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Show Perimetry, Retinal Nerve Fiber Layer Thickness and Papilledema Grade After Cerebrospinal Fluid Shunting in Patients With Idiopathic Intracranial Hypertension Jennifer L. Rizzo, MD, Khoa V. Lam, BS, Michael Wall, MD, Machelle D. Wilson, PhD, John L. Keltner, MD Background: To investigate the effect of cerebrospinal fluid (CSF) shunting on quantitative perimetry and papilledema in patients with uncontrolled idiopathic intracranial hyperten-sion (IIH). Methods: We retrospectively reviewed all cases of IIH with CSF shunting at our institution between 2004 and 2011. Perimetry was performed before and after surgery in 15 patients, and the mean deviation (MD) was compared before and after surgery to assess the effect of the intervention. Results: Fourteen of the IIH patients were female and 1 was male. The average age was 34 years. CSF shunting resulted in significant improvement in the perimetric results with an increase in the MD of 5.63 ± 1.19 dB (P , 0.0001). Addi-tionally, average retinal nerve fiber layer (RNFL) thickness measurement by optical coherence tomography decreased by 87.27 ± 16.65 mm (P , 0.0001), and Frisen papillede-ma grade decreased by 2.19 ± 0.71 (P , 0.0001). Conclusions: Our results suggest that CSF shunting results in improvement in perimetry, RNFL swelling, and papillede-ma grade in patients with IIH. Journal of Neuro-Ophthalmology 2015;35:22-25 doi: 10.1097/WNO.0000000000000181 © 2014 by North American Neuro-Ophthalmology Society Greater than 90% of patients with idiopathic intracra-nial hypertension (IIH) experience visual field loss on static or kinetic perimetry, and it may become permanent (1). Because the disease can progress rapidly and result in irreversible visual loss, it is imperative to monitor and treat patients with IIH promptly and effectively. Patterns of peri-metric field loss often resemble glaucoma, including gener-alized depression of the visual field (2,3). Fortunately, treatment of patients with IIH improves visual function in at least half of patients (1). Weight loss and oral medications, including acetazol-amide, topiramate, and furosemide, are initial therapies for IIH if the disease is mild (1). When visual compromise is severe or if medical management is insufficient, surgical options include optic nerve sheath fenestration (ONSF) and cerebrospinal fluid (CSF) shunting (CSF diversion). Uncontrolled studies of ONSF and CSF shunting suggest that these procedures are effective in restoring visual func-tion and improving symptoms of IIH, although neither is always effective and both can result in treatment failures (4-6) or adverse outcomes (7). In some centers, CSF shunting procedures have become mainstays in the surgical treatment of IIH. Most commonly used are ventriculoperitoneal (VP) and lumboperitoneal (LP) shunts. Retrospective studies suggest that these procedures can result in improvement of the visual field (with kinetic perimetry) (8) and lessen symptoms of headache in some cases (9). There are no case series of automated perimetry out-comes after CSF shunting in IIH patients. Our goal was to measure these outcomes in this patient population using the perimetric mean deviation (MD). Additionally, we studied Frisen papilledema grade and measurement of the average thickness of retinal nerve fiber layer (RNFL) by optical coherence tomography (OCT) to assess for changes in papilledema related to CSF shunting (10). Department of Ophthalmology and Vision Science (JLR, KVL, JLK), University of California Davis Eye Center, Sacramento, California; Departments of Neurology and Ophthalmology and Visual Sciences (MW), University of Iowa, Iowa City, Iowa; Department of Public Health, Clinical and Translational Science Center (MDW), University of California Davis, Davis, California; and Departments of Neurology and Neurological Surgery (JLK), University of California Davis, Sacramento, California. Supported by the Research to Prevent Blindness Unrestricted Departmental Grant and the National Center for Advancing Trans-lational Sciences (NCATS), National Institutes of Health (NIH), through grant UL1 TR000002. The authors report no conflicts of interest. Address correspondence to Jennifer L. Rizzo, MD, Department of Ophthalmology and Vision Science, University of California Davis Eye Center, 4860 Y Street, Suite 2400, Sacramento, CA 95817; E-mail: jennifer.rizzo@ucdmc.ucdavis.edu 22 Rizzo et al: J Neuro-Ophthalmol 2015; 35: 22-25 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. METHODS A retrospective chart review was performed at the University of California Davis Eye Center to include all patients with the diagnoses of IIH and CSF shunting between 2004 and 2011. On review, we were able to identify 34 