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2022 APR 16 (NewsRx) -- By a News Reporter-Staff News Editor at Obesity, Fitness & Wellness Week -- Current study results on Central Nervous System Diseases and Conditions - Pseudotumor [...]

A study conducted by researchers from the University of Kentucky College of Medicine evaluated the safety and efficacy of optic nerve sheath fenestration using visual acuity, perimetry, and optical coherence tomography. The study involved 55 patients who underwent the procedure, showing improvements in visual acuity, perimetric mean deviation, and optic disc edema after a 12-month follow-up. The research concluded that optic nerve sheath fenestration via a medial transconjunctival approach is a safe and effective method for preserving vision in patients with papilledema, especially in cases of idiopathic intracranial hypertension. [Extracted from the article]

Background/aims: Optic nerve sheath fenestration (ONSF) is a surgical intervention in the management of idiopathic intracranial hypertension (IIH) infrequently performed in the United Kingdom. Numerous surgical approaches have been described, including medial transconjunctival, lateral and endoscopic. We describe our outcomes and complications from ONSF via a supero-medial eyelid skin crease incision in patients with IIH. Methods: We performed a retrospective review of consecutive patients undergoing ONSF for IIH between January 2011 and December 2017 by a single surgeon. Results: Thirty patients were included in the analysis with a median follow-up of 14.5 months. Bilateral ONSFs were undertaken in 27 (90%). The data from one eye per patient were analysed. The mean kinetic perimetry score in mean radial degrees of the I4e isopter improved from 27.3° to 35.7°, p= 0.04. After removing cases with optic atrophy, the median modified Frisén grade of papilloedema improved from 2.5 to 1.0, p= 0.007. A total of 5/30 (17%) patients had complications: two (7%) had recurrence/late failure (one managed medically and one with cerebrospinal fluid [CSF] diversion surgery), one had transient cotton wool spots post-operatively, one had transient retinal haemorrhages and one patient had a transiently oval pupil. No patients had repeat ONSF, but CSF diversion surgery was subsequently carried out in 4/30 (13%) patients. Conclusions: ONSF via a supero-medial eyelid skin crease approach is effective at improving visual function in patients with IIH. The complication rates are low when compared with CSF diversion surgery and other surgical approaches for ONSF.

The authors report the case of a 75-year-old man with preexisting glaucoma and recurrent retinal detachment who underwent intraocular silicone oil placement OD resulting in subsequent retrolaminar silicone oil migration to the optic chiasm and vision loss OS. MRI showed silicone oil tracking posteriorly along the right optic nerve to the chiasm. He was placed on high-dose corticosteroids and underwent a successful optic nerve sheath fenestration with improvement of vision in the contralateral eye. Clinicians should be cognizant of the potential for translaminar posterior migration of intraocular silicone oil, as well as the utility of optic nerve sheath fenestration to decompress the anterior visual pathways and restore vision.The authors report a case of retrolaminar silicone oil migration to the optic chiasm that was successfully treated with optic nerve sheath fenestration.Supplemental Digital Content is available in the text.

According to the news reporters, the research concluded: "Early optic nerve sheath fenestration is an effective modality for treating optic disc edema due to a wide myriad of causes and helps resolve the associated symptoms." Keywords: Edema; Health and Medicine EN Edema Health and Medicine 269 269 1 07/24/23 20230730 NES 230730 2023 JUL 30 (NewsRx) -- By a News Reporter-Staff News Editor at Medical Devices & Surgical Technology Week -- Data detailed on edema have been presented. Records of 18 eyes of 15 patients who underwent optic nerve sheath fenestration for vision threatening optic disc edema were reviewed retrospectively, and results were analyzed.". [Extracted from the article]

