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

Sarcoid optic disc edema and optociliary shunts.

We report the case of a patient with sarcoid granulomatous optic disc edema with optociliary shunts, normal visual acuity, and negative orbit computed tomographic studies. A literature review disclosed four cases of optociliary veins associated with sarcoid optic neuropathy, all the patients having very poor vision. Optociliary shunts may not carry a poor visual prognosis in optic nerve sarcoidosis.

Sarcoid Optic Disc Edema and Optociliary Shunts Ahmad M. Mansour, 1\t.11. \\'e repI)rt the l.be 1)1.1 p.ltient Inth ~.lI'n,id gr.1I111Il'm.l­tL) 1I5 I)ptil dl5l edeIn.l with l)pt')lilIoll'v ~hllnts, nlll'lll.11 \'i5ual aluitv, and neg"ti\'l' l)rblt ll)lllpUll'd tl)lll11gl\lphil 5tudie5, .\ IIter.lture re\'il'\\' di5lll)5ed tt)UI' l.151'5 1)1 llptll­lilian' \'l'in5 a5511li.1lt?d \\'ith 5Mll)ld llptil neun)p.1tlw, all the patient5 h,wing \'en' plll1r \'ision, OptlllilIoll'v shunt5 mal' nllt larrv a poor \'islial prognl1sis in l1ptil nervl' 5arcI'ido5i5, From the Department of Ophthalmologv, Montdiore Ml'd­icaI Center-Albert Einstein College of Medicilll', Bronx, New York, Address correspondence and reprint requesh to Dr, A, Mansour, 502 E, Melbourne Ave" Silver Spring, MD 2(11)111, U.S.A. 47 Optociliary shunts constitute collateral channels draining blood from the central retinal vein or one of its maJor branches. They are commonly en­countered in venous occlusive diseases or com­pressive lesions of the optic nerve, The case of a patient having optic nerve head edema, optocil­iary shunts, and systemic sarcoidosis is described, CASE REPORT The patient was a 26-vear-old black woman ad­mitted for evaluation of bilateral optic nerve head edema, Two months previouslv, she had the pri­mary manifestations of systemic sarcoidosis with , , arthralgias, uveitis, and cutaneous lesions. A skin biopsy revealed noncaseating granulomas \\ :th negative acid-fast bacillus stain. She was placed on a regimen of systemic and topical corticosteroids. One month later, she started to complain of a gen­eralized throbbing headache with intermittent epi­sodes of visual obscuration, A slight elevation of the optic nerve head was noted on the right side. A computed tomographic (CT) scan of the brain was normal. Disc elevation increased in the right eye and became apparent in the left e~'e 2 weeks prior to the current admission. A CT scan of the orbits was done and was normal. The physical examination l.ln 'ldmission was normal, including a complete neurological assess­ment. The eye examination revealed vision of 20/20 