Journal of Neuro-Ophthalmology, March 1986, Volume 6, Issue 1

Angiographically normal central retinal artery following the total resection of an optic nerve glioma.

Although the central retinal artery and its collateral circulation, especially within the anterior optic nerve, have been extensively studied, there continues to be controversy regarding the existence and significance of anastomoses between the central retinal artery and ciliary circulation. We present the case of a 16-year-old boy who underwent total resection of an optic nerve glioma beginning proximally at the chiasm and ending distally flush with the globe. After resection, heavy bipolar cautery was applied. Postoperatively, normal central retinal artery circulation was documented angiographically, suggesting that, at least in some cases, significant anastomoses can develop between the central retinal artery and ciliary circulation in the laminar and prelaminar areas.

Angiographically Normal Central Retinal Artery Following the Total Resection of an Optic Nerve Glio111a ~lit(h('11 L. LL'\'in, 1\1.11., 1\1tric" ~. O'CUI1I111r, M.D., Gilbert Aguirre. \I.P., and M'1l'ilyn . Kincaid, M.D. .-\ltlh'lI~h 111<' (l'ntr,ll rl'lin,,1 ,Htl'n' ,111<1 it .. (l,lI.ltl'r.ll (ir­( Ul.lll,';" l':-Pl'(1.11l\ \\ Ilhll1 lhl' ,1I11~'m'r 'Ttl( Iwn'l'. h,1\'l' L'l'~11 l'\It'lhl\'l,I\' ~tlldil'd, thn,' (,'ntinll,,~ I" bl' (llI11rl'­\' l'r~\' r"~,1rdll1~ thl' '\I~lt'l1(l' ,'n..1 "1~nlril'.lIll·l' 111 ,In,h­It' 111;'~l':-'Lll'I\\'l:l'l1 thl' (l'll1r,11 rl'tin,l( .ull'n· ,1I1d (ili.HI' (Ir(ul,llll'n. \\'t' prl'.,l'l1t thl' (,bl' ,'1,1 Ih-y,',H-\lld b(1\' \\'hll und"r\\'l'nt t"t.ll rt':-L'(II,ll1 ,'I .111 ,'pll( nl'I'\',' ~lilll11,' bt'ginnin~ pnl\im,l!k ,11 tht:' (\'l,l~m and l'l1ding di .. t,ll1l' rlu$h \l"ilh tht' ~"'bl', All"r r<'''l'dinn, hL"l\'~' bipl1l.lr L,llI' tt'ry \\'a~ aprlied r,'~I\'rl'r.lli\'l'I.\', l1<'rl11,ll (l'nlr.ll rdin.ll .ult'ry LJr<:ulalllln I\',l~ d,KUl11l'llll'd ,1l1gltlgr"phi(,llly. ~uggt'$linl': Ih.lt. ,11 k'<l:-l III $"IlW (" ..l·..... igJ1it'i ',1111 ,111,1'" t,'m,l"t's (an dt'\"'I"p bl't\\'l'l'l1 tht' ("l1lral rl'l III ,1 I ,Hll'rl' and dlitH~· (lr(UI,lll'lIl ill the l,ll11ll1,H ,'l1d prd,'minoH ,1red~. From Ihe Dl'partm"nt 01 Ophth.,lm.oIl1};y. Unll','r~II~' "I Texa H~alth Sell'nel' Cl'ntl'r ,JI San Anlonlo. rl'\,'''. This work wa.' prl"l'nll'd in pMI "l th,· Annu,ll Nl'un""p'" Ihalmology Svmpu,ium .,t th,' Unl\'l'r.. il\· III Mi,'llll, D",,,mh"r . 1984, Bascom Palml'r E\'L' In .. tilull'. Mi'lnll, f'J"nd,l. Address eorrespondl'ncl' ilnd rl-pnnt rnll! '~b III Dr, J'. ~, O·Connor. 12709 Toeppt'rwl'll1 Rd., ~lI,ll' 2111l, S.ll1 Anh'l1lll, T;>. 