Abstract: Background: Traumatic optic neuropathy (TON) is an important cause of severe visual loss following blunt or penetrating head trauma. Following the initial injury, optic nerve swelling within the optic nerve canal can result in secondary retinal ganglion cell loss. Optic nerve decompression with steroids or surgical interventions or both have therefore been advocated as a means of improving visual prognosis in TON. Objectives: The aim of this review was to examine the effectiveness and safety of surgical interventions, using steroids and observation in the management of TON. Method: We included only randomised controlled trials of TON in which any form of surgical intervention either on its own or in combination with steroids was compared to any steroid regime alone or no treatment. Conclusions: There is a relatively high rate of spontaneous visual recovery in TON. There is no convincing data that steroids provide any additional visual benefit over observation alone. Recent evidence also suggests a possible detrimental effect of steroids in TON. Each case therefore needs to be assessed on an individual basis and proper informed consent is paramount. Neither there is evidence that surgical decompression of the optic nerve provides any additional benefit. On the other hand, surgery carries a definite risk of complications such as postoperative cerebrospinal fluid leak and meningitis. The decision to proceed with surgery in TON remains controversial and each case needs to be assessed on its own merits.

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