Optic nerve sheath fenestration (ONSF) is a surgical technique commonly and effectively employed in the treatment of recalcitrant, vision-threatening papilledema. Unilateral blindness, a known risk of unilateral ONSF widely cited with 1%–2% incidence. In this case, a 58-year-old patient who presented symptomatic with bilateral hemorrhagic papilledema unresponsive to medical therapy underwent uneventful unilateral ONSF via standard superomedial eyelid crease incision. The patient presented postoperatively with severe bilateral vision loss. Workup revealed widespread metastatic malignant disease involving the optic chiasm and optic nerve sheath.The authors present an unusual case of widespread metastatic leptomeningeal carcinomatosis discovered after acute bilateral vision loss following unilateral optic nerve sheath fenestration.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajo.2005.11.037 Byline: Richard C. Allen (a), Jeffrey A. Nerad (a)(b), Jorge C. Kattah (c), Andrew G. Lee (a)(d) Abstract: To describe the outcome of a patient with visual loss and optic nerve edema that resulted from osteopetrosis who underwent an optic nerve sheath fenestration (ONSF). Author Affiliation: (a) Department of Ophthalmology and Visual Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa (b) Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (d) Department of Neurosurgery and Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa (c) Illinois Neurological Institute, University of Illinois College of Medicine at Peoria, Peoria, Illinois. Article History: Accepted 21 November 2005 Article Note: (footnote) Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, New York.

Byline: Arielle. Spitze, Peter. Lam, Nagham. Al-Zubidi, Sushma. Yalamanchili, Andrew. Lee Background: Idiopathic intracranial hypertension (IIH) has been increasing in prevalence in the past decade, following the obesity epidemic. When [...]

A study conducted at the Institute of Ophthalmology Mayo Hospital in Lahore, Pakistan, examined the efficacy and safety of Optic Nerve Sheath Fenestration (ONSF) in patients with Idiopathic Intracranial Hypertension (IIH). The study included nine female patients with a mean age of 24 years. After ONSF, there was a significant improvement in visual acuity in both eyes at various follow-up intervals. Some patients experienced minor complications, but overall, ONSF was found to be an effective and safe surgical procedure for salvaging vision in patients with IIH. [Extracted from the article]

The purpose of this study was to report a rare case of retinal reperfusion injury after optic nerve sheath fenestration surgery.

Optic nerve sheath fenestration (ONSF) is a surgical procedure that is sometimes performed in patients with optic disc edema from increased intracranial pressure. The objective of this study was to assess the consequence of ONSF on optic nerve axons, retinal ganglion cells (RGCs), and retinal amacrine cells.

Purpose: Optic nerve sheath fenestration (ONSF) is a surgical procedure commonly performed in the Anglo-Saxon countries for the treatment of medically refractory idiopathic intracranial hypertension (IIH). We chose to compare 6 different trans-orbital surgical approaches to ONSF. We also desired to determine the number of optic nerve decompression procedures performed in France in 2019 and 2020.

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.

Purpose Optic nerve sheath decompression is advocated for the treatment of certain types of optic nerve dysfunction with progressive visual loss such as pseudotumor cerebri and progressive non arteritic anterior ischemic optic neuropathy. Symptoms can recur however in 25 to 33% of cases due to obstruction of the fenestration.Material The authors describe the use of a valve for optic nerve sheath fenestration. The valve is made by introducing one end of a silicone tube between the two layers of arachnoid tissue overlying the optic nerve head and suturing the other end to the sclera. The latter tube end is obstructed except for two slits created laterally and has two small silicone wings used to anchor the sutures. When pressure inside the tube exceeds 10 mmHg, fluid spills through the two slit openings. This valve has been designed to improve the results of optic nerve sheath fenestration operations. Results Three patients underwent surgery using this technique. Visual acuity improved in one patient and visual loss did not progress in the two other patients.Conclusion A theco-conjunctival shunt in the form of a valve to prevent obstruction of optic nerve sheath fenestration is an option that must be studied on a larger scale.

Most oculoplastic surgeons in our survey favor the medial approach with a window biopsy for optic nerve sheath fenestration. Biopsies have limited value in the setting of idiopathic intracranial hypertension.