78233. U SA Th,,' anatomy and collateral circulation oi th central retinal Mtery within th optiC nerve have been ~tudied extenSively (1-10) There continues to be considerable Cl ntrovers\', hnwe\'er, con­cerning the pre encE', ii anv, of ana lllml ses be­tween the central retinal artery and sh,'rt pl)sterior ciliar~1 circulation within the laminar and prelam­inar areas, The iolllH\'ing case suggests that, at least under certain circumstances, a clinically sig­nificant ana tum lsi~ can de\"t:'1l1p bt'twt'en thl? central retinal arter~' and shllrt F'l)steril1r ciliar~' ar­t ries in the IaminM <lnd prelaminM areas, CASE REPORT An athletic lb-\.'eM-llld bl)\, ' \\',b tirst seen in :"ll-vember ]982, \\'Iwn hI:' wmplained that "the d-sil1l1 in l1''l\' right t'\'e is getting bad again." In De­( emb r l<,l~l. thl' patil'nt be~,lIl h,l\'in~ mild pain l'n 1l111tilln lli till' right l..'\·t', 1,1sting inr ,1 ie\\' days. that dl,<Ul'd spul1l,lnL'lluSl\'. In J.11ll1.1r\· IllS2. the p,lin rl'curn'd ,1nd \\'.lS ,1((llmp.lnit·d b\' f1u-li"e svmptllnls. IW,ldad1l', ,1Ild blurn' \'isilln l.ln th.' right. A 'inus sl'ries \\',lS nlHmal. B~' larch 1982. the flu-like illness had resllived but the patient's visiun \\',lS 20 (,ll - 2 lin the rihht. A 2 + larcus Gunn pupil, dis," edem'l, ,llld ,1 centl"ll scotoma wert' dl1cull1t'nkd, A rt'gimt'n Ill' prt'dnisone, 60 mg/d,ly 1M 2 Wl'l'ks ""'''15 begun, ,md the patient's visilln impwved tll 20iJn + 2, the ocular pain re­slll yed; ,1 nd the stewid dlls,lge was tapered, In Septt'lllber 1l)~2, the pcltient's Yision again de­creased, A rq;i Illt'n lli steroids was restarted but no impwvL'l1lt'nt Wd~ llllted. A ('llmputed tomo­!- irdphi( (CT) ~Cdn llbtain d at this time (Fig. 1) was read as "clln:;i. It'nt with llptiC nt:uritis." On t'xaminatinn here in Nllvember 1982, the pa- i\ 1. 1. II,V1N 1'I 1\ I . FIG. 1. Initial computed tomographic scan obtained in September 1982, read as being conSistent with optiC neuritis tit'nt'~ bt,~t (\>rr\'\'ll,d \'1~iI1l1 \\',1" 211 21111 \'n the right ,1I1d 2LlII~ 1)11 llll' Il't't. TIll'rl' \\',1'" ,1 2 t\l,ul'u", unn pupil pn Ihl' right. PIll' pi Ihl' bhih.1r,l cl)klr piatt'S (l'\CI'pl llll' malingering plate) 1\'\.'1'1' ~t'en \)n the right, but ,111 \\'t'r,,' l',l ... jh· itkntilied un the 1~11. E\\'phth,)lllwmL'try rL',ldillg ... I,'l're Ih.;1 mm on the right ,111d Ih.O mm un till' Idt I'n ,) b')~l' \)1,;/0 mm. pldm,1I1n vi~ual lit'ki~ dpcuml'nlt'd ,1 central c\)tl)ma PIl the right. Fulldl.... ·\<1mina!i\)I) reveal d a 5Ow\)lIl'll righl disc with \'l'l1\lUS cl)l)ges­tilH1, scattered peri papi IIclr~' hl'mprrh,lgt'S, il nd early templlf(lI p, 111)1' (fig. 2). Nl) 11ptllCiliM\' "hunt vessels were IlI'led. The left disl' ,,',lS 11llrmal. Carelu) examination uf th~ pateint'" ,,"in dis(k)~ed 11\1 caf~ au Jait sppl;,. Tht:.'re was Ill' lamily hbl\H~' pf neurofibwl11alllsis, mental rt'tMd,lti\lI), I'l' pha­kl) ml'toses. On I'Chpgr,lphy, the right \lptic ner\'t' I·va 18 mm in di,)meler vvith well-I)utlint'd (\'stic areas. Th 'ubarachnoid Ihickn~ss W<1S 9.7 mm LIn th right, comp.1rt'd with -1.6 mm 1111 IhL' Idt. FIG. 2, Swollen right optiC disc. With venous conges­tion, scattered peripapillary hemorrhages, and early temporal pallor OptiC canal \·11·1'· ... 