patients whose records included a diagnosis of IIH and CSF shunting. Of these 34 patients, 15 fulfilled the Modified Dandy Criteria for IIH, had documented papilledema, had a shunt placed to treat IIH, and were included in the study. These patients underwent surgery if they experienced persistent headache and/or progressive vision loss despite maximal medical therapy and weight loss recommendations. The timing of the surgery was variable depending on the severity of signs and symptoms. All patients were required to have undergone automated perimetry, either full threshold or SITA 24-2 or 30-2, at baseline before the shunt placement, and the same visual field testing method was repeated after surgery. Mixed effects regression models were fit to compare presurgical and postsurgical MD, average RNFL thickness measurement, and Frisen grade, controlling for differences due to age and sex, using the SAS software version 9.3 (SAS Institute, Cary, NC) procedures GLIMMIX (Frisen grade) and MIXED (MD, average RNFL thickness measurement). Stan-dard linear or logistic regression models cannot be used for data with multiple measurements per subject because it violates the assumption of independence that standard regression models require. Mixed effects models control for intrasubject variability (differences between the eyes within a subject) and hence allow for repeated measurements on a subject (11). RESULTS Fifteen patients met entrance criteria. Fourteen of the patients were female and 1 was male. The ages ranged from 16 to 66 years, and the average age was 34 ± 12.7 years. Two of the patients underwent LP shunting, and 13 had VP shunting. Of the 15 patients, 4 underwent revisions of pre-existing shunts. Perimetry was performed between 0 and 7 months before the surgical intervention and between 2 and 17 months after surgery. Cirrus or Stratus OCT was obtained in 14 of the 15 patients preoperatively and in all 15 patients postoperatively. The same OCT device was used consistently in each patient. Fundus pho-tography was obtained preoperatively in all 15 patients and in 13 of the patients postoperatively. A masked observer (M.W.) performed Frisen grading (12). An example of patient testing results is shown in the Figure 1, which demonstrates the preoperative and postop-erative fundus photos, perimetry results, and OCT mea-surement of the average RNFL thickness. Table 1 shows the average values of MD, average RNFL thickness measurement, and Frisen papilledema grade before and after shunting. Mean Deviation Average preoperative MD was 211.03 ± 9.53 dB, and average postoperative MD was 25.40 ± 7.16 dB, yielding a difference of 5.63 ± 1.19 dB (P , 0.0001). All 15 patients (100%) had improved MD postoperatively in both eyes. Retinal Nerve Fiber Layer The preoperative average RNFL thickness measured 184.32 ± 93.63 mm. Postoperatively, the average RNFL thickness measured 97.05 ± 23.59 mm. The average RNFL thickness measurement was significantly smaller in postoperative measurements compared with preopera-tive (P , 0.0001). The average RNFL decreased by 87.27 ± 16.65 mm after surgery. Of the 14 patients with RNFL thickness data, 11 patients (78.57%) improved in both eyes, 2 patients (14.29%) improved in 1 eye but worsened in the other, and 1 patient (7.14%) worsened in both eyes. Frisen Papilledema Grade The average preoperative Frisen grade was 2.46 ± 1.50. The average postoperative Frisen grade was 0.27 ± 0.44. The average Frisen grade was significantly smaller postoperative measurements compared with preoperative (P , 0.0001). FIG. 1. For Patient 3, fundus photographs, automated visual fields, and optical coherence tomography (OCT) measurement of the average retinal nerve fiber layer (RNFL) thickness are shown. OD, right eye; OS, left eye. Rizzo et al: J Neuro-Ophthalmol 2015; 35: 22-25 23 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Frisen grade decreased by an average of 2.19 ± 0.71 after surgery. Of the 13 patients with Frisen grading both preop-eratively and postoperatively, 9 patients (69.23%) improved in both eyes, 1 patient (7.69%) improved in only 1 eye while remaining the same in the other, 2 patients (15.38%) re-mained the same in both eyes, and 1 patient (7.69%) remained the same in 1 eye but worsened in the other. DISCUSSION While IIH patients with minimal or no visual loss can be managed conservatively with weight loss, if visual failure develops medical or surgical treatments are used (1,4). There are 2 main surgical options that may be offered to patients. ONSF has been shown to improve or stabilize visual function in approximately 90% of cases of IIH in retrospective case series (13-15). About 10% of these patients continue to worsen despite ONSF (5,16,17). CSF shunting procedures also may be