Partial visual recovery from radiation-induced optic neuropathy after hyperbaric oxygen therapy in a patient with Cushing disease

Abstract

Here we describe the case of a 41-year-old woman with a history of Cushing disease who had previously undergone unsuccessful neurosurgery, followed by stereotactic radiosurgery. More than 4 years after this treatment, she presented severe visual impairment, which started in the left eye and was documented by neuro-ophthalmic evaluation. Radiological assessment by contrast-enhanced magnetic resonance (MR) imaging initially suggested the diagnosis of glioma of the optic nerve and the patient started corticosteroid treatment (first with prednisone, 80 mg/day, followed by dexamethasone, 8 mg/day). Despite the therapy, vision in the left eye rapidly worsened until light was no longer perceptible; similar symptoms and signs also developed in the right eye, evolving to complete temporal hemianopsia. The clinical evidence was confirmed by the rapid progression of the MR picture, which showed homogeneous enhancement of the chiasm and optic nerves. On the basis of these findings, the original diagnosis of glioma was excluded, and radiation-induced optic neuropathy was diagnosed. As corticosteroids had proved inefficacious, hyperbaric oxygen (HBO) therapy was promptly instituted and vision steadily started to improve. This improvement was documented and confirmed by the progressive recovery of the visual field in the right eye and the changes in the sequential follow-up MR scanning. Optic neuropathy is an infrequent but dramatic complication of radiation therapy. Symptoms develop, on average, 12 months after treatment, and the onset may be acute and characterized by the progressive loss of vision in one or both eyes. HBO has already been used to treat this complication, but its efficacy is still controversial. Here, in addition to describing this particular case, which presented a significantly delayed radiation injury of the optic pathways, we provide a brief literature review and discuss some important points. 154 813-818 European Journal of Endocrinology

Nasopharyngeal Cancer

“…Limited data supported the use of hyperbaric oxygen (HBO) and steroids for symptomatic control in the acute phase of radiationinduced cranial neuropathy; however, no effective long-term control has been demonstrated with any type of therapeutic efforts (Mihalcea and Arnold 2008;Boschetti et al 2006;Levy and Miller 2006). Unfortunately, no proven effective treatment for radiation-induced nerve damage is available.…”

Neuroprotective Effect of Hyperbaric Oxygen Therapy on Anterior Ischemic Optic Neuropathy

“…In a review of its uses in the eye, Butler et al (2008) suggested various ocular disorders that may potentially benefit from HBO treatment, such as central retinal artery occlusion, radiation optic neuropathy, and selected cases of ischemic optic neuropathy. However, except in a few cases (Boschetti et al, 2006; Levy and Miller, 2006), findings for radiation-induced neuropathy have been disappointing (Danesh-Meyer, 2008). Beiran et al (1995) successfully treated two patients with AION using HBO.…”

Catastrophic vision loss from radiation-induced optic neuropathy

“…Systemic steroids and anticoagulation have been found to be ineffective 15. On the other hand, hyperbaric oxygen is a treatment option if initiated promptly (ideally within 48–72 hours of vision loss) and before optic nerve pallor develops and with at least 2.4 atmospheric pressure 16 17. Systemic and intravitreal bevacizumab injections have been proposed with promising results in select cases 18 19.…”