1\'L're llbtained and howed I'nl,HgL'ment III thl' Ilrblt,ll end LIn the right. A re­pl'at T se, n, thi" tim\: with trut:' cI)wnal \'ie\A.'s, \\'a~ Cl'nsi~tt'nt Il'Ilh ,1n pptic ner\' glioma (Fig. 3), bl'ginning 1 mm internal tl' the ~k)be and ex­tending -l 111m di~t,ll tl) the l)ptic foramen_ A com­~' lt'le blt)l)d wunt I,'ith differential. coagulation ~tudies. ch mi:-tr~' ~'rl)fik: urine anah'sis and en·thrl)c\·te sediment,ltl\ln rilte were normal. l")bsen'atilm wa" ,lLh'ist:'(L \,'hen the patient re­turned in Decembt'r 1'1(,\2, hI:' \-isil)n \I'as now linher Llluntjn~, ,)nd tUl1ll'r e\d:;it)n was recom· n1l'ndt'd. On DeLL'mbt'r 2'1, ll.)tC, a right frontal (ranil)tl)m~' \I'ith lInn'llfin~ l,i the right I'ptie canal ,1J1lt tl1\' ri~ht l)rl'it 1,',1~ perfl)rmed. The tumor was FIG. 3. Left: A repeat computed tomographic scan in November 1982. demonstrating a fusiform enlarge­ment of the right optic nerve on axial views, Right: Marked enlargement of the optic nerve demonstrated on true coronal view consistent with an optic nerve glioma, /~[T1 AI. A/\'['Un :\/Tn~ l >/' /ll /.IN/: CUOM/\ 3 FIG. 4, Postoperative fluorescein angiography per­formed on January 13, 1983. documenting a normal choroidal and retinal circulation during the arterial (top), arteriovenous (middle). and late phase (bottom) of the angiogram. :-l'clio/ll,d prm,illl.llly ,It 1111..' chi,1sm and removed It'om till' oplic l',II1,11 ahln~ with il:- ~url'(lul1dil1g dut',ll :-1ll'.lth. TIll' m't'Vl' ,lnd it:- dural :.healh were IIll'n gr.bpl'd ,1'" om' unit and Ih . lumor l'ctioned flush wit h Ihl' globl', followed by Ihl' tl ppl iCc1tion of IW.1VV bip<lltlr l',1Ukry 10 th\..' :-Iump. A patenl n'ntr,11 rl'lin,11 ,Htl'ry W,l'" lIb"'l'rvl·d lin Ihl' fir;,t po:-lll~wr<1li\ll' day ....Iuorl· ...l'cin angiography on 1,1nuMy 1:1 docullll'nkd ,1 normal chllrllidal tlnd rl'lin,11 l'irl'ul,llion during Ih\..' drl 'rial, arkrillvl'­nllU:-, ,1nd 1,111..' ph,I"'l' (10 min) (Fig. 4). Mild sWl'lIing ,lnd iIKt'l'a",ing (lplil' atrophy wer\..' noted (Fig. 5) ,1:- wl'il a:. no light p 'rcepti(lll (, LP) vl ... ion, ,1n am,1Uro[ic pupil, ,1nd mild plll;,i .... Rt·pc, I angi­< lgraphy on February 17, wilh ....pecial ,lit 'Iltion to Ihe choroidal circulalion, wa::. again nllrmal. Ophthalmudynanlllml.'lry al thi lime wa~ ':Ill bll on the right and 100lh5 lln Ihe Jdt. n micl'l1scopic e>.aminatillll, the prt';'l.'nct' of a c(lmplet\..' l'l1-~ section of Iht! optic n n'e \\'a" confirmed, and Ihe arachnllid \\'as id\..