OU, normal intraocular pressures, full mo­tility, and absence of proptosis or afferent pupil­lary defect. The slit-lamp examination showed quiet anterior and posteril'r segments, There was moderate edema of the right optic nerve head and minimal elevation of the left optic disc. Prominent optociliary shunts were noted in the right eye (Fig, 1). No vascular congestion or sheathing could be dt'tected. The Goldmann visual fields were within normal limits. A lumbar puncture revealed an opening pressure of 185 mm H~O and a clear cere­brospinal fluid with a protein level of 35 mg/dl, glucose level of 44 mg/dl (serum glucose level 83 :\ tv! tv!I\N~(JLJI\ FIG. 1. Top: Right fundus shows moderate optiC nerve elevation, with multiple abnormal vessels uniting the major branch veins to the peripapillary choroidal venous system, Bottom: Left fundus dem­onstrates minimal elevation of Ihe nasal Side of the opllc disc mgdlJ, 4 IVlllphuC\,tl's, l1l'gdtl\'l' \'DRl, ,1Ild lH'gd­tivl' culturl's, Thl' p.1til'nt's hl',ld,lCI1l' dl'Cn\lSl'd following lhl' IUlllbM punLlurl', i\ rl'pl\lt IUlllb,lr puncture h,ld ,1 norlll,ll upl'ning prl'SSUrl', Hluod sludil's, including lin'r dnd tl1\'!"llid lunc­liun tl'sts, Wl'rl' within till' Ih ll'1ll ,1 I r,mgl', :\ rq'l\lt high-rt'sl,lulion CT SC,lIl of 111l' llrbih ,1Ild br,lin wilh cllnlr,ls1 n1l'diulll ,1dlllinlslr,ltilln 1,1ill'd III dis­dUSl' ,111\' ,1rll'rill\'l'nOUs ,lnllllldh', Flulln'Scl'in ,1n­giugr, lplw dl'lllonslr,l!t'd Il',lklgl' in lhl' \l'lhIUs ph,lSl' frlllll the oplic l1l'n'l' 1lL',ld c,lpill,lril's in b\lth l'\'l'S (Fig, 2), Multiple oplociliMv shunts filled \~'ilh dn' 1,11l' in the artl'riovenuus phase, Ihl" di,lj,.;nllsis uf sarcoid uplic nerve he,ad l'dl'lll,l WdS l'sl,lblished bv L'xclusion of papIlI­l'dl'llld, p,lpillilis, pseudolumor cerebri, retro­bulbdr Il'SIOIlS, ,1nd arteriovenous maltormatlOns, I Ill' p,llil'nt W,lS discharged Ull a regimen of sys­kill ic CI Ir! icostl'roid t Ill'r,l pv, She reported no ch,lngl' in Cllllic,ll st.1ll' b\' ll'lephone, but there \\'dS no tollow-up l':-.aminatiun, DISCUSSION '-,Mlllidl)sis is d s\'sll'mic granulom,ltous disease 1>1 UIlKnll\\'n l'lillll;g\ lhat affects \'uung adults, I Ill' h'mph,ltlc, pulm'lln'lf\', ucular, and cutaneous ,,\'''tl';'''' Ml' till' prilll.1n' tMgets, Ocular involve­nlL'nt i" dl'll'Cll'd In 1:;', and uptic nerve involve­111l'nt in I', of p.1til'nts \\'ith s\,.,tl'mic sarcoidosis (1), TIll' cl'nlr,ll lll'nllU<' S\'sll'm i., invlllved in 5';; ot p,ltil'nl-. \\ith till' s\'''ll'mic disL'.1<;e, and the llptic nl'rn' IS till' "l'CI ,nd C\lmmune"t cranial ner,e in\,\lkl'd ,1lkr the 1,1(1.11 