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This review summarizes key advances in therapeutic EV development, including MSC culture, EV production, isolation, and characterization, with a focus on the current strategies and limitations of EV quality assessment. In addition, we propose a pathological-node-based framework to integrate the current evidence for EV therapies with optic neuropathies. Despite differences in EV sources, molecular composition, and proposed mechanisms, the therapeutic effects of diverse EV preparations converge on three shared pathological processes: retinal ganglion cell (RGC) preservation, neuroinflammatory regulation, and metabolic homeostasis maintenance. Finally, we discuss major challenges for clinical translation, including EV heterogeneity, functional EV subpopulations, targeted delivery, engineering strategies, and the establishment of biologically relevant potency assays. 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