·nlified completely urrollnding th nervI: (Fig. hal. he neoplasm was present centrally. Al hight'r mag­nification, tht' tun1l1r \\',lS _een III clm... i.,,1 Ill' ma­lure- appearing astl'l1cyle - wilh ::.on1l..'\\'hal en­larged nuclei and indbtlnct cytopla~1ll (Fig. hb and c). Rosenthal fibers \\'ere idt'nlifit'd \\'ilhln astr 1­cytk pwCt:'s es. cca -illnal p'oclmll'll'ma bl)dies wert' al'O St' n. Th tunlllr \\',1S pre'ol..'nl In the ::.ec­tions 111llSt dislal fwm Ihe brain; 111 \) r\..' pw\.ill1al sections were ir t' llf tUl11llr. The nlllrt' di~t,ll sec­tions demon tr,ltt'd IMgt' \'ess\..'1s wilhin tht' tunlllr (Fig. 61..1) tlMt were Illlt prt:'s\"'nl ill nlllt't' ~'l'l'\.lmdl sections. FIG. 5. Fundus photograph of Ihe righl diSC taken on January 13. 1983. demonstrating Ihe residual swelling and increasing oplic atrophy on the right. AI. I.. 1.1. \ '1, IJ AI.. I-Iu, 1>. a: CroSS section 01 me optiC nerve with tumor centrally. The entire optic nerve is present. with diaphanous arachnoid surrounding it (hematoxylin and eosin, . , 3.5). b: Tumor cells. with dark nuclei and an irregular arrangement of celts and vascular spaces. are present on the left. On the right is normal nerve parenchyma (hematoxylin and eosin.. 90) 6d I, / I'J, : 1/ : \IU11\) . \ / I / I.:. ( )I ' IIt - / 1\ \ 'I. C1.1(ltvl II Fig. 6. (cont.) c: High-power view shows variable size of the tumor cell nucleI. Cyto­plasmiC borders are Indistinct (hematoxylin and eosin.. 360) d: Cross section of the distal optiC nerve with tumor, one large and several small arteries can be seen within the substance of the tumor (hematoxylin and eosin.. 36). 5 .\1. ( t ( \ t,\l It ..\ I . \ I'I'r"I"lvnl "ll,hl"II' 1'1 1,11,1I11t'1I1 IlIlll'"'" I""" It! 'I1til, ,t! 1'1\ 1"."1\'1"1.111\ " I ",',Ill" "bI.IIIH't! 111 :\1'"1 )I)S-; (II: ;-1,1111 \lI h u"'l IllS") (1-1 .. H) h,II,," lIf'I' ,,11l111.IIII'11 111 "\11,1;11"1 IllS") rt'll',dl'cI" 1;·dll'I'lI"r "','11"11\' ",01'''1'1,1. III II 111,,1 11111'.1 IlVr\l' 111111111'11 ,\:11', 1"1"11 till Ill\' II h hl .!I1d _11/;, 1"'11111 ,Ill llll' 11'11 ,\11,1111.1111'1"1\ , Ilf'lI 1111 till' n,L;hl •• 1I1d .. 11t11'111.11 t ,,11,1111'\1111 'l'-lIdllll,I,1 'Ill 111l' Il'Il 11I11dll'" I h,. \I" ,h., tll11 'J I 'd ,I \\ 1'11·.11'\ I'ltll'",1 tlplll ,II· r"I'11I' but 1111rll1.11·.1~'I'I'''III1r:. rl'lll1.d ,\I kril'" .1I1d 1','IIl'- ,'11 Ihl' I'Ihhl .ll1d .I 11I1rl11,d cI, ..., "11 1111' Ii'll (h~ "I \\"b.n III .1 ..·... ,I"1[1.·d .I dil'",1 .111.1"["1111 .... 1" bl" tl,'L','n llll' ,,'l\tr,11 r,·lln.ll ,nll'I'\' ,111.1 II1lr,I",,"',,1I cir,k' ,.1 LII1I1 111 111l' rl',l:,j()11 III Ihl' 1.1111111.1 lrll'I""d. ,1~ \""Ii ,h ,111.h(,II11,I-..I''' [, '11\"'11 lilt' ....'1111',t11l'l1l1"1 .HI '1'\' .ll1d llw c1I'lt.'rt. I I'k I~ ,1/ lh ' 1)1., 111,11 'I' lll­I'I'lIl1, hl1g till' .111tl'n\lr ,'pti, 11 '1'\','. /1,\, 1'l'11 2-.J) IIIl lhL' ,Itlwr hc1l)d d"11 I t'll th.ll .1111' , '1111',11 I'l'Iil1.1) .lrll:'n· bl'.1JKI1l''' <111.1 ... 