nern' (2) Thl' \MI\IU" lll,lnlk"t.1tiun .. ui llptiC nen'e sar­cuidu.. i" include papilledema, p,lpillitis, optic nl'n'l' tumur, and llptic atrl1ph\' (Llblt:'s I and 2) (I-IH), l\lpilltodl'm'l i" seclmdar\' tll central l1l'n'uu" s\"ll'm S,lfCllldI1si .. in the illrm \If diffuse \1f 111cali/l'd granu]um,ltl1lb iniiltratilln lli the brain \1f nll'nill,~t's (2, 1ll,1:-1. Gr,lnu!tlm,ltlluS llptiC neu­rup, lth\' i" Ch,lf,lckri/t'd h' atterent pupillary de­tech, MCU,ltt' and \MillU" nern' tiber bundle de­It'ct", ,1nd gt'l1l'r,lli/ed tield cllnslrictilln, \'isual ,1cuit\ \ Mit'" trlllll 211211 (:;,11,1:;1 tll n\l light per­C\ Ttil1n 14,.'-',I.J,l;,lhl, In gr,lnul\1mat\1us optic l1l'U rll~',l t11\', the l1pt IC nt'rn' ,,\\'elli n~ ca n be min­im, ll (Il'lt \'\'t' in till' pre"ent C,lSt' rt'p\lrt) or se\'ere \\'ith a c,lulitI11\\er cllnligur.1tilln (:-,11,12,13,15), Tht' ek\,ltil1n Ill,)\' bl' ,1\',lScltlar, resembling large drust'n, ,11' \,)>;Cld.H (12,13). mimicking a capillarv IWIll,lIlgiI1m,1 \It the L1ptic nen'e head (8), Optic IWI'\\' IW,ld ~r,lIlull11ll,)" ,He tliten differentiated Irl11ll tUlllllrs b\' tlwil' \\',l\.ing and waning (5), their tn'qu\'nt bd,llt'r,)IIl\', their c\lmplete and rapid re­gl'l ·.... Il1n with slt'rt1id t1ll'r,lpV (8,15). and their as­~ tlci,ltt'd fundus ,1Ild ~vstl'lllic stigmata of sarcoid­11si~, Cr,1111d\1m,)s C,lIl il1\'lll\'e the retrobulbar por­titln l1i till' \1ptic 1ll'1'\'\', mimicking optic nerve ~liL1m,l (:i,tJ,lhl. rill' end .;tage of severe and recur­rl'nt s.HCL1id nl'uwp,lth\' i.; llptiC atrophy, l)ptl1cili.H\' \'l'in.; .He dilated collaterals con­Iwcting tilt' central retinal vein or its branches to the pl'rip,lpill.Hv chL1f\lidal venous system that dr,lins inll1 the \'llrte:-. vein.;, They appear as single llr multipk tortuous vessels carrying venous l WrOl'/I/,\/,:,)'>lIl1,\' IS FIG. 2. Top: Early arteriovenous phase of fluorescein angiography of the right fundus showing early filling of the optociliary veins. Early filling of the shunts de­notes absence of a primary venous occlusive disease Center and Bottom: There is late staining of both optic discs. Late disc staining should be tested In the fellow eyes of patients with granulomatous OptiC neuropathy to rule out early granulomatous infiltra­tion that is not evident by conventional funduscopy and clinical assessment. TABLE 1. Optic nerve head in sarcoidosis Papilledema Hydrocephalus (10) Brain masses,CNS glioma (17) Meningeal infiltration (2) Papillitis Uveitis (14) Granulomatous papillitis (15) Retrobulbar neuritis (18) Vascular mass Capillary hemangioma' (8) NeovascularlZatlon (13) Optocillary