Optic nerve sheath fenestration is a surgical procedure for the treatment of many optic neuropathies. The authors developed an experimental model carried out on healthy adult rabbits in order to study the morphological consequences of an iatrogenic meningeal 'breach' in optic nerve axons, macroglia, and meninges corresponding to optic nerve fenestration. The fibrous scar which developed at the level of the fenestration was accompanied by glial hypertrophy, along with meningeal laminae which were stuck together. There was no axonal loss, but there were reactive astrocytes with gliofilament bundles. These morphological data assisted the authors in building up hypotheses which partly explain the acknowledged efficiency of this procedure for specific optic neuropathies.

• Optic nerve sheath fenestration is an increasingly useful surgical technique for relief of visual loss due to a number of optic disc pathologic conditions. To date, surgeons have employed either a medial approach with disinsertion of the medial rectus muscle or a lateral approach with removal of the lateral orbital rim to gain access to the retrobulbar optic nerve. We report herein a technique for approaching the optic nerve through a lateral canthotomy incision that does not require removal of bone or disinsertion of an extraocular muscle. It has been used to provide ready surgical exposure of the optic nerve in 17 eyes of 14 patients. This technique combines the advantages of lateral exposure of the optic nerve with an ease of operation similar to that of the medial approach.

OBJECTIVE: To determine the efficacy of optic nerve sheath fenestration in eyes with the progressive form of common anterior ischemic optic neuropathy. This investigation complements a previously reported initial series of 26 similar patients. PATIENTS AND METHODS: Optic nerve sheath fenestrations were performed in 21 eyes for treatment of common (nonarteritic) ischemic optic neuropathy with documented progressive deterioration of visual function. All patients underwent thorough preoperative and postoperative ocular evaluations by the Neuro-Ophthalmology Service at the Bascom Palmer Eye Institute, Miami, Fla. RESULTS: During a mean follow-up of 22.5 weeks (range, 3 to 104 weeks), results were as follows: visual acuity increased by 2 or more lines on the Snellen chart in two eyes (9.5%; the combined improvement rate for the two series was 14.9%); visual acuity decreased by 2 or more lines in two eyes (9.5%). CONCLUSIONS: Data from this series of 21 surgical procedures indicate no beneficial effect on visual morbidity in cases of common ischemic optic neuropathy and confirm the generally poor visual outcome implied from the results of optic nerve sheath decompression in our initial series. Based on this experience with a total of 47 eyes, we have discontinued optic nerve sheath decompression as a form of therapy for ischemic optic neuropathy.

Purposes:Macular abnormalities such as chorioretinal striae, pigmentary disturbances, exudates, and subretinal hemorrhage or scar can occur in patients with Pseudotumor Cerebri. The purpose of this study is to determine the potential resolution of the macular abnormalities after optic nerve sheath fenestration, as well as the visual significance of these changes.

• Optic nerve sheath fenestration was performed in 26 eyes for treatment of the progressive type of common (nonarteritic) anterior ischemic optic neuropathy. During a mean follow-up period of 21 weeks (range, 6 to 52 weeks), results were as follows: visual acuity increased by two or more lines on the Snellen chart in 7 eyes; visual acuity decreased by two or more lines in four eyes; some regression of visual field defects occurred in six eyes, including two eyes in which acuity also improved. These results, attributed to surgical decompression, do not exceed the spontaneous recovery rates reported in the literature pertaining to nonarteritic anterior ischemic optic neuropathy and fail to substantiate the sanguine visual outcome in recently reported series of patients undergoing optic nerve sheath decompression.

