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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. [ABSTRACT FROM AUTHOR]

Purpose: To report the unusual development of bilateral myelinated retinal nerve fibers (MRNF) adjacent to the optic nerve in a child after treatment of idiopathic intracranial hypertension (IIH) with unilateral optic nerve sheath fenestration (ONSF) and to discuss the etiology of acquired MRNF., Methods: The patient's clinical history, including visual acuity, refractive error, ocular alignment, fundus examination, and optic nerve photographs, was retrospectively reviewed. A literature review was performed for acquired MRNF in children using PubMed. The results of the demographic and clinical findings of our patient were compared with those of previously reported cases., Results: The child developed bilateral MRNF adjacent to the optic nerve 5 months after unilateral ONSF. In reviewing the literature, 8 of 10 cases of acquired MRNF in children had previous abnormalities of the optic nerve, 4 of 10 had associated bilateral optic nerve head drusen, 3 of 10 had associated optic nerve glioma, and 3 of 10 had a history of significant increased intracranial pressure requiring surgical intervention., Conclusions: Although the etiology of acquired MRNF is uncertain, this case plus a review of the literature suggest that it may be related to changes in the lamina cribosa combined with possible optic nerve injury caused by optic nerve head drusen, optic nerve glioma, or increased intracranial pressure and that it can occur months to years after intervention., (Copyright © 2012 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: 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)., Design: Retrospective review., Participants: A total of 78 patients underwent ONSF, and 20 patients served as controls., Methods: 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., Main Outcome Measures: Grade of papilledema., Results: 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 (P<0.0001 and <0.0002 for operated and nonoperated eyes, respectively), 1 in each eye at 3 months (P<0.0001 for both operated and nonoperated eyes), 1 in each eye at 6 months (P<0.0001 for both operated and nonoperated eyes), and 0.5 and 1 for operated and nonoperated eyes, respectively, at 12 months follow-up (P<0.0001 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., Conclusions: 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., (Copyright © 2011 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

An optic nerve sheath fenestration is indicated when papilloedema leads to progressive visual loss despite previous, conservative measures and when no cause of increased intracranial pressure can be indentified and eliminated. This rather rare constellation usually occurs in idiopathic intracranial hypertension. The procedure is performed via a medial transconjunctival orbitotomy. If headaches and neurologic symptoms other than visual deterioration prevail, the placement of a ventricular shunt is preferred. This review covers the symptoms of idiopathic intracranial hypertension and optic nerve sheath fenestration with its technical aspects and results.

Optic nerve sheath fenestration (ONSF) is rarely used in France. The aim of surgery is to release pressure around the optic nerve. Although debated, ONSF can be used in selected cases of benign intracranial hypertension. The authors describe the approach of the anterior part of the optic nerve and the technique itself. The indications, results and potential complications of this technique are developed in this paper.

The outcome of two patients with visual loss from osteopetrosis who underwent an optic nerve sheath fenestration (ONSF) is reported. A 20-year-old male and 26-year-old female with osteopetrosis had optic nerve edema. Computed tomography and magnetic resonance imaging demonstrated optic canals stenosis. Both patients underwent unilateral ONSF. After ONSF, the patients experienced improvement in visual acuity and optic nerve appearance. Therefore, when papilledema is recognized in osteopetrosis patients, it may be reasonable to start with an ONSF even if the optic canal seems to be stenotic because of the lower morbidity that is associated with this procedure compared with other surgical options. [ABSTRACT FROM AUTHOR]

Introduction: Raised intracranial pressure (ICP) has been previously associated with craniometaphyseal dysplasia (CMD). To our knowledge, expansile cranioplasty has not previously been described as a treatment for raised ICP in this setting. We describe our evaluation and surgical management of a patient presenting with seizures, headaches, and CMD., Case Report: An 18-year-old male presented with seizures, headaches, and diminished visual acuity, and was found to have chronic bilateral papilledema. Lumbar puncture demonstrated raised opening pressure (50 cm of water). Plain skeletal radiographs revealed long-bone dysplasia, and computed tomography (CT) of the head demonstrated diffuse thickening of the calvarium, diminished subarachnoid spaces, and slit ventricles. The raised ICP was managed with bilateral fronto-parieto-temporal expansile cranioplasty and right optic nerve sheath fenestration. At 6 months follow-up, the headaches and papilledema completely resolved. The visual acuity improved as did the seizure control. Follow-up CT demonstrated the normalization of the subarachnoid spaces and ventricles., Conclusion: Expansile cranioplasty, in conjunction with optic nerve sheath fenestration, may represent a safe and effective treatment for raised ICP associated with CMD.

Purpose: This study proposed to develop a technique for efficiently accessing the posterior orbital space using endoscopy and attempted application of free electron laser (FEL) energy, biopsy forceps, electrocautery, and CO(2) insufflation to posterior orbital tissues., Methods: Through an inferior transconjunctival incision, access to the posterior orbital space was attempted in 14 eyes of 7 non-survival pigs. FEL energy (6.1 microm, 30 Hz, delivered via 250 microm hollow-glass waveguide), biopsy forceps, and monopolar electrocautery application were endoscopically attempted in the posterior orbit. CO(2) gas insufflation effects were assessed by analyzing arterial blood gases at 30-minute intervals for 1.5 hours., Results: The posterior orbit was accessed in 13 of 14 eyes, the optic nerve was encountered, and FEL energy was applied in 8 of 14 eyes. Use of biopsy forceps and electrocautery were successful. Although ANOVA results for arterial blood gas changes were not statistically significant, visibility was adequate without CO(2) insufflation., Conclusions: The posterior orbit was endoscopically accessed and the optic nerve was exposed and successfully treated with FEL energy. CO(2) insufflation did not alter blood gases, but did not further enhance visibility in this study.