shunts (3) OptiC nerve mass OptiC nerve glioma (916) OptiC nerve drusen Central retinal vein occlusIOn (16) Atrophy All above causes Orbital-optic nerve sheath meningioma (15) Intracanallcular (9) Intracranial (17) bluod. Small uptuciliarv shunts are mistaken fur new vessel furmation at the disc, while large shunts are confused with congenital venous loops (Table 3). Optociliarv shunts are thought to arise ful­luwing an impedance in the outflow drainage of the central retinal vein. Tht' shunts are encoun­tered most commonly in central and hemicentral retinal vein ucclusions, as wt'll as in uptic nen'e sheath nwningiumas (Table -!) (llJ-3:;). Chronic papilledema (2/1), pseudutunwr ct'febri (21), \'as­cular malformatil1ns uf the orbit (211), drusen (2-!) and arachnuid Cysts (22) of the uptic nerve, sphenu-urbital Illeningiulllas (27), and l)ptic gliomas (3:;) are uccasiun,111v assuciated with L)ptU­ciliary shunts. Optociliarv shunts carrv a pUL)r \'i­sual prognustic sign in l1ptiC nerve sheath Illenin­giulllas, as the\' .1ppear \\'ith the unst't uf uptic at­roplw (30,3b). The \'isual prognl1sis in ct'ntral rdinal \'ein ucclusiun St'L'IllS bdter with the occur­rL'nCt' uf tlw shunts Crable :;) (ILJ). Few in\'t'stig.lturs h.Wt' obst'n't'd the e\'0Iutil1n uf uptuciliar\' shunts. Perlmutter ,md CO-\\'L)rkers (21) nuted ., marked decrt'ase in the caliber uf the shunts after uptic nerve decL11llpressiun in t\\'L) pa­tients with pseudutumor cerebri. In1t's ,1nd CL)­workers (3b) fl111l1\ved ., pa tien t wi th nptic nerve sheath nwningiull1,' IL1l' ., period uf 8 vears and noted the ,'ppt'ar,mce nf the shunts to parallel the unst'l of uptic .,trophv. Additinnal shunts ap­peared and then in\'oluted as the uptic disc be­C, lll1e cumpkklv atrophic. There ,UL' twu repnrkd cases nf sarcoid optic nl'urupathv .,ssociated with uptuciliary shunts (:\37), and in twu "dditiunal cases the shunts were ,lpparent in tlw fundus picturt's, yet no mention of TABLE 2. Survey of ocular findings In sarcoid granufomatous optic neuropathy Age (yr) Sex Bearlisley t!t al (1 !OJ 23 M 16 M 24 F 33 M Lustgarten et al (16) 32 F Krotwl et 31 (3) 24 F Gass emd Olson (41 41 M lalles and Schele (5) 25 F Turner et al (6) 29 F Ingestad and Stlgmar (71 26 M Noble (8) 36 M Statton et al (9) 37 F Brownstein and Jannotta (10) 17 M Jampol et al (11) 29 F Kelley and Green (12) 46 M Goldberg and Newell (13) 23 24 M ---'-- Race B w B W B B B B B Visual Visual acuity Eye acuity at last Response to Fluorescein Involved at presentalion visit sterOids" angiographyO 00 20200 20,20 OS HM NLP OS 2020 2015 OU 2025 2025 OS 2030 NLP OS HM 6240 00 2020 