1,'111(1"'" In lhl' 1,1111111.11 1'1' f' '. Idrnin.Jr t"l:'hll'l1. HI' "',l'- • bll' [tl cI,'CUI11I'I1I (2) .Ill ,I1J::-t,"l1P"'I~ bdll','el1 lhl:' pl. 1 br,ll1,h '... \It lh . (1'11· lral rdil1,ll .1I'kr~' 'lihi lIw r,' -UI'r,'nI 111,11 [1r,1I1I:h . II lh' lrcl ,II - Il1n. 1\'1l1-h ,,'nt' "u"u, 111' \'j"'ll'lt.· h Ih 11,1 "l',1 'I' .... L b'rl1101l1 '1011 (II)). 111 lh . hl"­\ opJlhologlc ... tllci\· (,I '\ I 11"1'111.11 hUll ,111 "pill l1el"\·I·.... ,dl'l1li1'it' ! "lilly III \I "'PI:'(llllt'lb 111 \\ hl(11 C ntroJl r lill,ll ,Hterl' bl',lJll'I1l'''' \'t'l ' dl"tl'lbull'd tIl [he \·,1:>(1I1.1Iul" III the 1,1I11il1,1 (nbn'",l in 1 1,I ...hi III "i111l1M tu th.ll ..1 '~'I'lhl'd l'\ \\',,111 (II) 1 h '" ,'uld nlll "'Llppl rt H 1\'rl:'ll· ... (1'2) ,1111"'11(11111 Ih,11 liwi . '\"1 ....1 o;igl111icl111 rl'ClllTl:'l1t chpI'I'Id,11 "u~'~'l\' 1<, llw lamil1a (ribr'h,l ,Ir rl'h·,II.Hl1in,lI' IWI\,' II lI.b tlWII' f"'I:'IJl1g th,lt the rdrlll,lmlllM 1'l'Ih'p",l 11\1" ", 1\" lu ,,", "'lIppli,'d b, l '11 ['-If'I·!.11 ,llhl 111I\~lllldlll.rI FIG, 7. Postoperative compufed tomographiC CCln obta,ned In April 1983 demonsl. allng a per I tent shadow or "ph ntom tumor' on aXial view , ·..."d... III pldllln,~ll1; "m,111 br,lnchL''' ,11th 'nlral 1·.-till.11 ,1rll'rI' "'1'1'1' .1J"" ... 't'11," ,\ rich 11 '1\\' Irl.. of -"I11,dl """"('1,, \\',l ",'1'11 til ,'xt'l1d from thl' relnl­1.1111111,11' IWrI l' [I' till' !'dil1.11 <;urf,Kl'. "ThiS ~~'''kl11 InTI\' ,111,I ... j\lI11I)",'d wilh tlHL't' tr,II1~"er"'I:' ,,\·,t m,,: \ .,lhllllildl1t .1rll'f1,d 'l1pul trll/ll thl' "hl'rl pl.l~terillr ..!liM' ,HII'I'Il'" 111 tilt' "..:I '1',1 til tht' l<lmil1,l rlbr 1....1. ,m,IiI "h"rl f'""l 'nlll' .. lIi,H\' bral1(hL'::- ,111c! ( C'-"­"'''' I1,d Ih"I"'lll.d ,dpllldl'll· ... III Ihl' pl'l'lill11ll1,H pllr· 11(111, dl1d hr;1I1L 11 .. dl'fI",'d Irull1 lilt' e\.'l1lr.l) rt:'ll 1101 I drll'J'I 111, I1d .II'lIund lilt.' dl I. .. \'(' ... "",1., '11 lh l' prc­1" 111111,lr 1'1'~I"11 1\"1" flolt It\ ['I.' prll1ldrih' "cl",ral l'rdJILh,'" "I lh' ... hilrl 1'""krHlf (llian' arteri ':' 1''' Iwr tl1dl1 111'1"1 ',d.ll br.ll1,h .... ,\1 tl1l" clll,uy ar­t 'I'll'" II 11" ,111,1~1"11l11"'''''' 1...1 l'dl\'IOVIl th ''- '111r.ll ret­111,11 "rlt'rI ,111.1 11Cl"krlilr (dl,H.' ,HI '!'It'S ur (11'-)1' III /11111 <It lhl' "111111,11' ill' f~rt'I"mll1:H ,lr!:"l, thel1 nll .lIlI'rl1.III' L' p,1(hl',1\ I' I"h "r th ' F'cl'-.;,l h ' II bIL'''..1 IIlt,l 1111' I' '1In,11 llr(lIJ.lll,'11 II ,111 "ellll"''' ' 1'1'11("'''''' 1,.1\'\'1'1,,1''' 111 lilt' ("illr,ll l'dlll,11 Mll'rI' bl'lllr~ If ,11 1111' 1.