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Show EDITORIAL COMMENT -------------------_..-. - ._-------- The Phanton1 Optic Nerve Phenomenon "Seeing is believing," the tlld s,wing gOl'S. In this issue llf the Illurn,ll, LL'\'in d ,11. descriL1L' finding perfectlY nLlrm,ll blLltld ntH\' through the central retinal arterv llf ,1Il t'\'t' dOl'I' h'l\'ing resected the optic nerve flush behind the globt'. NLlW, if \'ou feel like \\Titing a hate letter to the editLlr and jumping up and dt)\\'n L)J1 the Jtlllrll,11 \\'ith track shoes, gll ahead, But after that reactiLln, please Lllnsider whv this article is being published in the first place, and the following comments will, it is hoped, enable us to start the new year off graciously b\' remembering the old adage tha t we must learn tLl disagree \\'ithtlut being disagreeable, There are man\' aspects of the problem we are addressing that I am not sure of at all. I do want to e\plain a fe\\' background points in mLlre detail, ho\,'e\·er. At the December 1984 NeurLl-ophthalmoILlg\' Course in ~liami, a patient was discussed who had just undergone neurosurgical e\tirpation Llf the intracranial segment of a large optic nef\'e glioma, Dr. P. S, O'Connor, an eminent member of the Editorial Board of this Journal, mentiLlned at that time that. after having excised an optic nerve glioma in another patient, a pustoperative axial computed tomographic scan had shllwn the presence of an apparently intact optic nef\'e, This nearly made the writer "cone down," but Dr, Burde immediately confirmed having seen the phenomenon, and it was later stated that Dr, Miller had also seen this, All of the lIptic m'f\T was then totally removed surgicallv bv the orbital route. A follow-up computed tomllgr,lphic SC,ln certainly revealed at least what appeared tll be an intact orbital optic nerve, and this was reported bv Shedden et al. in this Journal (Vlll 5, pp, 201}-212, September 1985) as "The Phantom Optic Nerve." An important point noted in that case W.1S th.lt whereas an axial view showed the optic nnve as intact, a corollal view confirmed that it was truly absent. The plot is thickened considerably, however, 9 with the article herl' published by Levin l'l al. The manuscript was reviewed by em l'xtreml'ly distinguished Editmial Board ml'mber whose comments are quoted, verbatim, as follows: "Thl' authurs present a remarkable presef\'ation of the retinal circulation immediatel\' following remL1\'al of an optic nerve glioma, I ha\'e great difficult\, accepting the fact that their Fig. 7 shows onl\' a phantom tumLlr. It appears to shuw impressi\'e evidence of a significant portiLln of the optic nef\'e pl1sterim tLl the globe still being present. Sll much is present that J would suspect it was sectioned pllskritlr tll the insl'rtiLln lIf the central retinal arkrv inttl the Iwn'e, In an\' case, \'en' cardu! multiple seri,ll sectillns (1f the ,1nteriLlr part Llt the optic nerve shLluld h.1\'e bt'en .1\',1 ila bit.' ,1 nd shLluld prove llne \\'av llr the other whether. indeed, the lIptic nen'e was sectiLlned just poslerillr tLl the globe, The reader will wllnder ",h\' the authLlrs