used for treatment of IIH. Both VP and LP shunting have resulted in improvement or stabilization of visual function in about 90% of cases in retrospective case series (5,6). However, despite treatment success with shunting, shunt failures occur frequently in greater than 50% of LP shunts (5,7) and approximately 30%-40% of VP shunts (5,6). Shunt failure can have significant consequences, such as acute rises in intracranial pressure that may result in severe and rapid visual loss with worsening papilledema (8). Additionally, the longer-term outcomes of CSF shunting are unclear regard-ing visual function. Few previous studies of CSF shunting for IIH patients have reported visual field data. In one report of the efficacy of LP shunting, patients underwent static or kinetic perimetry, with improvement in static perimetry defined as at least 1 dB of improvement in MD (6). Another study evaluating the role of LP shunting used kinetic perimetry exclusively (8). A study of VP shunting for IIH included assessment with visual field function but did not report the type of perimetry or criteria defining improvement (5). A recent report of visual acuity and shunt survival in patients with LP shunting included results of automated perimetry, and MD was a secondary outcome measure (18). We are unaware of any previous studies analyzing the quantitative effect of CSF shunting on perimetry results. Our study analyzed preoperative and postoperative out-comes and demonstrated that patients treated medically and with CSF diversion procedures had improved MD. Our OCT data showed that the average RNFL thickness is also reduced by surgical intervention resulting in a reduction of the average RNFL thickness. As reported by Rebolleda and Munoz-Negrete (19) changes in RNFL in cases of mild papilledema are associated with visual field sensitivity losses and that sensitivity increased with resolu-tion of papilledema. However, they also noted that the decreasing RNFL volume may also be due to loss of axons with resulting optic atrophy. Additionally, our Frisen grading data demonstrate that CSF shunting results in an improvement in disc appearance in both eyes in most patients. Frisen grading was also used in the Neuro-Ophthalmology Research Disease Investigator Consortium Idiopathic Intracranial Hypertension Treat-ment Trial to evaluate 6 months of acetazolamide and diet for mild visual loss in IIH. Significant improvements in Frisen grade in both the study eye and the fellow eye were noted in fundus photographs and site investigator ratings (20). Although Frisen grading is subjective and dependent on experience, a study by Scott et al (21) reported good correlation between Frisen grading of optic nerve photo-graphs and OCT analysis of optic nerves. In their study, Frisen grading was also bound to be more reliable than OCT at higher grades of papilledema. Limitations of our study include the time gaps between preoperative evaluation, surgery, and postoperative testing. Although only the data most proximate to surgical intervention were included, it is possible that there were other causes of change in visual function. Additionally, both 24-2 and 30-2 visual field protocols were used so that comparison of the MD between patients cannot be compared exactly. Although some patients had multiple visual fields before surgery, others had this performed only TABLE 1. Average Preoperative and Postoperative MD, Average RNFL Thickness Measurement, and Frisen Grade Average Before Shunt Average After Shunt Change MD, dB 211.03 ± 9.53 25.40 ± 7.16 5.63 ± 1.19 (P , 0.0001) Average peripapillary RNFL thickness, mm 184.32 ± 93.63 97.05 ± 23.59 287.27 ± 16.65 (P , 0.0001) Frisen grade 2.46 ± 1.50 0.27 ± 0.44 22.19 ± 0.71 Odds ratio: 35.7 (P , 0.0001) P-values are from the mixed model results. Odds ratio for Frisen Grade represents the probability of having lower values after shunting. MD, mean deviation; RNFL, retinal nerve fiber layer; dB, decibel. 24 Rizzo et al: J Neuro-Ophthalmol 2015; 35: 22-25 Original Contribution Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. once, and this may have resulted in preoperative visual field measurements that overestimated the severity of the condition (22). It is possible that patients presenting with severe acute visual field loss may have been excluded from the study because of a lack of preoperative data. Patients with profound visual loss may not have had visual function measurable with perimetry, or they may have gone quickly to surgery without perimetry. Therefore, our patient pop-ulation may be skewed toward those with less severe visual loss. The results of our retrospective study suggest that CSF shunting may be an effective treatment for IIH. 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