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Show f. Clin. Neuro-ophthiJ/mol. 1: 9-30, 1981 Fluorescein Angiography of Optociliary Shunt Vessels NORMA V. BOSCHETTI, M.D., Ph.D. J. LAWTON SMITH, M.D. ROBERT H. OSHER, M.D. J. DONALD M. GASS, M.D. EDWARD W. D. NORTON, M.D. Abstract Progn'SSive loss of vision, optic disc pallor, and optociliary shunt vessels (the Hoyt-Spencer sign) constitute the c1inic.J1 tri.Jd of optic nerve shuth meningiom. Js. However, optociliuy shunt vessels may also follow central vein occlusions, and less commonly occur with a few other conditions. This report presents a comp.;1utive study of fluorescein angiograms performed on eight patients with optociliary shunt vessels. Four patients had optic nerve she..th meningiom. J.S, and four patients h..d central retinal vein occlusions. The following differences in the fluorescein ..ngiogr.Jms were noted in the two groups. In the optic nerve sheath meningiom.. group, the shunt vessels fill earlier (in the arteriovenous phase), the flow drains to central venous tributaries, ..nd the late staining is hyperfluorescent to other veins. However, in the central vein occlusion group, the shunts fill later (in the venous phase), show .. flow draining to the outer disc mugin, ..nd late staining is eufluorescent with other veins. Although optic nerve sheath meningiomas and old vein occlusions are usually rather easily differentiated by a complete examin..tion, the fluorescein angiographic pa"ems are not only pertinent with regards to the pathogenesis of optociliary vessels, but in certain cases may be clinically helpful in making an important clinical differentiation. Progressive loss of vision, disc pallor, and optociliary shunt vessels constitute the clinical triad of optic nerve sheath meningiomas.· Shunt vessels have also been described following central vein ocdusions/ and less commonly in a variety of other conditions.:l-7 This report compares the fluorescein angiographic pattern of optociliary vessels occurring with optic nerve sheath meningiomas with those following central retinal vein occlusions. From the Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine. Miami. Florida. March 1981 Case Reports CiJse 1 A 65-year-old woman was first seen on March 26, 1975, complaining of progressively decreasing vision in the left eye. Visual acuity was 20/15 in the right eye and 20/20 in the left eye. There was a 3+ Marcus Gunn pupil and 2 mm exophthalmos of the left eye. The fundus was nonnal in the right eye, but the left disc was diffusely swollen without hemorrhages (Fig. 1iJ). The differential diagnosis at that time was thought to be between ischemic optic neuropathy, optic nerve meningioma, or thyroid optic neuropathy. The patient was followed by her ophthalmologist but was referred back 4 years later due to further visual loss. Neuro-ophthalmologic examination on April 16, 1979, revealed a visual acuity of 20/15 in the right eye and 20/80 in the left eye. There was a 4+ Marcus Gunn pupil and 3 mm exophthalmos on the left. The right disc was nonnal, but the left disc now showed classic optociliary shunt vessels on its swollen surface (Fig. 1 b). Skull roentgenograms and optic canal views were within nonnallimits. A computerized tomographic (CT) scan (Fig. 2). however, showed diffuse enlargement of the orbital segment of the left optic nerve consistent with an optic nerve sheath meningioma. Fluorescein angiography done in 1975, before the diagnosis of the meningioma, showed many vessels on the disc 18 seconds after injection. One of these vessels (Figs. 3,1-3 cf) filled during the arteriovenous phase, remained fluorescent during the venous stage, and remained filled in the late stclges even when the veins were already empty. The subsequent follow-up study done August 24, 1979, showed three dclssic optociliary vessels at the 