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Endoscopic transconjunctival optic nerve sheath fenestration for progressive idiopathic visual field deficit: a case report.

ABSTRACT: Intra-orbital optic nerve sheath fenestration (ONSF) is an effective option in patients with progressive vision loss due to idiopathic intracranial hypertension. Most proposed techniques involve surgical trauma and require disinsertion of the medial rectus muscle; thus, less invasive surgical procedures are needed. Here, a feasible and effective technique of endoscopic intra-orbital ONSF through a conjunctival incision is presented, in a patient with a progressively compromised visual field, papilloedema, and distended subarachnoid space around the optic nerves. The retrobulbar segment of the optic nerve was exposed for incision, avoiding manipulation of the lateral orbital rim bones and irritation of the ciliary microvessels and nerves. The patient regained the entire visual field. ONSF was safely and effectively performed endoscopically through a narrow corridor gained by brushing away the orbital fat with minimal traction on the medial rectus muscle. The small postoperative wound was associated with faster and easier convalescence, and less tissue trauma versus conventional open approaches.

SUBMITTER: Lyson T

PROVIDER: S-EPMC8638564 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Unilateral Optic Nerve Sheath Fenestration in Idiopathic Intracranial Hypertension: A 6-Month Follow-Up Study on Visual Outcome and Prognostic Markers.

Project description:Loss of vision is a feared consequence of idiopathic intracranial hypertension (IIH). Optic nerve sheath fenestration (ONSF) may be an effective surgical approach to protect visual function in medically refractory IIH. In this study, we evaluate the impact of unilateral superomedial transconjunctival ONSF on bilateral visual outcome using a comprehensive follow-up program. A retrospective chart review of IIH patients who underwent unilateral ONSF between January 2016 and March 2021 was conducted. Patients fulfilling the revised Friedman criteria for IIH and who had exclusively received ONSF as a surgical treatment were included. Main outcomes were visual acuity (VA); perimetric mean deviation (PMD); papilledema grade; and optic nerve head elevation (maxONHE) 1 week, 2 weeks, and 1, 3, and 6 months after surgery. VA (p < 0.05), PMD (p < 0.05), papilledema grade (p < 0.01), and maxOHNE (p < 0.001) were improved after 6 months on both the operated and non-operated eye. Prolonged surgical delay impedes PMD improvement (r = -0.78, p < 0.01), and an increasing opening pressure initiates a greater ganglion cell loss (r = -0.79, p < 0.01). In this small case series, we demonstrate that unilateral superonasal transconjunctival ONSF is a safe procedure with an effect on both eyes. Optic nerve head elevation and PMD are feasible biomarkers for assessing early treatment efficacy after ONSF.

| S-EPMC8400184 | biostudies-literature

A 20-year multicentre retrospective review of optic nerve sheath fenestration outcomes

Project description: Not available

| S-EPMC10501074 | biostudies-literature

Optic nerve sheath meningioma endoscopic endonasal surgical management.

Project description:BackgroundMeningiomas of the optic sheath have been traditionally treated with radiotherapy, among other reasons, because of the poor results in terms of visual preservation of the open surgical approaches.Case descriptionTwo cases of optic nerve meningioma were operated through an endoscopic endonasal expanded approach due to rapidly progressing visual deterioration and doubtful diagnosis. In the first case an exclusively bone decompression was performed. In the second one a partial resection of the intradural portion and complete opening of the dural sheath was undertaken. In both cases visual acuity remained stable without further treatment for the 2 years follow up.ConclusionsEndoscopic endonasal decompression of the optic nerve by removal of the optic canal and opening of the optic sheath is safe. This approach is feasible for optic sheath meningioma. This treatment might be considered as an option in patients with rapidly deteriorating visual acuity.

| S-EPMC9623684 | biostudies-literature

The Role of Endonasal Endoscopic Optic Nerve Decompression as the Initial Management of Primary Optic Nerve Sheath Meningiomas.

Project description:Background ?The management of optic nerve sheath meningiomas (ONSMs) remains controversial. Surgical decompression through traditional resective techniques has been associated with significant morbidity. While radiation therapy, the current modality of choice is not exempt of risks. Transnasal endoscopic optic nerve decompression (EOND) offers a direct route to the orbit, optic canal, and orbital apex, providing a minimally invasive alternative. Objective ?The main objective of this article is to assess EOND as the initial management of symptomatic patients with primary ONSM. Methods ?Patients with ONSMs without a history of radiotherapy who underwent EOND were retrospectively reviewed. Postoperative imaging, duration of follow-up, and visual outcomes at the last ophthalmology visit were assessed. Results ?Four women (age range 25-63 years) with primary ONSMs that underwent EOND were identified. All patients displayed subjective and objective baseline signs of vision loss. Additionally, baseline proptosis, diplopia, optic nerve atrophy, and ocular pain were identified. In none of the cases, the optic nerve sheath was breached. Following EOND, all patients deferred treatment with adjuvant radiotherapy. At a mean postoperative follow-up of 14 months, all patients were clinically stable without evidence of disease progression on imaging or physical examination. At last ophthalmologic evaluation, three out of four showed objective improvements from baseline visual acuity and visual field (remaining patient had baseline optic nerve atrophy). Conclusion ?These results suggest that EOND could be a viable initial treatment modality of selected primary ONSM cases. Further studies are warranted to determine long-term efficacy and its role in a stepwise progression of management, preceding radiotherapy.