\111111,1 I I'll rll I 011 tl1l' 11th 'I' h,ln...-l. " ~u,h dl1 ,111," Ul1l1'"I''' III ,1"11111, Iii IICUtf .... p.-c1l1"Il'11 ,l' th· ll'nlr,II r tll1,ll ,lI'll'rI lll,l\ b· '"I1""'l:'d b.,' dt,,,,I"I'­I11l.' n '\ ,1 \·.,11,11 '1.11 Clr':U).ltlo'll C;,lutler .111d 51'lll (111 Illllilci. 111 "I 1I ,i I,'" ,-,1ITI"d "l1lll1 th~ r,lbblt. lb,ll UI1.1<.'1'lll'I'Ill,ll "I1\illlo'Il" \ ,1,1! ,i\" 1111"cted Inlr,1\'t'­11111l~ 1I' p''''''''d ,11"11)-: thl.' rt'lll1dl • rlt'rI' II' th,' lal11­Ill,! (I'i 'n''', \\ h,'fl' Il "1" ..11\ erlt'd III Ih drl ridl Llrlk, I LII1I1 \\'Ithlll th" "el r.l 11. hl'I\'I;,"'t'L ,,\'m­~', ltl1l'h tl' ',>';l'l1l" \,','r~ u~,,'d. thl' dyt' p,l~sl'd ill. I1h th t' rl'llll,l] .lfl '1'\ Il1l\l lh,' 1',,1111.1 "I!hl 'ul bt'in~ dl­\ · ..·rlt'd tl' th,· 'If(I,' ,'I 111111. Th, ... ",uh~e~tl'd th,11 all ,111,bl"l11l"I" ['d'\ 1'l'11 lh,' L,'lllr,ll 1','1111.11 ,1flt.'rI· ,1nd llll' cHck ,It LII1Il 111.1\ "hi .11 Ih" Ie,' 'I III th 1.1111111.1 (nbW",1 th,ll J" ul1d l'r \ l'gt'tnl\\'l' .- '\1111'01 Ihwu~h Ih,' mt·llt.lll\1n 'li ~llll1lll::.-IJ" <1p~~.H,1Iu,; ,1t Ih,' l'I'Inl ..'t "I'I~\I1 11\ Ih,' .111,hll'l1l1,IIC ch,lnn",1 11'1'111 Ihl' (,'11 r.ll rl'IIIl,1I ,11'1 'n' \11'tl.l1 (I.J) dt'­,,,",,( nbc.! .111 ,ll1,lll'hll\1" ~Illlllll" ,11'f',lr,1tll~ 111 th dll)-: III Ihl" ,1111111.1/. h,'l\'l" 'r. lhl' l'l,tinaIMI r\' I~. l>!',1I1.:h lIt tl1l' cdl,H\ .1I't 'no "lI"~ .;11 11 C, Ih,lll,,,'lrdf'­,, 1.111\111 III hUI11,ln" \II ,1Il,1\I'l11i':-~11'1~II;m')"t'<' f,lund 111 ,,111<.'1' ,1111111,11" 111 1I'" I b,' dlll1l' "'llh (,lulllll1. \\",I",r (\-.11') d,' .....-rib 'd ~l'\·'·r. I p.lli"l1t~ \','I'y "111111.11' t,l L'ur f',lIl,'nl 111 \\'hlll1l, tllllL"\'in~ )[bital tTIllIl\ ,II ,,'Ith "1·"11\1I1il1.~ "f 1111:' hll ..'m,1 tl~,~h "'ith t)1l' ~..:II'I"l, .1 11 'l'1l1.11-,lppl:',Hin.l; 'l'ntral relilh11 M­IL'I'I' ,,',I'" Ilb"l'l'\ "',I. lilt.' P,IIIl'I1I~ .1b I had t1ptic disc ""\,,,'IIlI1.~ I'r"lll' 'r.lli\' ,II'. i"ll ,1nhiLl~rClm~ ,,'~re per­III 1'111 "d I Un1l'rllll~ I b::''''I'\'er' (1.2,5,tI, ) han' f'I'II1I ..'d IIUt th,11 lht' biL111d slIppl\' oj the <1ntt:riur (l~'I1l' 111,.'1'\' • I'M' '~ In)n1 en:' tL e\'e ill the siz and .1I'1'.ln~"'l11eI11 III It... \',l~(ular SL L1rees, lust belie\' .1 re.11 PrPl,)I\Tt: ,'I Ih e \'.lsclIl<Hiz.llion of the optl Inn .\1 :\1\ Inn :\1111\ (l/'II<" 11\\'1 <;,1< JM/\ FIG. 8a. Postoperative computed tomographIC scan obtained III August 1985. demonstrating a perSlslent shadow or "phantom tumor' on aXial view FIG. 8b. Postoperative computed tomographic scan. sagittal reformat. 7 FIG, 8e. Postoperative compuled lomographlC scan. coronal view, l:!C ner\'e does not exi·t (17). Clinicall\', hllwevl'r. \lUI' case and those tli Wll!tt'r :-lIggl'st th,)t, ,It k,l~t under certain circum~tdnL\..'