Incidence of Traumatic Optic Neuropathy After Craniofacial Trauma: A Systematic Review and Meta-Analysis

Traumatic optic neuropathy (TON) is an uncommon but vision-threatening complication of craniofacial and orbital trauma, and reliable estimates of its incidence and visual outcomes are needed to inform prognosis and clinical decision-making. We conducted a prospectively registered systematic review and meta-analysis (PROSPERO: CRD420251235951) to determine the literature-pooled incidence of TON after craniofacial trauma. MEDLINE, Embase, and the Cochrane Library were searched from inception to 9 August 2025 for observational studies or randomized trials reporting TON incidence following craniofacial trauma. Study, patient, and injury characteristics were extracted; risk of bias was assessed using the Cochrane ROBINS-E tool and certainty of evidence using GRADE. Pooled incidence estimates were generated using random-effects meta-analysis of proportions with Freeman–Tukey double arcsine transformation, with preplanned subgroup and sensitivity analyses. Sixteen studies met inclusion criteria (7,896 eyes; 7,871 patients). The pooled incidence of TON was 6.3% (95% CI 3.30–11.80), with substantial heterogeneity (I2 = 94.6%) and study-level estimates ranging from 1.0% to 44.0%. Excluding high risk-of-bias studies yielded a pooled incidence of 7.9% (95% CI 3.20–18.30; I2 = 94.5%). Incidence estimates were similar between trauma/tertiary centers and smaller hospital-based cohorts (6.0%, 95% CI 0.03–0.13). Visual outcomes were consistently poor: across six studies, most patients presented with profound visual loss and recovery was uncommon. Overall, very low-certainty evidence suggests that TON occurs in approximately 6.3% of patients following craniofacial trauma, underscoring the need for prospective studies to refine incidence estimates and better define prognostic factors and outcomes.