• The mechanism by which optic nerve sheath fenestration relieves papilledema associated with increased intracranial pressure has not been clearly defined. A model was constructed to determine if the induction of fluid flow along the nerve sheath and through the fenestration could account for a reduction in pressure around the optic nerve, as might be expected according to Bernoulli's equation of fluid dynamics. The model states that as the velocity of a fluid increases, the pressure it exerts decreases. The model simulated fluid spaces corresponding to the intracranial vault, chiasm, and optic nerves. The unfenestrated model showed direct transmission of elevated intracranial pressure to the nerves, consistent with the production of papilledema. When one nerve was fenestrated, fluid flow along the nerve was initiated and pressure in that nerve sheath dropped substantially. In addition, pressure in the unfenestrated sheath dropped due to fluid communication across the chiasm. These lower intrasheath pressures were consistent with the bilateral resolution of papilledema after unilateral fenestration. The reduced intrasheath pressures persisted even when the intracranial pressure was again elevated to pathologic levels as long as active fluid flow continued along the nerve sheaths. Thus, induction of cerebrospinal fluid flow along the optic nerve sheath by fenestration appears to locally reduce the pressure around the optic nerve, in spite of persistently elevated intracranial pressure. This is in accordance with what would be predicted by Bernoulli's equation.

• In patients with pseudotumor cerebri accompanied by loss of vision, optic nerve sheath fenestration is an effective route to prompt recovery of vision. A lateral orbitotomy approach to decompression of the optic nerve is appropriate for the ophthalmologist with adequate orbital experience. A rectangular window of dura and arachnoid, measuring approximately 3 × 5 mm, is excised from the bulbous portion of the optic nerve. It is important that the arachnoid within the window is excised because an intact arachnoid is an effective barrier to cerebrospinal fluid egress. The use of operating microscope, microsurgical instrument, and microdissecting techniques are emphasized. Twenty-eight patients (40 eyes) with progressive visual loss were treated by surgical nerve sheath fenestration. A study of the indications, results, and complications of this procedure is presented in a companion article.

A 16-year-old adolescent girl with multiple risk factors for thrombosis presented with acute onset of headache, decreased vision, and papilledema. Evaluation demonstrated cerebral venous thrombosis (CVT) involving the left transverse and sigmoid sinuses and left internal jugular vein. Following bilateral optic nerve sheath fenestration (ONSF), she experienced improvement in vision and resolution of papilledema. In selected cases, ONSF is an effective surgical option for the treatment of papilledema due to CVT after medical treatment has failed.

A 36-year-old woman with bilateral optic neuropathy and orbital and central nervous system metastasis from breast carcinoma developed progressive bilateral vision loss with severe optic disc swelling. She underwent optic nerve sheath fenestration of the left eye resulting in modest improvement in vision and resolution of disc edema. Optic nerve sheath fenestration is a known treatment for papilledema, but its effectiveness as a treatment for an optic neuropathy caused by perineural or intrasheath metastasis is less clear. Optic nerve sheath fenestration should be considered as a treatment option for an optic neuropathy caused by perineural or intrasheath metastasis, especially in cases where alternative treatments are not tolerated and visual loss is severe at presentation.

The authors report a case of papilledema in a 61-year-old woman with chronic demyelinating polyneuropathy. The cerebrospinal fluid protein level was elevated (2.68 to 4.51 g/L), as was the cerebro-spinal fluid opening pressure (27 to 40 cm H2O). A unilateral optic nerve sheath fenestration proved to be effective in preserving vision, and the papilledema resolved completely.

• Twenty-eight patients with pseudotumor cerebri underwent 40 optic nerve sheath fenestrations for relief of visual loss or to preserve vision. Twenty women and eight men underwent 16 unilateral fenestrations and 12 bilateral operations. Papilledema disappeared or was strikingly reduced in 24 of 28 patients. The other four patients had gliotic discs (two patients) or were followed up for only a short time. Visual acuity improved in 12 of 40 eyes and remained the same in 22 of 40 eyes. Seventeen eyes had preoperative visual acuity of 20/30 or better. In six eyes visual acuity decreased. Of eight eyes operated on that had visual acuity of 20/200 or worse, only three showed improvement. Visual fields improved in 21 of 40 eyes and remained the same in ten eyes. Five of the ten eyes that did not change had poor vision before surgery. Eight eyes in five patients continued to lose acuity postoperatively. Each of these eight eyes had a concomitant loss of visual field. An additional two eyes developed visual field loss with preserved visual acuity. The indications for surgery are early evidence of progressive loss of visual field or acuity in a patient with pseudotumor cerebri. Severe vision loss presents little opportunity for improvement but fenestration may be used in a last effort to preserve or restore vision.