2080 OS 2020 NLP OS 20 20 2020 00 2040 OS 2030 00 20200 2020 OS 20200 NLP OS 20 400 NLP OU OU 20 20 2020 N OS 00 M 00 2050 20 30 Beardsley et al (15) Lustgarten et at (16) Krohel el al (3) Gass and Olson (4) Latles and Schele (5) Turner et al (6) Ingestad and Stlgmar (7) Noble (8) Stalton el al (9) Brownstein and Jannolta (10) Jampol et al (11) Kelley and Green (12) Goldberg and Newell (13) Visual field defect N N Afferent pupillary defects Radiologic findings N N N CSF analysIs N N N Other frndlngs Perrpapillary detachment Peflpap,llary detachment Yellow ON mass CSF protein (90 mg dl) Initial CT scan negatIve. CT scan optiC glioma oplocrilary shunts ON biOpsy orbital approach Craniotomy CT enlarged ON. optocll,a ry sh unts Large ON mass Autopsy done ON mass waxes and wanes Marked constrrctlon of fields Marked constflct,on 01 frelds ON mass growing (12 D height). optocillary shunts. CSF. 9 mononuclear cells FA capillary hemangioma complete regression on sterOids OptiC foramen enlargementON glioma' orbital approach for ON biOpsy ON as the frrst sign of sarCOidOSIS Autopsy done Doughnut elevation of ON. no late leakage. CSF. 7 lymphocytes. enlarged blind spot Golfball over ON With new blood vessels. autopsy done ON mass with mass of blood vessels ON mass With mass of blood vessels I • positive findings. N. normal lindlngs negative findings t t ON F no mentioned. HM. hand movement. NLP. no II'ght percep- Ion . opllc nerve. A. fluorescein angiography. - ., SystemiC sterOIds ,. Findings of OptiC diSC staining or leakage , Computed tomography of orbits or optiC foramen radiography 5/ TABLE 3, Olflerential diagnOSIS 01 vascular abnormality at the dlSc-lH,j<J Optocillary vell1 Cillooptlc vein CII,oretlnal artery OptocilliHyartery Venous loop Arterial loop New vessel fOI nut'(1n Telanglectaslil Arteriovenous andstomoses 1'.1111·l1h 111 hd\'ll1g 211 211 \'iSI(lI1, 1111 grll".... l'\'idcl1cl' (If llplll' 111'1'\'1' c'lll.ngl'Illl'111 b\' {\\'(I orbita! C-' "tlldil''', .tb"I'I1\1' lit ll'lltr,d rdillal VI,ill (ICllu .... illll. ,lIhi 11111d rklt I'\V) t(l 1ll1,dl'r.tk (right c'H') llptic 1lL'1'\'I' hl'.ld c'k\'.ttillil It i.... l(lIlCluckd thdt ('f,t,,­l ili.ln ~hlll1h IlldV l111l (drr\' .1 f' ('lIr \'I"lI.l1 l'J'(lg­1111.... i~ III grdllllllll1l.ttllll .... lIpli( IWI'I'l' IW.ld .... 