Optic nerve sheath fenestration for treating papilloedema in the era of cerebral venous sinus stenting

Abstract

Background Pseudotumour cerebri (PTC) is the syndrome of intracranial hypertension without intracranial mass or hydrocephalus and is the commonest cause of papilloedema seen in many eye clinics. In the last 10 years, we have increasingly used TSS in patients whose papilloedema was not well controlled with medical treatment and have done fewer ONSFs. Here, we review our experience at Royal Prince Alfred Hospital Sydney with ONSF in 35 patients over the period 2002–2021. Methods Retrospective case series of 35 patients, 30 of whom had primary PTC [i.e., idiopathic intracranial hypertension (IIH)] and 5 with secondary PTC. Results Eighteen patients had bilateral ONSF and 17 patients unilateral ONSF, in each case of the worse eye. Thirteen patients then underwent transverse sinus stenting (TSS), in each case following ONSF. The primary outcome measures were visual acuity (VA) and mean deviation (MD) on visual field (VF) testing. MD improved by 5 dB or more in 34 of 70 total eyes (48.6%); VA improved by 0.2 logMAR (two lines on Snellen chart) or more in 21 eyes (30%), and by both in 15 eyes (21.4%). Final MD was −10 dB or better in 38 eyes (54.3%); final VA was 0.3 (6/12) or better in 54 eyes (77.1%), and both in 39 eyes (55.7%). Conclusions The results confirm that ONSF can relieve papilloedoema in both eyes and improve both VF and VA, even in cases of fulminant PTC with severe acute visual impairment.

Transverse Sinus Stenting Reverses Medically Refractory Idiopathic Intracranial Hypertension

“…Note that central visual acuity is preserved in papilledema until damage to the optic nerve is very advanced, due to relative sparing of the maculopapillar bundle ( 22 ). The visual field is thus the most important quantifier of visual threat ( 23 , 24 ).…”

Progress and recognition of idiopathic intracranial hypertension: A narrative review

“… 160 ONSF can relieve papilledema in both eyes and improve visual acuity and visual field impairment caused by IIH, and it can be used when other CSF diversion procedures or medical therapies have failed. 161 , 162 Although opinions vary on the best time for surgery, initiating ONSF at an early stage can significantly prevent vision deterioration. CSF shunting reduces compression of the peripheral arteries and veins of the optic nerve by diverting the CSF into the abdominal cavity.…”

Optic nerve sheath fenestration: Does it still have a role in treating patients with elevated intracranial pressure?

“…In this issue of the journal, McCluskey and colleagues present a series of patients with papilledema and vision loss from both primary pseudotumor cerebri syndrome (PTCS; denoted as idiopathic intracranial hypertension [IIH]) and secondary causes of increased intracranial pressure (ICP) such as venous sinus thrombosis and malignancy. 1 The authors present this work in part as a comparison with a prior cohort on which they previously reported, stating that the frequency of the use of ONSF may have changed since the advent in 2002 of transverse sinus stenting (TSS) as an alternative for treatment of medically refractory PTCS. 2 In this new cohort of 35 patients (70 eyes, 60 of which were from patients with IIH), they report a wide range of visual acuity and visual field outcomes following ONSF with similar results of either unilateral or bilateral surgery.…”

“…Optic nerve sheath fenestration (ONSF) has been described by some ophthalmologists as ‘a procedure in search of a disease’, and its use in the treatment of papilledema varies widely by institution and national region. In this issue of the journal, McCluskey and colleagues present a series of patients with papilledema and vision loss from both primary pseudotumor cerebri syndrome (PTCS; denoted as idiopathic intracranial hypertension [IIH]) and secondary causes of increased intracranial pressure (ICP) such as venous sinus thrombosis and malignancy 1 . The authors present this work in part as a comparison with a prior cohort on which they previously reported, stating that the frequency of the use of ONSF may have changed since the advent in 2002 of transverse sinus stenting (TSS) as an alternative for treatment of medically refractory PTCS 2 .…”