BACKGROUND: Whether surgical nerve decompression is indicated for the treatment of posttraumatic reduced vision with optic nerve compression in the bony canal has been a subject of controversy for decades. On balance, the recent literature suggests that this procedure is indeed indicated, as a supplement to high-dosed cortisone therapy. The risk of surgery-related side effects is usually rated low in the literature. CASE REPORT: We report on a woman patient in whom craniocerebral trauma involved a fracture of the left optic canal with unilateral loss of vision. In the decompression operation, intraoperative symptoms gave rise to the suspicion of an arteriovenous fistula, which had not been revealed by computer tomography and which was seen as sufficient grounds for discontinuing the procedure. In addition to a carotid artery-sinus cavernosus fistula (CCF Barrow type A), subsequent angiography revealed a dissected aneurysm at the branching of the occluded ophthalmic artery. DISCUSSION AND CONCLUSIONS: In decisions on whether surgical relief of pressure on the optic canal is indicated after trauma-related visual loss, the possibility of secondary lesions near the tip of the orbita and the optic canal must be taken into account. These are not always revealed by computer tomography. The indications should be critically weighed up in each individual case, with additional imaging examinations, such as MR-angiography, CT-angiography, or conventional angiography, performed as needed. The options and indications for imaging are discussed. The procedure can by no means be rated as "minimally invasive", as is postulated by some authors.
BACKGROUND: Whether surgical nerve decompression is indicated for the treatment of posttraumatic reduced vision with optic nerve compression in the bony canal has been a subject of controversy for decades. On balance, the recent literature suggests that this procedure is indeed indicated, as a supplement to high-dosed cortisone therapy. The risk of surgery-related side effects is usually rated low in the literature. CASE REPORT: We report on a womanpatient in whom craniocerebral trauma involved a fracture of the left optic canal with unilateral loss of vision. In the decompression operation, intraoperative symptoms gave rise to the suspicion of an arteriovenous fistula, which had not been revealed by computer tomography and which was seen as sufficient grounds for discontinuing the procedure. In addition to a carotid artery-sinus cavernosus fistula (CCF Barrow type A), subsequent angiography revealed a dissected aneurysm at the branching of the occluded ophthalmic artery. DISCUSSION AND CONCLUSIONS: In decisions on whether surgical relief of pressure on the optic canal is indicated after trauma-related visual loss, the possibility of secondary lesions near the tip of the orbita and the optic canal must be taken into account. These are not always revealed by computer tomography. The indications should be critically weighed up in each individual case, with additional imaging examinations, such as MR-angiography, CT-angiography, or conventional angiography, performed as needed. The options and indications for imaging are discussed. The procedure can by no means be rated as "minimally invasive", as is postulated by some authors.