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To evaluate the effect of optic nerve sheath fenestration (ONSF) on papilledema grade in the operated eyes and the contralateral nonoperated fellow eyes in patients with idiopathic intracranial hypertension (IIH).Retrospective review.A total of 78 patients underwent ONSF, and 20 patients served as controls.Charts of patients with IIH who had ONSF at the University of Iowa Hospital and Clinics were reviewed for age, gender, body mass index, and clinical findings. Optic disc photographs were graded by a masked observer using the Frisén papilledema grading scale at preoperative baseline and postoperatively at 2 weeks, 3 months, 6 months, and 12 months follow-up. Wilcoxon signed-rank test was used to examine the change in papilledema grade in both operated and nonoperated eyes at each time point.Grade of papilledema.Sixty-two patients (52 women and 10 men) with a mean age of 32 years (range, 13-57 years) underwent unilateral ONSF. The median grade of papilledema for operated and nonoperated eyes was 3 and 2, respectively, at preoperative baseline. Postoperatively the grade was 2 in each eye at 2 weeks (P0.0001 and0.0002 for operated and nonoperated eyes, respectively), 1 in each eye at 3 months (P0.0001 for both operated and nonoperated eyes), 1 in each eye at 6 months (P0.0001 for both operated and nonoperated eyes), and 0.5 and 1 for operated and nonoperated eyes, respectively, at 12 months follow-up (P0.0001 for both operated and nonoperated eyes). There was no significant difference in grade of disc edema or reduction of disc edema on the basis of age, gender, or body mass index.Unilateral ONSF significantly decreases the grade of papilledema in both ipsilateral (operated) and contralateral (unoperated) eyes. The reduction of the papilledema and the stability of visual field in the contralateral (nonoperated) eyes suggest that bilateral ONSF may not always be necessary in patients with bilateral visual loss and papilledema due to IIH.

Purpose: To describe a visual complication of optic nerve sheath fenestration. Methods: Case review of two patients who underwent seemingly uncomplicated optic nerve sheath fenestration. Findings: Both patients had a surgical complication that resulted in significant depression of their temporal visual field and development of a wedge-shaped region of subretinal pigmentation in the nasal fundus. Conclusions: Both patients had choroidal infarctions as a complication of optic nerve sheath fenestration. Choroidal infarction should be considered in cases of unexpected loss of visual field after this type of surgery, although the funduscopic signs that assist in making the diagnosis may not be evident for several weeks after surgery.

Evaluation of the efficacy of optic nerve sheath fenestration in pseudotumor cerebri has been hindered by a lack of quantitative indicators of visual function before and after treatment. Nine patients (14 eyes) were treated who had pseudotumor with optic nerve sheath fenestration, in whom automated perimetry was used as a major parameter in the decision to undertake surgery and in evaluating the results. Visual field results demonstrated significant improvement in this group of patients. Seven of 8 eyes with total loss less than 1500 dB had improvement or no further deterioration. Using results of the last preoperative examination as baseline, it was found that six of the eight had improvement over 150 dB. In one patient, a slight deterioration occurred postoperatively. Those eyes with total loss above 1500 dB demonstrated stabilization of fields postoperatively. Statistical analysis of total loss preoperatively and postoperatively for this group of patients demonstrated significant improvement for five of the six comparisons investigated. Average preoperative total loss and average postoperative total loss were not significantly different. Comparisons of results of the last preoperative examination to those of the first postoperative and most recent follow-up examinations, and evaluation of average total loss postoperatively showed significant improvement had occurred. Results of the first postoperative examination and those of the most recent follow-up examination showed significant improvement from the average preoperative total loss.

Objective To report the clinical and histologic features of lymphomatous infiltration of the optic nerve by systemic T-cell non-Hodgkin's lymphoma (NHL). Design Interventional case report. Participant A patient with peripheral T-cell NHL. Methods A 39-year-old man with a diagnosis of peripheral T-cell NHL, stage IV, with CNS involvement and decreased vision was found to have lymphomatous infiltration of the optic nerves. Main Outcome Measure Visual acuity. Results Despite treatment with chemotherapy and an optic nerve sheath fenestration, the patient lost vision in the right eye and subsequently underwent an optic nerve biopsy. The histopathology showed diffuse infiltration with a clonal population of lymphocytic cells that were CD3 positive and CD20 negative, consistent with T-cell NHL. Conclusion Optic nerve infiltration from systemic B-cell lymphoma is rare and has been reported; we report an unusual case of bilateral optic nerve infiltration secondary to peripheral T-cell NHL.

Purpose: Optic nerve sheath fenestration has been advocated as an effective treatment for progressive nonarteritic ischemic optic neuropathy (NAION) and anecdotally effective for selected patients with NAION who have not had progressive visual loss. To determine whether optic nerve sheath decompression is of any benefit in patients with NAION, the authors reviewed their experience, surgically treating 23 patients with progressive NAION and 15 patients with static or nonprogressive NAION. Results: Patients with progressive NAION had a significant improvement in visual function as measured by Snellen visual acuity after optic nerve sheath decompression ( P = 0.0005). There was no statistically significant improvement in visual field mean deviation ( P = 0.11). The 15 patients undergoing optic nerve sheath decompression for static NAION failed to demonstrate significant improvement in either visual acuity ( P = 0.90) or visual field mean deviation ( P = 0.87). Preoperative standardized echography was used to measure the optic nerve sheath diameter and ascertain its compressibility (30° test). There was a significant difference in compressibility between eyes with static NAION and eyes with progressive NAION ( P = 0.001). Accumulation of optic nerve sheath fluid was documented in three eyes initially presenting with NAION and then with development of progressive visual dysfunction. Conclusion: Optic nerve sheath decompression improves visual acuity but has little effect on overall visual function in patients with progressive NAION. Optic nerve sheath decompression does not improve visual field or acuity in patients with static NAION. Detection of significant intrasheath fluid by standardized echography helps to objectively differentiate patients with NAION who may benefit from optic nerve sheath decompression.

Purpose To review our experience with optic nerve sheath decompression for pediatric pseudotumor cerebri. Design Retrospective chart review. Participants Seventeen eyes in 12 children younger than 16 years of age. All patients were either unresponsive or intolerant to medication. Intervention, Methods, or Testing An optic nerve sheath fenestration was performed. Main Outcome Measures Optic nerve appearance, visual acuity, color vision, and visual fields. Results The average age at surgery was 10.1 years of age. The average follow-up was 39.6 months. Headache was the most common presenting symptom. All patients showed improvement in optic nerve edema. Visual acuity improved or stayed the same in all surgical eyes ( P = 0.0078). One patient required a neurosurgical lumbar peritoneal shunt, and 2 patients required acetazolamide on the last follow-up appointment. No patient had postoperative infection, loss of vision, or strabismus develop. Five of the patients in this study required sheath decompression on the other eye. Conclusions Optic nerve sheath decompression in children is safe, and the results are similar to those obtained in adults. Close follow-up is required, because 5 of 12 patients in this study required a contralateral optic nerve sheath decompression.