chose not to publish the later CT scan shllwing that the phantLlm tumLlr had cl1111pletelv disappeared, [ would recLlmmend that this p,lper ntlt be accepted unless the 'lllthors can pwvide nwre histl1pa thllit19ic evidenn.' to prLl\e tha t tIlt' cen tra I retin, ll ,lrtn\' within till' llptic 1lL'f\'l' \\',lS indeed cut. I think it is entirt'h' possiblt' th,l! th,lt might happen if thl' glitllll.1, itsl'lt, caused sufficient chwnic t'mbeHrassJllL'nt of the circul,ltilln llf till' CL'lltr,ll retilul arterY that it permitted the deH'k1pmt'nt tlf e\.lensive collateral circulc1tillll, I haH' tWlIble belie\'ing that happelll'd, Iwwevl'r, in till' absence of an\' e\'iell- nct' ll! collatl'r,11 \'<lsl'lIl,lr ch,lngl'S tlll the optic disc. .. Dr. lYClllllll1r \\',lS l'Llnt,lctl'd ,lflt'r thl' ,lbllve editorial tlpinillll W,lS received, .1I1d he supplied additillllal illfl1rm,ltilln, I\t this juncturl', it slwuld be emph.1si.ll'd th,lt evl'l'V reader intt'rt'sted in this subjt'ct should c.nl'lullv re.ld tht' .nticle bv Dr, Wlllkr th,lt Dr. O'Conllor supplil'd: 'The special blllllLl supplY of the retill,l ill llptic nerve gliomas" by Dr, J, Reimer Woltl'r, which appeared in the 10111'1111/ 0/ Pediatric 0l'lrtlralllll1logy 13(4):198-203, !IJ I 1)1 I ( >I,}, II , I'l 1:1,\jf( 1;\1 (woe Nf.RVf. luk I\ugu~t ILJih, 1\ Il'w pntilll'llt LJullk.., Irlllll th,lt ,Ht'icll' drl' rq)rUdUd'd Ill'rl': "Thl' prl'~l'llt p,lpl'r i~ tll ~huw th,lt dt JLod..,t ill ~(llllL' l,1"l'''' 1I1 lIptil Ilern' glilllll,l, ,1 "'pl'lldl tq)l' 1I1 rl'tilldl bllllld ~u~)ph' I11U~t bL' d..,..,lIllll'Li tu ('\I..,t I hi'" dllll\v", IIII' l'lllltiIlUllll.., bllllld 111I\\' ill till' rL'tllld ,11kI' ~L'P,Hd' tiull ,1Ild rl'lllll\'dl 1I1 till' illtr,lIlL'lIrdl pdrt Iii till' l'L'lltr,ll rL'tilldl drll'r\, " Ihn'l' l'd"'('''' \\'l'n' rL'pllrkd b\' Dr, \\'lIltn ,llld till' tllllll\\'ill,l.', lllllllllL'llh Illdd(" "Thl' ~urpri..,illg Ub"'lT\'dtilill ut bllllld ..,upplv ..,ulll· cil'llt tIl ,111(1\\' tllr l'lllltiIlUllll'" bllllld 111I\\' III till' retin,l ,1fkr rl'lllu\'<ll ul till' illtrdlll'ur,d pdrt 1I1 till' centr,ll rL'till,ll drtl'n' h,l'" 1I1lk bl'l'll IllddL' ill Cd"'l'''' llf llptiC Ill'r\'l' gliollld'" tll till' bl'~t Iii IllV "Illlwl· l'dge, In ,1dditioll to thl' pn''''l'llt l',I"'l'''', Dr, 11Ihil \\' Hender~on 01 thi~ E\,l' [)l'p,HtlllL'nt hd~ ob..,l'n'l'd the ~allll' phl'nollll'non in ,1 bov \\'hll undl'rwl'nt ~urger\' eiL'\'en \'eoH~ ,1go for a right lIptic nl'r\'l' ,glioma b\' frontal n,lniotolll\', I \\'<l~ tuld abllut d , fourth ca~e of thi~ "ind bv an l'\'l' ..,urgeon will> also ob~en'ed pl'r~i~ting retinal biliod tlllW atilT rl" moval of ,ln optic nervl' gliollla, Thi~ ~urgeon prl" sented the ca~e at a local llleeting, but Ill' IUlInd such sincere doubt and di~belid dbout thL' pll..,..,i· bilitv of such an occurrencl' among hi~ colle,lgul'''' that he became doubtful ,lbout hi~ own ob~l'n',l' tiLms until he saw mv iirst publication on the ..,ub· Ject (/' Pedioll', UpilthollllOl, 1ll:1-l2, lYi~)" The next thing Dr, O'Connor did \\'a~ tIl ha\'l' further serial ~ection~ cut ,KWS~ the ~pl'cinlL'n, He added the pathologi~t as a coauthor