1\'l'lIlllg. REFERENCES TABLE 4, Causes 01 optoC/11arV shunts (OCS) Vascular Central retinal vein ocCJUSIOl1 63"0 have OCS VISion 05 22° 0 have OCS VISion 0 5 119) Heml,central velll oCCIUSI(Hl (unpubllsllPll datal Combined branch vein occlusion (unpubllslled datal Compressive ChroniC papilledema (26) ON Sheath me'lt'lgloma (28 - 3-11 Spheno-orbltal mentng,oma (27, ON glioma (351 ON arachnOid cysts (22) ON drusen ,2-11 Pseudotumor cerebrt 1211 Granulomatous optiC neuropathy (337) Orbital vascular mal ormatlons 120) C~ronlC glaucomatous optiC atrophv Conge'ltlal I"; (251 ON coloboma 1'11351 Sturge-Weber I~I 123! (' old central retinal ve,n occlusion I I,lllll"", I). \ I ~~'\ "'" ,llll.l 1.11\i.:,I,,\ :\ ~)t ul.lr '-..Hl.lIid- (1 .... 1.... 1.'ill{"'> j '!li;l.i!,iI}!!I'! >,', II} 4h: 11~ ) ~\} JlCh I )\,Idr'll.'\' I' ~('L1r(d()I~11 Illtll'lljt'''-l,lllil)h irl '''dr, Illdl)'",]''' I/I!I'I,/' \11',1 'f7' \:,/1 -.\~7, IIJ~:- "",,1,,'1 (, 1\ (h,,,I," II ,II'" "Tlltlh I, " (,r,lTlul"m,l-ti'll .... I)~~tll lh'llr\')),lt!1\ \,. l qq: JII=1', JII::'::' ['1 .... 1 \,<1" ..... I [) \1 cilld lllc.,(,)) \.. "'drliliL1II .... I" \\lth (I~~tl(. 111.'1\\' dnd ft.'lillcll 111\\II\'I..'llll'nl :\/(;') t '.'li,'!.i;,llnil';' 4-t· q~.; 1..);11, Iq-:-h 1.111"', ,.\ .\1 ,Ind ",h"IV, Ii I, I ,,,Iull,,n ,'I l1lulll~'I.: .... ,11,.11 tllllllq .... III ....clr(IJld .'L,r,ltlUII.rnd ,J! tilt' I'r'tll. dl-"'~ \/Ii i l '.!'J::I:,Ii!l!lI! 7-1: hii (lh 1'1-2 /l lllrnl'r.!{ (. 1.11111_"'" I) " l,t.-d '\l'lInl-{lphthclln11( "c1r~ lIl[d""I" 1-:, i {J;d;l!:,I':!!!"! 54: l....;--I....h~ lq-; - In.~l'''t.ld h: ,ltlli L.,tl~l1l.lt· L ~,Jrlllhj'I-...I" \\lfl1 l'llll.H .lnd In F'llth,d.H11Jl f.... lIl11t~H\ m.lnllt'-...LI:lllll-'" i. f,; ( ';li:ri;,;!"il'; -lq: I III I'CI S :-':,'1'''' "' l, I ),"I,1f ',I1""d,,,,, ""Urrtl1:~ ,1' ,I unil,)(,-r,11 p~""lli. dl"~ \.'''1 ul.lI 1"""'1111) '\"1 1 I,;.:::fl,;/!I; •. j 87, -4~jl -lll."1 lq-q LJ ~tcltt\11l "I)ll,dl. .lrId I L)rn.L:.JrI L.,.lrl',lIdl"-J" lIt tht' tl~... tll I1l'l\l' \' l'!·,:!i:./!II::',.' 7"1: ,,~-+ '-1"10 14 N III I~rll\\ n .... lt·11l L., ,1Ih.J I.Hll1iltt.l f- L., .....cH"I'l,,1 L,LIIlUll1rllcl III till.' tlf... tll lh'I\\..' .Ind rdlll,1 1'\..'~"'\lrt .. 1 ,I I. cl"l· l ,,"~ t l:,i: :!;';!'II,.I \.): ~-~ ~~\I Iq~..J ,m'! .\hL",lJ1 1\ ~l~'lh .1 I.,bl' \., i· I )::;:!:!.i!"i,'! 87· II 1,'l11i',,1 .\1 \\""dI1l1 1\ Ilt'I\ I' .....If, \lhi,I''''I'', R"~'I,'rf ,It ~;; "1/"1(1, Il/~~ t'" ~1·llt,\ I L., ,llld (,r\'l'1l \\ 1\ L.,.H,:,I) ...h1:--1 .... In\l.lh\n~ tht' \)~~th. th'r\l' hl',hl -\,~ll: ()!{,!ii '/');'i" 8\l: ..J~h--4"',I...,_ lLj:-~ j-; ';\ddI.1 t.'T",'<..'" "-l ,In,,l '.:\.'\\l'll \\ :--,lfuJl"l,hj'--. \\lth rl'tlncll 11l\'\lh'l'llll'111 I', l 3]: '-4.~_~jl"', l~q--l- 1..J Ih\I\\'!'l~, cllhi ~hlt'lli" -\ TUJll\lr" \d th\.· \l~'tl( nl.'r\'l' Ill',ld l,/,r'!l;diJli\'r' 2'-l: ~\q-2h-.i 1"IS; I; 1~1',H"i"ll'\ Hr\l\\ n ..., \\ I d ,II 111..'