Brain Diseases and Conditions, Cardiovascular Diseases and Conditions, Central Nervous System Diseases and Conditions, Health and Medicine, Hypertension, Intracranial Hypertension, Pseudotumor Cerebri, Retinoic Acid, Therapy Keywords: Brain Diseases and Conditions; Cardiovascular Diseases and Conditions; Central Nervous System Diseases and Conditions; Health and Medicine; Hypertension; Intracranial Hypertension; Pseudotumor Cerebri; Retinoic Acid; Therapy EN Brain Diseases and Conditions Cardiovascular Diseases and Conditions Central Nervous System Diseases and Conditions Health and Medicine Hypertension Intracranial Hypertension Pseudotumor Cerebri Retinoic Acid Therapy 595 595 1 07/31/23 20230731 NES 230731 2023 JUL 31 (NewsRx) -- By a News Reporter-Staff News Editor at Cardiovascular Week -- Fresh data on pseudotumor cerebri are presented in a new report. [Extracted from the article]

A 10-year-old boy with bilateral colobomatous cavitary disc anomalies presented with a 3-month history of vision loss in his right eye. MRI of the head and orbit revealed bilateral tubular cystic enlargement of the optic nerve/optic sheath complex with thickening of the optic nerves without inflammation or neoplasm, suggestive of bilateral optic nerve meningocele. An optic nerve sheath fenestration was performed OD, and he experienced an improvement and stabilization of vision in his right eye during a 1-year follow-up period. The authors recommend that surgical decompression, particularly optic nerve sheath fenestration, should be considered in cases with progressive vision loss due to optic nerve meningocele.Optic nerve sheath fenestration for bilateral optic nerve meningocele in a 10-year-old child with progressive vision loss resulted in visual improvement.Supplemental Digital Content is available in the text.

The authors report a case of transient third and sixth nerve paresis as a complication of optic nerve sheath fenestration in a patient with pseudotumor cerebri. The motility and pupillary abnormalities that are commonly associated with this procedure are reviewed briefly

A 16-year-old woman complaining of headache and declining vision in both eyes had papilledema, normal brain imaging, and a lumbar puncture showing a moderately high opening pressure (35 cm H2O) and normal cerebrospinal fluid constituents. For a diagnosis of idiopathic intracranial hypertension (IIH), she was treated with acetazolamide and methylprednisolone, but vision worsened, so she underwent bilateral optic sheath fenestration (ONSF). Within the 1st postoperative week, vision had improved and papilledema was less prominent. However, by the 14th postoperative day, vision had worsened and headache persisted. Lumbar puncture showed a very high opening pressure (65 cm H2O), so she underwent ventriculoperitoneal shunting. Although there was a slight initial improvement in vision, it eventually declined further. This case emphasizes that ONSF may yield initial improvement in vision and reduction in papilledema yet not prevent eventual visual loss in IIH. Whether the visual loss in this patient resulted from persistently elevated intracranial pressure after ONSF or was prefigured before ONSF occurred is unresolved. It is a reminder that patients with IIH must be monitored carefully after ONSF. If there is a suggestion of further visual loss, shunting should be considered if intracranial pressure is high.

Two patients with idiopathic intracranial hypertension underwent optic nerve sheath fenestration. One patient developed decreased vision and choroidal folds 1 month postoperatively. The other patient developed proptosis and pain 9 months postoperatively. Neuroimaging showed a cyst-like structure adjacent to the optic nerve in each patient. In each case, symptoms and signs resolved after surgical excision of the structure.