~, large ana~t(lnHl~l'''' can de\'elop between thl:' central retinal arkf" .1nd the laminar and prelaminar pp terillr ciliary arll'ry circulation, he I:' mil\' de\'l'h,p becau~l' III ~lllW compromi e in the l:l'ntral retin.,1 .HlL'ry !'rlllll tumor compression. W(\!ter (15, In) ((luld 11lll .... tlb.. stantiate thi , howev\:'r. since histtlpathlllpgil' Sl'C" tions revealed a patent central retinill .Hll'ry in Sl'V" eral of his cases, If such il potential <1n.l~llIIllP~i... exists, more aggre sive early thl'r.1py, induding modalities such as hyperbaric oxygen, m.)~' be in­dicated in cases of (l'ntral retinal ,lrtl'rV 11ly]usill11 of recent onset. Finally, it is important to note th,lt gliom.ls, lil-.l' other tumors, ca n masq uerade as 11ptic 1ll'1I ri ti... (18), and just as optic neuritis call lw l1lisdi,lg-nllSt'd l'n CI St..ln ,1:- tunll1r (I'll. ,1 dI1(1II1lt'nlni ltlnwr C,lI) hl' l'ITI'IWIlllS!\' di,l.~llll:-l·d ,1'" tlpticlWlI-ritis lln 11lL' ~,1I1ll' It· !. Lli"lll,b ,1I1d ,'llwr ,lptic nl'[\'l' Wnwr:- m,n' ,11 " ,1f'f'l:"lI' ttl f'l'l'~i~l t'n l't'f't',lt T sc,)nning l'\'l'l1 \\'Iwn CtlIl1f,ll'tl'!.'- l'\ciSl'd, Till'S\:, "phantlll1l lunwr:-" dl'cn',lSt' in silt' \\'ith tinw ,111d c,m bl' idl'nlifit'd b,· ,1 1,11'1-. t1r' subst,lnCl' ii (,11',)n,11 l'l'Cllnstrudilllls .11',' I','rlnrnwd (I, Ll\\'I"n Smith. pl'rslln,ll c\1m I1IlI nlc.11 i\ 'n), SUMMARY 1\ 11l-\'l',ll'.. "I,t h,,\' llriMin,llh' di,lMIH1Sl'd as having ,ln lll'li,' lh'lIl'itis \\',lS 1,1lt'r r'llUlld tl) h,l\'t' an llpti,' nt'n'l' glit1lll,1. l~l'Sl'dillll lIt th\:' tumllr PH1\.i­Ilhllly .lt llw chi,lsm ,1nd distall\' r'lush with the Mlllbl' W,l~ illllllWl'd by thl' ,1pplic,ltillll lli heavy bi­plliar (',wter\'. 1\lstl)pt'r.ltivt'lv, the patient was M. I., UVIN 1:-1" 11L. FIG, 9, Left: Fundus photograph obtained In August 1984, documenting a well-developed optic atrophy but normal-appearing retinal arteries and veins on the fl,und tl' havl:' "n "ngillgrilphiLilllv nllrmaJ cllll­midal. optic nerve hedd, ,md r\:'tinal artery cin:ula­tion, along with normdl llpth"lll1l11i\'ll,llllllllletr~', suggesting the dt'vt.'i lpmellt llf :;ignific,lnt (l,II"t· erals betw en the CE'ntral relin"l c1rtt'r~' .md pll:;tl'­riar ciliary artery branchl:'s in thl' 1,lminc1r ,HId prt'­laminar area. Acknowledgment: This sllld~' \\'cl~ slIppllrkd 111 pMl bv an unrl'strictl.'d gr,1111 fflllll Rl's'·.Hch tel ['H'I l'nl Biindnl's:" REFERENCES Wl"llcH, "- C.: An",I"lllll"" h'I\\',"'" llll' fdlll"l ,mei (,h.HI Mi"f1,11 ('f«lI,lIl"'" Il, I (lJ",IIt<lI""'I. olO: 11'-1' I. I"'I> ~ Sln~h, <;" ,,,,<1 D,,,,, J~ . Till' lI'"lf,,1 ,lflnl "I till' f,'llIl,1 .-\ ,Iudl' III ,h di,lrlbUlllll1 ,md ,'","1\'11""," I;, I l l,,11· 1I1I11"i,,/ 44: ~"1I-2"'!, 1'11>11. 3 I f"n,·h.