| S-EPMC6864426 | biostudies-literature

Combined endoscopic transethmoid and transconjunctival en bloc resection of optic nerve tumors in patients lacking functional vision

Project description:Background Surgical treatment of optic nerve tumors is challenging. The study’s objective was to evaluate the efficacy of a combined endoscopic transethmoid and transconjunctival approach in patients without functional vision. Design A retrospective, noncomparative case series. Methods Retrospective data were collected from all patients who had undergone tumor resection using this approach at the authors’ institution between 2015 and 2021. Preoperative assessments included magnetic resonance imaging and ophthalmological examinations, and re-assessments were conducted three months after surgery and regularly during the follow-up period. Results Seventeen patients, mean age 35 ± 19.0 years, were enrolled. Of these, 64.7% presented with visual acuity (VA) of light perception or no light perception. Gross total resection was realized in all patients. The average decline in exophthalmos was 3.63 ± 1.93 mm. Tumor histopathological analysis identified 12 optic nerve sheath meningiomas and 5 optic gliomas. The mean follow-up time was 30 months during which there was no local recurrence in any of the patients. Conclusions The combined endoscopic transethmoid and transconjunctival approach offers an additional choice for accessing optic nerve tumors. The procedure is both safe and effective and provides an alternative transcranial route to the orbit.

| S-EPMC9614269 | biostudies-literature

Endoscopic Bilateral Optic Nerve Decompression for Treatment of Idiopathic Intracranial Hypertension.

Project description:To evaluate the results of bilateral endoscopic optic nerve decompression (EOND) with the opening nerve sheath (ONS) technique in patients with idiopathic intracranial hypertension (IIH). Between the years of 2017 and 2019, we retrospectively evaluated nine IIH patients with progressive visual impairment despite medical treatment and who were treated with the EOND and ONS techniques. We also demonstrated our surgical technique recipe on postmortem human heads in a stepwise manner. There were 9 patients (7 females and 2 males) between the ages of 21 and 72 included in this study, and the mean age was 40.8. All patients had an impairment in visual acuity and/or their visual field, with signs of papilledema and/or optic atrophy. The patients were followed up with for 9-48 months. Improvements in visual acuity were observed in 7 out of 9 patients (78%). Visual field defects improved in 5 out of 8 patients (62.5%). Papilledema was resolved in all patients (100%). Headaches improved in all symptomatic patients (100%). No intraoperative or postoperative complications were observed. EOND is a safe and effective surgical procedure in selected patients with IIH. Bilateral wide bony decompression and nerve fenestration can also be an additional benefit for headache relief. Further clinical series and long-term follow-up are needed for more precise results.

| S-EPMC7998922 | biostudies-literature

Correlation of optic nerve and optic nerve sheath diameter with intracranial pressure in pigs.

Project description:OBJECTIVE:Several studies have shown an association between intracranial pressure and the diameter of the optic nerve sheath measured by transbulbar ultrasonography. To understand the pathophysiology of this phenomenon, we aimed to measure the changes of the optic nerve, optic nerve sheath and perineural space separately with increasing intracranial pressure in a porcine model. METHODS:An external ventricular drain was placed into the third ventricle through a right paramedian burrhole in eight anesthesized pigs. The diameters of the optic nerve and the optic nerve sheath were measured while the intracranial pressure (ICP) was increased in steps of 10mmHg from baseline up to 60 mmHg. RESULTS:The median diameters of the optic nerve (ON) increased from 0.36 cm (baseline- 95% confidence interval (CI) 0.33 cm to 0.45 cm) to 0.68 cm (95% CI 0.57 cm to 0.82 cm) at ICP of 60 mmHg (p<0.0001) and optic nerve sheath (ONS) from 0.88 cm (95% CI 0.79 cm to 0.98 cm) to 1.24 cm (95% CI 1.02 cm to 1.38 cm) (p< 0.002) while the median diameter of the perineural space (PNS) (baseline diameter 95% CI 0.40 cm to 0.59 cm to diameters at ICP 60 95% CI 0.38 cm to 0.62 cm) did not change significantly (p = 0.399). Multiple comparisons allowed differentiation between baseline and values ≥40 mmHg for ON (p = 0.017) and between baseline and values ≥ 50mmHg for ONS (p = 0.006). A linear correlation between ON (R2 = 0.513, p<0.0001) and ONS (R2 = 0.364, p<0.0001) with ICP was found. The median coefficient of variation for intra- and inter-investigator variability was 8% respectively 2.3%. CONCLUSION:Unexpectedly, the increase in ONS diameter with increasing ICP is exclusively related to the increase of the diameter of the ON. Further studies should explore the reasons for this behaviour.

| S-EPMC6999916 | biostudies-literature

Combined endoscopic endonasal transorbital approach with transconjunctival-medial orbitotomy for excisional biopsy of the optic nerve: technical note.