\ t'n "d"l'" lit .... ,lr",'I,l\I"I .... lIt till' \'f~tl, 11,'1\\' '\'" ():',':t},""".":,I,' 4-;' t)~ --- Iq,,,,~ !" lll .... l~,lltl'n, I L., \llIhlt'l. I ~ l't ,\I ..\llllIHI"U.ll ~"'rt'''''''''Ilt.I· thlll pi 1"lll.ltl·\{ tl~)th' Ill'I\t.' ....,Hlllh.lthl .... I l';:'1 \·dr.',' ,,/'l;. U"d!~II,'! 3: I, I."', Iqt'~ 1- L.,I.I\ Ill, \1 I ,llhf \..,1.1 .... 1..'1 I L., I.. )~~tll. 11"'t1II'f'l,ltIH' .1111.i \..-t·~ I't'l'lcll .... ,Ir~ Pldtl .... I" I l ;';1: .\t !i1"-\'I'f:th,lI"rl'! 3: 2:;l.J ~h~ Iq~~ IS "",f, ,'\ "vl,,,t'ull',H "i'lI< 1ll'1I1"1,,'II1\ In ")J(",d,,,,, \1/11 (If'i::J:.;fnl!·f 12: ~l..jtJ ~q..J I~ISII TABLE 5, OilferentiatlOn 01 the two major causes of optocillary shunts thl'lr prt'~t'Il(l' I\,l~ Illltl'd b\' till' ,Hithlll'~ (7, !h) Tht' \!Sual ,1CUltlt'~ Il1 the,:-c' Illur patlc'llh (I'll\.' bilat­eral alld Ihrt'c' uIlILltl'ral; \artni Inltll 1l(1 iI~ht f'c'r­( t:ptl\lll 1\1 halld m\ltl\lll '! 1\'(1 had ,] d(ll'Utllvllkd qlJ~lldt: \II "'uddc'll I'I~~ 01 \"""1111 Ir\lm llldLl"I\lll \It the (t'lltral rl'tillcll \c'lll (Ih,]')) ! hn'l' f'.JtII'l1h 11cld IlptlC nt:rn' thl(KVlllng b\ r.ldll'gr.lpllll ~tLlliJl'~ ,ll1d tht' luurth had !2-dll'ptL-r l'!n,ltl(ln (I' thl' ll~'tl" nen't' ht'ad. Our p.ltll·1l1 ddlvr~ In11ll thl'''I' 1"L1r ONS, OptiC nerve sheath ~-I ,j~·l I"~I ~(I "-pll."lt .... l " IlIl1l 1\\ .\1 .Ind hlhlhl1ll. I l \·!"u,JlIt.l" .... ,llhl ~'~'l'l\ltltl' \,1",1I1.1I 1ll.llllJflll.llll.llb In thl' l'\t' ~ln...-t l)rbll \/11 I l'f1htJ1,linli.i H2: 2,:- 2''''. \1..1:-,,'1 21 1"'rI,,",II,'1 I c "-IIIll.;"'" Il\'l ,>I 111"'~'f','"nn>.; "~'­f~' l IIl.lI"\ "hlllli \ 1·".... 1.,1 .... ,llld p"'l'udl\llIlllllf l.-t'll'bfl ,'\!If ('I'!:/!t.I!!!Il!f H4: -()1- ~(C, Iq~ll .\1,11 .. , ,'-. " ,,\lei (,,,','n, 1\ t\ ,'r,,,·hn,,,d (\',h ,,1\'\)1\'111>'; ,) f)!lrllllll l\1 tilt' 1I1tLll)rht.)1 \l~.."tl.· 1"h'I"\'I,' \'-11; t l/ l hthl/!II()! 4.1: 11171121 1"7'; 2, /,1'\'1 ( 1\ (1'''''"11"k,,,, L:\ ,1Ild ill"I''''r, D 'II Bilateral Papilledema course Fundus appearance F1uorescetn angiography (filling) PrognosIs Vein occlUSion Rare Mild-severe resolved Thunderstorm Early-late artertovenous Very rare Mild OptiC atrophy Pertpap,llary s\rtatlons Ea,ly arter lovenous Poor III ~ 11.... ~.1" l, ,llld l "llldrh .\ l\"tlild 111.lIUL\1 l'dt'IlL\ ~,ltUr.'lII.lIUr"l' lit Ihlll,1}"'h,1~11.· ..... jjlj· ~ )11/:!I:';/'III'! 28 (";'t1P~'Ill ;\ M, MANSOUR Cilip-pplh: \'l"11l d ........"'·I.lh..d \\'llh ph.lktllllolltl .... l .... ('/IIIt/wl· 1II"/".'