to the paper, and included these picture~ in the p,lpl'r (~l'l' Fig 6), He also ~ent a televi~ion cas~l'tte t,lpl' lllade ,lt the time of surgery, which ~howed unequi\'ocalk that the optic nerve hold indeed bl'en rl'IllL1\'l'd and resected flush behind the globe, That tape is being returned to Dr, O'Connor and can be rl'viewed with him by anvone intl're~ted in pur~uing thi~ further. The manusnipt wa~ then reviewed bv ,1notllL'r "heavy hitter," ;\ notable ~ugge~tion b\' th,lt ed· itor was that the author ~hould ofll'r ,1 con!L'eturl' as to why thi.., phantolll tUlllor i~ prl'~ent: "Is II ~carring or fluid along thl' pl'L'\'il'u~ tr,let of the optic nerve) Werl' CT nUlllber~ obt,lined III thi~ 'ma~s' and cllmpared to the normal nl'n'l' ,1nd to till' ,1tknuation of the abnormal nerve prior to re~ l'dion) Did the 'mass' enhance with contrast? Wh,lt i.., the litlL'ar den~ity along the lateral aspect 1I1 till' phantom ma~s) Does the author know of dn\, pll~tnll>rtem ~tudies of an orbit in which an lIptic nervl' ha~ been resected? What have those gf()"'~ dnatomic,ll ..,tudie~ shuwn)" Dr, l YConnur fllund that the phantom nerve \\',1'" \'I..,ibll' bv (01'01/01 reformatted views in his (,1"'l', d'" wl'II' a~ un the axial CT scan, and ob\' illu..,l\, Wl' ..,imply du not have at this time an expl, l n,l til In f( 'I' thl' phl'nomenon, Dr. O'Connor applil'd much p,ltil'nce, lung suffering, and humility \\'Ith thi.., paper Hl' ..,ent pertinent references, madl' till' l'xtra "'l'dion.., showing an artery consistl'nt with d centr,11 arll'n' in the nerve specimen clu~l' tu the globe, and ...upplied the television tape 1I1 the nerH' being rL'moved right at the posterior ..,cleral ring, I belil'H' that. although many readers will nut agrl'e \\'ith hi.., report and many others will wact \ioll'ntk tu till' whull' pwposition, there is an eiL'mL'nt llf truth hL're which cannot be negiL'ctl'd, l'\'l'n II II I'" hard to ..;wallow, I hope that the article and thl'" L'dltllrIal \\'ill "'pur others to report ."imilar ca5e~-llnl' \vay or the other. I hope that ."oml'llllt:' \\'111 ma"e good CT and magnetic rl'."onanCl' ."can..; III a pl)5tmL1rtem orbital specimen, then re5ect the orbital l)ptiC nerve en toto, and tllL'n repeat the CT and magnetic resonance ."can.", and 'lee \\'hat that 5hL1w5, That ma\' not be the final an5wer. ho\\'e\'ef, becau5e what happens with a nllrmal optic nene and \\'hat happens in a patient \\'ith a long-5tanding optic nerve glioma ma\' \\'ell be entire'" different. The point is extreme'" important. ho\\'e\'er, and that is why it is being ~)ubli~hed, Dr, (YCL1lltwr's CL1mment ~bout the \dlOlt' lll,llter i5 that 5lmw L1f what he says lllU5t be !,l"en lln laith, \\'e 5hl)uld remember that it i5 po.,,5ibll' tll ht'M ,1Ild nl)t understand, and to ~t'e but not percei\'e, Since faith is the substance of thing~ hl'pt'd for and tll[' [','ide/I(t' (It Ihil/,\S /101 seC/I, Dr. O'COnllL1r'S ."uggestiL1n appears to 'be a good W,1\' to 5tMt ill\'estig,lting this interesting and puz/ ling clinic,ll lll\'sten', Let us pmceed to establish the lin,ll e\',lluatiL1n of the matter by further study, J. Lawton Smith, M.D. |