Project description:Background Access to the intraorbital optic nerve segment can be facilitated via a transcranial approach that allows access to the entire orbital cavity. The endoscopic endonasal approach (EEA) combined with a transconjunctival-medial orbitotomy represents an alternative technique to achieve the same goal. Objective Report a surgical technique that allows total resection of the intraorbital optic nerve with minimal trauma and excellent results. Further extend and define the limits and indications of the EEA to orbital surgery. Methods A patient with rapidly progressive, but asymmetric, vision loss underwent EEA for optic nerve biopsy. Due to the undetermined histopathological diagnosis and complete unilateral vision loss, diagnostic total optic nerve resection was indicated. The entire intraorbital length of the nerve was resected via an endoscopic endonasal transorbital approach combined with transconjunctival-medial orbitotomy. Results A 2-cm intraorbital nerve segment was sent for pathological examination. The patient maintained normal extraocular movements and experienced no complications. The postoperative course was uneventful and the patient was discharged the next day. Conclusion The EEA provides another option for access to the entire optic nerve. It is a safe and effective technique lacking cosmetic defects and providing an alternative corridor to traditional transcranial approaches to the orbit.

| S-EPMC3658658 | biostudies-other

Ultrasonographic measurement of the optic nerve sheath diameter in dysthyroid optic neuropathy.

Project description:BackgroundThe aim of this study is to evaluate the optic nerve sheath diameter (ONSD) in eyes with dysthyroid optic neuropathy (DON) and its relationship with clinical characteristics and disease severity.MethodsPatients diagnosed as thyroid-associated ophthalmopathy (TAO), with or without DON, and healthy participants were recruited. Vertical and horizontal sectional images of the optic nerve were collected by B-scan ultrasonography. ONSDs at 3 mm and 6 mm behind the eyeball were measured independently by two researchers. Multivariate regression analysis was performed to evaluate the association of ONSD with demographic and ocular parameters in TAO patients. Areas under the receiver operating characteristic curves (AUROCs) were applied to evaluate the diagnostic accuracy of ONSD for DON.ResultsA total of 47 healthy eyes, 36 TAO eyes without DON, and 33 eyes with DON were studied. ONSDs at 3 mm and 6 mm of DON eyes were significantly higher than those in non-DON and healthy eyes (all P < 0.05). There was no significant difference in ONSDs between clinically active and inactive eyes (both P > 0.05). DON occurrence showed a positive association with both ONSDs at 3 mm (β = 0.49, 95% CI: 0.14-0.83, P = 0.007) and 6 mm (β = 0.58, 95% CI: 0.20-0.96, P = 0.003). ONSDs at 3 mm and 6 mm showed a desirable diagnostic capacity to distinguish DON from non-DON eyes (AUROC was 0.77 and 0.75, respectively).ConclusionsAn increase in ONSD is evident in DON eyes independent of clinical activity. Ultrasound-based ONSD has sufficient ability to distinguish DON from non-DON eyes.

| S-EPMC8027451 | biostudies-literature

Ultrasound of Optic Nerve Sheath Diameter and Stroke Outcomes.

Project description:We aimed at utilizing ocular ultrasound to determine its utility in predicting outcomes among stroke patients.DesignSingle-center prospective observational study.SettingEmergency department and ICUs.PatientsPatients suspected of stroke.InterventionsNone.Measures and main resultsBilateral optic nerve sheath diameter was measured on arrival and within the first 2 days of admission. Outcomes were inpatient survival, Cerebral Performance Category, and modified Rankin Scale at 3 and 6 months. Analysis was conducted using descriptive statistics, paired t test, chi-square test. Eighty-six patients were enrolled with ischemic or hemorrhagic stroke. Mean age was 67.2 years (± 15 yr), and 54.7% of patients were male. There was no difference between left and right eye measurements (p = 0.467 and p = 0.903, respectively) or between longitudinal and transverse measurements (transverse p = 0.163 and longitudinal p = 0.270). Mean optic nerve sheath diameter differed in patients who survived versus died prior to discharge in both ischemic (0.53 vs 0.58 cm; p = 0.009) or hemorrhagic stroke (0.57 vs 0.62 cm; p = 0.019). For every 0.1 cm increase in optic nerve sheath diameter, odds ratio for death were 4.2 among ischemic stroke (95% CI, 1.32-13.64; p = 0.015), and odds ratio 6.2 among ischemic or hemorrhagic patients (95% CI, 1.160-33.382; p = 0.033). Increased optic nerve sheath diameter correlated (r = 0.44; p < 0.0001) with poor functional outcomes measured as modified Rankin Scale scores of 3-6 at 6 months.ConclusionsElevations in optic nerve sheath diameter were associated with increased inhospital mortality and poor functional outcome at 6 months. Optic nerve sheath diameter may serve as a noninvasive marker of inhospital mortality and functional outcome. Further multicenter prospective trials for evaluating and treating optic nerve sheath diameter in ischemic and hemorrhagic strokes are warranted.

| S-EPMC8613366 | biostudies-literature

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