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.

Idiopathic intracranial hypertension, also known as pseudotumor cerebri, is a condition of increased intracranial pressure without the presence of mass lesions and with normal cerebrospinal fluid composition. Patients may experience papilledema and vision loss. Optic nerve sheath fenestration (ONSF) is one method of stabilizing visual function and decreasing optic nerve edema. The authors report on 10 patients who underwent bilateral ONSF and in whom visual function was stable or improved postoperatively. The results obtained in these cases suggest that ONSF plays a role in visual preservation in idiopathic intracranial hypertension patients in the acute setting.

A woman with idiopathic intracranial hypertension (IIH) experienced rapid regression of retinochoroidal venous collaterals ("optociliary shunt vessels") following optic nerve sheath fenestration. The presence of these vessels is a nonspecific sign of chronic retinal venous compression in patients with optic disc edema including IIH.

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Ophthalmological problems such as papilledema, loss of visual acuity, and oculomotor palsies are common in patients with shunt malfunctions. The authors report on three patients with shunts who presented with visual loss. In each case, the diagnosis of shunt malfunction was delayed because other classic signs and symptoms of intracranial hypertension were absent. All three patients underwent optic nerve sheath fenestration (ONSF) with resultant stabilization or improvement of visual symptoms before the shunt malfunction was recognized and treated. Consideration of these cases suggests a potential protective role of ONSF for patients with shunt malfunction.

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.

Background and Objectives: The Amide II wavelength (6.45 microm) produced by the free electron laser (FEL) can efficiently create an optic nerve sheath fenestration in rabbits. We wished to determine if it would be equally successful in macaque monkeys and to determine the histopathologic changes between traditional scissors or knife optic nerve sheath fenestration to FEL fenestration., Study Design/materials and Methods: Optic nerve sheath fenestration was performed using either the FEL (6.45 microm, 30 Hz, 2-3 mJ, 325-microm spot size) through a hollow waveguide probe in 12 eyes or with a scissors or a knife in 6 eyes. The monkeys survived 1 month with the fellow optic nerve operated acutely just prior to sacrifice. Optic nerves were evaluated histologically., Results: Less tissue manipulation was required using the FEL surgical probe. Electroretinograms showed minimal or no change. Tissue responses using either method were similar following chronic or acute incisions. Mild upregulation of vimentin and glial fibrillary acid protein (GFAP) was seen in astrocytes adjacent to the fenestration, but no change in S100 beta was evident., Conclusions: The FEL energy at 6.45 microm delivered through a hollow waveguide appears capable of efficiently and safely producing an optic nerve sheath fenestration in monkeys. This innovative surgical technique should be considered for human use., (Copyright 2003 Wiley-Liss, Inc.)

Purpose: To study the modifications undergone by the macroglial cells after meningeal breach of the optic nerve in the rabbit, without optic neuropathy., Methods: The optic nerve sheath fenestration technique carried out in humans was adapted to rabbit without axonal injury in the optic nerve. The effects of meningeal fenestration on glial cells were examined by immunocytochemical procedures (day 15) using the antibodies against two astrocyte markers: glial fibrillary acidic protein (GFAP) and vimentin. Proliferation of glial cells was evaluated with single 5-bromodeoxyuridine (BrdU) labeling or double GFAP and BrdU labelings. Qualitative data on glial cells were evaluated with the electron microscope., Results: Optic nerve sheath fenestration on healthy adult rabbits resulted in a decrease of volume of the subarachnoid space located at the level of the meningeal scar, with a significant increase of the optic nerve area. The meninges presented a fibrous scar. In the optic nerve parenchyma, astrocytes appeared hypertrophic in the vicinity of the fenestration. The whole nerve contains numerous BrdU-labeled mitotic cells, a number of which double-labeled for both BrdU and GFAP belong to the astrocyte line. There was no loss of optic nerve axons., Conclusions: The inflammation produced by the surgical breach of the peri-optic meningeal sheaths induces a significant reactivity, including proliferation of astrocytes in the optic nerve. Reactive astrocytes may interact positively with axons and may modify the extracellular environment in the optic nerve.

To the authors' knowledge, there is a paucity of published accounts of management of radiation-induced optic neuropathy (RION) by optic nerve sheath fenestration (ONSF) in the conventional medical literature. With higher doses of radiation being given by using conformal techniques, more radiation-induced optic neuritis and neuropathy will be identified. We report here the successful use of ONSF to restore vision to three consecutive patients with pending anterior RION, and the importance of early identification and intervention in these potentially reversible cases.

Background and Objective: To determine whether 6.45-microm free electron laser (FEL) energy can successfully perform optic nerve sheath fenestration and to compare the acute and chronic cellular responses with this surgery., Study Design/materials and Methods: Optic nerve sheath fenestration was performed in rabbits by using either FEL energy (< 2.5 mJ, 10 Hz, 325-microm spot size) or a knife. The optic nerve integrity and glial response were evaluated histologically acutely or 1 month postoperatively., Results: The FEL at low energy effectively cut the optic nerve sheaths with minimal reaction in the underlying nerve. With FEL or knife surgical techniques, a mild astrocytic hypertrophy only adjacent to the fenestration was observed acutely in the glial fibrillary acidic protein (GFAP) -immunoreacted sections. The chronic healing responses after either technique appeared similar with: (1) a thin fibrous scar at the fenestration site, (2) cells uniformly distributed (hematoxylin and eosin), and (3) up-regulation of GFAP and S100beta in astrocytes adjacent to the fenestration site., Conclusion: The FEL at low energy performs an optic nerve sheath fenestration in a small space with ease. Both FEL and knife incisions cause a similar rapid glial response near the fenestration site that remains 1 month later., (Copyright 2000 Wiley-Liss, Inc.)