\lI 117: 110 111>, )'ISO 24 ",n'" , 1 l )1",<1"\"-1, I 01",1 1\,1",,1-... , 1',,1 1111""''''''11' .. ng" llgr.lpln· III l'lrnll.,ftn\' dl .... lllrb.lI11l"·., 111 drll .... t·1l til lilt' (Iplll dl ....' ()/lltlllil/l111/1\'1l(/ In.J: ·1·JlI ·ih~. Iq7~ 2~ Ih.llllll' lin 1!l',I,..g IIII' ",'nnln", "pl,I-.'H 11',11','1' l ,1'1"""". "'"III''IIoII,!,1 I ,lll.'mh"ili. 41: ~7'1 ~,~I'i, I'llI' ~Il ~,'Ildl'l"'" ~I I) :\ ,1.' .......11" ,Illtlll {)l p.lpllh·dl'lll.l btl ....l·d tlll.l tilltln.· ... " .. lll .lllhh)~I"I)llll ....Iud\· til Ill' l ...... • .... 1"111',. {'/,II 111.,11111 1/ >1'1 1I}" NlJ: 1:-; IQ2. 111hlJ . t,,,dl',g,"''', 1\1 1\1, Co,I\'II''', I' I , .. nd '>, h"'/, N I ~phl·lhl·lll·blt.lI 1l11'lllllgl1111ld \\'Ith (I~)tth dJ.lr\' \·('111 .... :\111 I I )/,IJlh"I'I/"/ 81: I>hh h711, I'Ch. 2S SIIl'lh. I I \'lIb,lIl1l\'Il,1\1 1\1, Y.""", I! tvl., ,11,01 I!lt'n' I.Ing. l l. C. R.,dl.ltinn Iht'rllpy Inr pnlll.lr\' "pill Ill'n',' 1111.:11­"' glllllh". I. l'/III ,\','11/" ,,!,hl/ItI!III"!. I: X~ "1'1, I'IXI 2'1 H"",I1I'II', :v.:. \' , Colll,lh, I I , "I.1i 1·11I"'-"""'1I1 ""g'''g' rdph\' til t)ptllldllH\' ....hun! \'1,,·...... 1,1 .... I (llIl, ,\','///11 ('I,IIt/IIt/II'II! I: '1-.111, IlJ,~ I 30 H"II"lIh,'r,I," \\', II' II,dll'lIh"r"l, I, \\'., "I' ,'lid .\1.,,· CHt\', C. S.. Vi,u,,1 pwgn,,"" "t "f'lic lIl'n'" "I1I',lIh Ill., 11 111 , giIHll,l .... prlh..iul'ing ..,hull( \·l· ........l'I .... on lhl' Pptll dhJ... ,\1.11/" ClIII. 1'.-",'. 53: S4-'!2, l'17X. 11. Wrighl, j, E., C"II, N, B, and Liariw', S, Primary oplic 11I'r\'l: nll'ningiom.:l, 131', I U/,hlh"/III"1. 64: 'i'i3-'i'iX, 1980, l' Alp.'r, M C. Man,lgl'nll'nl of primary oplic nl'rvl' menin· gll'Ill"". I (111/. Ne///"'''I,ltlhl/IIII"I, 1: ]()J-1l7, 19X1. 11 ) 1.'1'1, I'\' W II' Kurd." R M, el al. Bilatl'ral optic nern~ "h,'''lh nll'n,ngll'm,,' /\/'{I/, O/,hlhallll,J/. 98: 14Y-1Sl, 1980, 14 1,'111.", B I', "nd '>m,th,.1 L. Bliakral "plic nl'n'l' sheath nll'lI,ng'"I11,''' pH',,'nt,ng ,1" thl' chia,mal 'I'ndrome, In ,\",'/1'" ,,/,hlhl//I11"/"X'/ U"d"I,', .1. L. Smith, Ed. !,,1.:1SSlin Pub· I"h,"g ( " , :'\;.'l\ )'''1'1-., /'177, pp 177- PO, 1~ 11'll'g", L't'bl'r "pllct,·,ill,If" \'.'nl'n. A/I', /', emele" Arclt. / (1I,ItIII"III,,,1 55: 2~h. 2h4, IYD. 1h 1111"", I, f..:., '-"h,ll/, II f1"d, W. f, l't.:ll. E\'lliution of Ilplcl(J!I.)r\' \·l·ln .... 111 t1pllt. nt'r~'l' ... hl'ath nll'nlngloma. E\'olu· tll,n :\"h ('I,IIII/,illIl"/ 103: ~Y-hn, IYx~ 17 ",r~h"l11, I II ."'lll""'phlhalmlC pH''','nl,'l",n "I ,arcoid· ()",t..., I"l" I, '-lIlt \1,'d 66: lh7-]hY, lY7~ 11' II,,\·!. \\ ,mol Ilv""II,n, f) Fit .. (1'/lI"r / 11/1.111' III XCllro· /"'.',, [",,',1" ( .\l",b\·, '>t I."u", l'ihh, P 42 1'J In//ll', i\ l~, '>I"'rb, '> l~ and :Vl"rn', B. \V OptoCiliary \.'11" /,,,1/, :\111 ..\,,,.1 lll'hlh"IIII"/ l)t"/,II'I/I/X"/. 83: ~4J-~-1h )y77