~. S' ill' ..'Illf.ll ,HI"fI' "I (Ill' f,'III1,1. It- f"I,' 111 II", bl,;"d '''f'f'"' III till' "f'"l 11';fI'" I~, I l'I,Itt/,.,I",.,1 47: h~l-hl>l. 1'11>1 4 ll,]\'fl·h, .... ~ .. AIl.lt"flll· .lfld I'hl·,i,.lll~l· "I Ihl' "I'll' lh'fI" h,';,d 1fill" ..Iw. ,I, tI" (11l/11I"""',,1 l It.,I'"I,,,.\.'1 78, 2oll1-2;ol. 1"74, -; Andl·r",.,I1, l) 1<: \'.l ....cul.'r '-I~IF'F'ly I,.thl' pplll·lll'r\t,· ,11 prJ· In,ll,',...\'" I (l1,"tli"IIII,.1 70: ,loll-.1';1, 1";-11_ h /--,fIl"'1, I. r.. ,m<1 I',dh. A :\1. 1',lll"'phl "tll"~I' "I Ilh' dl,tal PtlftUlI1 III Illl' "I't,,' 1I,'rl'" 2 \'.h"ul.lr f,'I.llll,",I"p, /111I I ll,,11l/wllll,'/ 66: IXiI- 1x7. I'I/lx. 7, h,m,"I', I . N,'l'l,',,,, 1\ .. •111<1 l ,,11,'11,', I ;\1. \',""'Ul,'f 'uppll' '" Iill' "f)l .. p"II1\\'.I\'. 2 l'ufll1l'f ,1",Ioc" bl' ml(rtl.ll'· right Right: A normal-appearing optic nerve on the left lL'flll,-:f.lf'llI "I th.- "F'II' n"11 ~ Br I OI'/lllhl/III,'1. 39: ~2il-2~~. 14~; x 1i""",n<1. I' .lnd L,,\ ,1'''1' \1 .-\n.~"'arch.lecture of the "pi', n,'f\" r,I!,t1IJ .~'" I l'pl,:h"II""/. 68: 979-9 6_ 14,,4 4 L~"t"'I', \1. .md H -nlo.mJ. P.. Angioarchitecture of the "1'IIC nl'n,' 2 L'lnln,l cnbf,'~a ,1;". I 0l'hthnlm"l. 68: 4Sh-\.fl.,l". l\..,lhU ill L,d"'fm,ln \\ F \IJlIln,m.,t' A_ E.. dlld Green, \\", R.: Hl'I,'h'~", ,llIdlc" "I tilt' \-,l,cula!Ufe elf Ihe anlerior optic 1l"fI,' 1" I l '/,1,1 1",1"",: 8:!: W:;-423, 19;-(:\. II \\'"ltt !: TIl<' bl,',',i 'un'k Il1 Ihe lamllla cribrosa (a cor­f,' dl"IlI. 'f1,1II; (),'hlh.II",,'/ j"" U.J.. 60: 6<), 19-10. l~ fl.1\' f,'h, ~ S -j·It,.,-,,'/ /;.-1,,'1 "'- l','tl'- .\'<'IIf"I'.11II!' Springer­\ ,'r1.1~ :-<"1\ ) "flo. l"';-~, F'f' l,-Ill 13 S.lUII,'f. Ii , .1nd S"',-:hll R. L'lllef~uchungen L:ber die Be­/ l,'hlln~,'n ", 1~.-h'·11 ( .. lllr.ll·und IltargefaBsystem im B.'f,',d, ,kf L1nl,n.l (ribre'", 1-"11 Graefe~. Arc/,. Ophlha/­11I,'/ 15:!: olL'-ol24. l"~2. 1-1. \1"II.ll. D H R"C:lIl.11,,'n ,'I Ihe dlllf,lidal circulation in the d,'~ "nd '-.11. I '-\;,,11 d-'''"I I 86: 4C10, \'132, I; \\ "It"f. I R T1w ~1"'(I.ll bl",'<1 "uf'pl~' ,'1 the retina in optic n,'rI",' ~It,'m.l~. I r,·d,.ltl l)I'hrllr11111"'. 13: 198-203, 1976, It'>. \\'"II"f, I R,: .H~<' "'pll( Ilefl't' gh"ma removed b,' the If.,n~(""I"I,..tll·.ll .If'pfll,l(h, I Pedllll' Ophlha/mol, 10: lol2-1-I1>. 1<);-.' 1;- h.lI""I', I...111.1 :00.; "l'I,'n " , A,: Phl'"ic,-anatom\, of the axial \ ,1,,'lrl,lfI/,III"" "j Ih" ,'pllC nt'f~'e, O,'c. 0/;/111111111101. 26: 3X--I<I. ['ll,t). 1:-; rt.,lknb,l.-h, D. D.. l't'oHn", T, P.. and Hollenhorst, R. W.: An "n"'".ll (,l~'" ,If "ptk nt'rI't'-chiasmal glioma, Am, J. l)I",tJ",llIIc'l 74: ~2J-~~3, 1'172, l<l lilll'Md. C. \\' .. O,ht'f, R. H., and Tomsak, R, L.: Com­p, l,'d 1"Ilh'~f,lphi.. ft'atuf<'S in optic neuritis. Am, f. Oph­111."",,' 1 89: t'>'I'I-702, 1980.