Optic nerve sheath fenestration is an accepted surgical treatment for pseudotumor cerebri when visual loss occurs despite medical therapy. When performed via a medial approach, optic nerve sheath fenestration may require considerable traction on the optic nerve. The nature, severity, and potential reversibility of neural injury caused by sustained rotational traction on an already-compromised optic nerve is unknown. We describe a patient who suffered complete loss of vision in the surgically treated eye following optic nerve sheath fenestration and who subsequently recovered 20/30 OD visual acuity. REPORT OF A CASE. A 22-year-old woman noted headaches, pulsatile tinnitus, and bilaterally blurred vision beginning 2 weeks after the onset of a middle ear infection. She denied pain with eye movements or other neurological symptoms. Physical examination showed an obese woman with a blood pressure of 138/88. Corrected visual acuity was 20/80 OD and 20/70 OS. Both pupils reacted sluggishly to

IN REPLY. —We would like to address each of Dr Hayreh's concerns. In NAION, is the visual loss due to blockage of the axoplasmic flow? Dr Hayreh states, and we agree, that in papilledema visual dysfunction is secondary to ischemia. Because optic nerve sheath decompression (ONSD) has been demonstrated to reverse severe visual loss in pseudotumor cerebri,1 we considered ONSD for other optic neuropathies in which ischemia may be involved. Dr Hayreh continues that "axoplasmic flow plays no role in the conduction of nerve impulses." While this statement is true in the strict neurophysiologic sense, alteration of axoplasmic flow has produced blockage of impulse conduction in several carefully studied experimental and human conditions. First, giant axonal swellings have been produced in rats by the administration of β-β1-iminodipropionitrile, a toxin that disrupts the cytoskeletal elements of axons.2 In this model, iminodipropionitrile blocks slow axonal transport more than

TO THE EDITOR. —I was very interested to read the expedited publication in the December 1989 issue of the Archives by Sergott et al1 claiming that surgical optic nerve sheath decompression improved visual function in patients with "progressive" nonarteritic anterior ischemic optic neuropathy (NA-AION). They hypothesized that in NA-AION, "progressive visual loss after the initial ischemic event could be due to interference with rapid axoplasmic transport produced by [cerebrospinal fluid] CSF pressure within the anatomically restricted confines of the perineural optic nerve space. Drainage of the CSF might allow recovery of fast axoplasmic transport with subsequent improvement in vision." This theory raises some very important issues that need comment before they are accepted as scientifically valid concepts.My comments are based on the following: (1) my prospective studies on NA-AION in more than 600 patients; (2) my studies of the blood supply of the optic nerve head for the

IN REPLY McHenry and Spoor raise an interesting point that fluid accumulation in theperioptic meninges may be associated with a progressive course of visual loss and better surgical outcome following ONSD in patients with AION. In our series of 26 eyes with progressive AION,1 only one of 17 eyes showed meager increased fluid in the subarachnoid space. In fact, in the Echography Laboratory of the Bascom Palmer Eye Institute, Miami, Fla, using standardized A-scan echography, we do not find increased sheath fluid in cases of AION, whether progressive or static.The surgical series of Spoor et al2 was recently published, including sonographic data on 12 eyes with progressive AION and 27 eyes with static AION. Mean optic nerve diameter in the progressive group was 3.47 mm, with afluid shift (30° test) rangingfrom 5% to 25%, and mean optic nerve diameter in the static group was 3.19 mm, with afluid shift

IN REPLY. —We appreciate the comments by Bazarian and Burde regarding our article. We certainly acknowledge that this model is simplistic, but it describes a mechanism of action that, for the first time, explains the many, and often paradoxical, findings we see clinically after optic nerve sheath fenestration. The application of Bernoulli's equation to this model illustrates how a filtration mechanism can locally reduce the CSF pressure seen by the optic nerves, while the intracranial pressure remains elevated. In fact, we believe an open fenestration site and elevated intracranial pressure are necessary to maintain filtration.We have observed flattening of chronic total retinal detachments and visual improvement in two cases of morning glory disc syndrome after large window optic nerve sheath fenestrations. In this syndrome, CSF is presumed to reach the subretinal space via the subarachnoid space of the optic nerve.1 Fenestration of the nerve sheath allows escape of