Venous Sinus Thrombosis and Alterations in CSF Dynamics, A Basis for ONSF for Vision Preservation: Theory and Case Examples
Jason D. Jensen; Lauren C. Ditta
University of Tennessee Health Science Center- Hamilton Eye Institute
Introduction: Cerebral venous sinus thrombosis (CVST) can lead to papilledema secondary to increased intracranial pressure (ICP). Early detection and treatment of papilledema is important to prevent permanent vision loss. Medical management is often a first line therapy, however, surgical interventions, including optic nerve sheath fenestration (ONSF) may be a vision preserving. Herein, we report our experience with pediatric patients with papilledema secondary to CVST, and the safe and effective role ONSF can play in preserving vision.
Methods: This was a retrospective case series of three patients (ages 2-14) with CVST. There were inherited (n=2) and traumatic (n=1) etiologies for hypercoagulability. Dilated fundoscopic examination revealed at least bilateral grade III papilledema. Elevated ICP was confirmed by lumbar puncture. Patients underwent either unilateral or bilateral ONSF without complication.
Results: At six months post procedure, all patients had vision > 20/40 bilaterally. Visual fields and color vision testing, performed in the two oldest patients demonstrated mild to no areas of loss and was full, respectively. In the toddler, optic nerve edema had been present for several months prior to treatment. Despite bilateral ONSF, he needed stereotactic placement of right parietal to peritoneal shunt system, and developed optic atrophy.
Discussion: ONSF is an important adjunct surgical procedure to aid in vision preservation in patients with CVST.
Conclusion: We believe that ONSF for the treatment of papilledema secondary to CVST in the acute setting to preserve vision in pediatric patients is not only safe, but also effective. Younger patients may be more at risk for permanent vision loss. Collaborative, multidisciplinary medical and surgical management yields optimal patient outcomes.
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