.
[20] M. Yanagisawa, S. Kato, S. Kunimatsu, M. Tamura, M. Ochiai, "Relationship between vision-related quality of life in Japanese patients and methods for evaluating visual field," Japanese Journal of Ophthalmology, vol. 55 no. 2, pp. 132-137, DOI: 10.1007/s10384-010-0924-8, 2011.
[21] S. Zahid, C. Peeler, N. Khan, J. Davis, M. Mahmood, J. R. Heckenlively, T. Jayasundera, "Digital quantification of Goldmann visual fields (GVFs) as a means for genotype-phenotype comparisons and detection of progression in retinal degenerations," Advances in Experimental Medicine and Biology, vol. 801, pp. 131-137, DOI: 10.1007/978-1-4614-3209-8_17, 2014.
[22] M. Xu, Y. Zhai, I. M. MacDonald, "Visual field progression in retinitis pigmentosa," Investigative Ophthalmology & Visual Science, vol. 61 no. 6,DOI: 10.1167/iovs.61.6.56, 2020.
[23] M. J. Kupersmith, M. K. Garvin, J. K. Wang, M. Durbin, R. Kardon, "Retinal ganglion cell layer thinning within one month of presentation for non-arteritic anterior ischemic optic neuropathy," Investigative Ophthalmology & Visual Science, vol. 57 no. 8, pp. 3588-3593, DOI: 10.1167/iovs.15-18736, 2016.
[24] J. Ye, H. Zhu, W. Yan, Y. Tu, X. Hu, W. Wu, "Retinal peripapillary microvasculature in indirect traumatic optic neuropathy predicted prognosis of endoscopic trans-ethmosphenoid optic canal decompression," Acta Ophthalmologica, vol. 101 no. 2, pp. e226-e235, DOI: 10.1111/aos.15243, 2023.
[25] T. Odaka, K. Fujisawa, K. Akazawa, M. Sakamoto, N. Kinukawa, T. Kamakura, Y. Nishioka, H. Itasaka, Y. Watanabe, Y. Nose, "A visual field quantification system for the Goldmann perimeter," Journal of Medical Systems, vol. 16 no. 4, pp. 161-169, DOI: 10.1007/BF00999378, 1992.
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Abstract
The International Optic Nerve Trauma Study (IONTS) group reported that there were no significant differences in the visual outcomes between those treated with surgical decompression and those treated with steroids. [...]neither corticosteroid therapy nor optic canal decompression is the better treatment of TON [6]. [...]the value was multiplied by 225 (15 squared) to obtain the area (deg2) of each isopter and each scotoma. In our case, we have used the KSM macro with ImageJ to obtain quantitative values of the size of the GVFs. [...]the course of the disease process can be easily determined by the changes in the quantified data. [...]the KSM-GVF program calculates only the area of each isopter and does not consider differences of sensitivity within the VF; for example, the central part of the isopter is more sensitive
You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer
Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer
Details

1 Department of Ophthalmology Faculty of Medicine Saitama Medical University Saitama, Japan, 38 Moro-Hongo Moroyama-machi, Iruma-gun, Saitama 350-0495 Japan
2 Department of Otorhinolaryngology Faculty of Medicine Saitama Medical University Saitama, Japan; 38 Moro-Hongo Moroyama-machi, Iruma-gun, Saitama 350-0495 Japan