Optic nerve sheath fenestration

Table 71.1

Indications for surgery

Vision-threatening papilledema refractory to maximal medical therapy

Table 71.2

Preoperative evaluation

History of medication use associated with idiopathic intracranial hypertension (IIH) – oral contraceptives, antibiotics, chemotherapeutics, steroids, and acne medications
Dandy’s criteria for increased intracranial pressure (ICP) – headaches, nausea, vomiting, transient visual obscurations, papilledema, non-localizing unilateral or bilateral abducens palsy
Documentation of body habitus and gender
History of prior therapy for IIH – weight loss, carbonic anhydrase inhibitors, CSF shunts
Magnetic resonance imaging of the brain, orbits as well as MRA/MRV
Lumbar puncture with documentation of chemistries and opening pressure
Prior visual field testing if available


Optic nerve sheath fenestration (ONSF) is most commonly performed for vision-threatening papilledema associated with idiopathic intracranial hypertension (IIH). Other conditions where ONSF may be performed include optic nerve sheath hemorrhage, cryptococcal meningitis with papilledema, dural sinus thrombosis, and cancer-associated intracranial hypertensions with papilledema.

The work-up of papilledema associated with IIH first involves a detailed medication history to identify possible associations. Signs and symptoms of IIH should be elicited and documented. Automated visual field testing and optic nerve photographs should be obtained and then MR imaging is performed to rule out a mass effect causing the increased intracranial pressure (ICP) as well as vascular studies to rule out sinus thrombosis. Once imaging is deemed normal, attention is focused towards lumbar puncture to establish the opening pressure, which is elevated over 20 cm H 2 O in non-obese and over 25 cm H 2 O in obese patients. Infectious meningitis should be ruled out by normal chemistries and cultures if indicated.

Weight reduction and oral acetazolamide therapy is the mainstay of treatment for IIH. Patients with severe headaches are candidates for peritoneal shunts and should be referred to neurosurgery or interventional radiology. Vision-threatening papilledema is addressed by ONSF.

ONSF can be performed through a medial orbitotomy approach with disinsertion of the medial rectus, lateral orbitotomy with or without bone removal or through a superomedial eyelid crease incision. The latter technique is our preferred approach owing to its rapid, minimally invasive access to the medial optic nerve sheath. The surgery can be performed with a microscope or headlight and with optimal exposure can be performed under 30 minutes.

Surgical Technique

Figure 71.1

Medial upper eyelid crease approach

A variety of approaches for optic nerve sheath fenestration have been described. In this case, the medial upper eyelid crease approach is described. This approach is safe and direct with minimal complications. The case is typically performed under general anesthesia, although monitored anesthesia care with local anesthetic can be utilized in select cases. A standard upper eyelid crease is marked in the medial aspect ( Figure 71.1 ). The operating microscope used for cataract and retina surgery provides excellent visualization and illumination during ONSF.

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May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Optic nerve sheath fenestration
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