1, 4, and 6 o'dock positions (Figs. 4d-4d). These filled in the arteriovenous phclse (Fig. 4 b) and remained fluorescent in the late stages (Fig. 4 cf) of the angiogram. CiJse 2 A 59-year-old woman was seen on August 3, 1979, with a history of transient obscurations in 9 Fluorescein AngiogrJphy of OptociJidrY Shunt Vessel~ Figure J. (d) Left optic disc of case 1 in 1975. (bl Left optic disc of case 1 in 1979. Note the three classic optociliary vessels (arrows). Figure 2. CT S In "f CJSC I on 1070. NOlc diffusely enlarged left optic nerve (Jr",w); compJre with "Iothl ncrve. This is typical of optic nerve sheath meningiumd. 10 Joumal of Clinical Neuro-ophthalmology ri~uf'C .\.J. I [llllr...•..'nil .1Il~h)~r,IIH ,,1,,\,,' I III ItJ7~ .ur,'\\ tallll\~.ll I~ ""·"t1nJ ... lt~ .trtl'(alVl·lh'U~ rh.l~l'_ March 1981 11 12 Figure 3d. A rate photograph (93 seconds after injection) shows the small vessel continues to f1uorescc. Figure "". Fluorescein angiogram of case J in 1979. There is no filing of optocihary vessels in drterial phase, Hgure 4 b. UptociliJry vessels do fill in early arteriovenous phase on this disc (see Jrruw,,). Journal of Clinical Neuro-ophthalmology f i~ur~ -I Co I h ... ,"'~h'~l,lIU \V., .. t.1l...l·U II.) lJ ""', lind...11tC'r 1111l'\.!IPI1. I.Ilht·f 1'.lrI\, III \t·It··u .. ph.1--"· Iht' ~lphl~III.I"· "t·....,·I...HI' ("\Tn nh'ft' r.J .. ,lv ..("t·ll 'h.lll 111 rlJ.: -t/' Figu", 4d. AnglOgr~m t~ken III seconds ~ftt'r ,",ection (d late study). The "pte>cili~ ry vessels show even more fluorescence thdn the other veins (n"te dr""vsl. the right eye since 1974. At that time she was told that her right optic nerve was swollen and was treated with steroids. She did well during 1975 but in 1976 the episodes recurred. Periocular steroid injections produced only transient improvement of the right eye. A fluorescein angiogram done elsewhere on June 4, 1976, was reported to show mdny arteriovenous communications on the surfan' of the right disc. This had been interpreted dt thdl time to be inconsistent with the possibility of optic nerve sheath meningioma. However, in October 1977, ultrasonography suggested d solid lesion in the right optiC nerve. The visual acuity slowly dncl steadily dropped in her right eye from 20/20 in June 1976, 1020/200 by June 1978, and to no light perception by the fall of 1978. March 1981 On examindtion in August 1979, ViSUdl acuity was no light perception in the right eye dnd 20/15 in the left eye. There was lid puffiness dnd 3 mm proptosis on the right, and the right pupil was amaurotic. The right optic disc was pale and slightly swollen, and had several shunt vessels on its surface. A CT scan (August 22, 1979) showed enlargement of the right optic nerve consistent with optic nerve shedth meningioma (Figs. 50l and 5b). Fluorescein angiography showed the shunt vessels filling early in the arteriovenous phase and emptying centrally into the venous system. The shunts filled early (Figs. 6a and 6b) and remained hyperfluorescent in the late stages of the study (Figs. 6 c and 6 d). 13 Fluorescein Angiography of Optociliary Shunt Vessels Figure 5 d. T '" ~1n ~h"w~ cnlJ:r~cd nght uptll. nerve LVn)l)tcm \vlth optic nerve sheath meningioma. figure S b. Ca. e 2. <-T scan (coronal section) shows enlarged right optic nerve (arrow), compJre with left nerve. 14 Journal of Clinical Neuro-ophthalrnology March 1981 rl~un.· ~.). t hh~rl'''' ,'Ill .1U).:,I\I~r.lIH ~,' l ..... " 2 rhl' \lphl\llt.lrv vt,.· .....I·I.. JI' Ill'! 1111 III tht' .IIIt'fl ••1 ph.l"" Figure b b. In the .Jrt(·rH.lVt"n(\u~ phJse. the opto.:-a1IJr.... \'("..s('l~ arc re-lJdv !!ocrn IJrh)"~1 Figure be. LJh.-'r 10 V('f1l1U" ph" ..C'. Iht.. uptuciltJry llmnC'dhUl" ,u{' ,'V('11 I1lllr(' (Juort'~( nl 15 Fluorescein Al1l1iol\r~phy of Optocilidry Shunt Vessels figur~ 6d. Noll.' Ihr hypt'rfluorrs enc<' of the optoclhdry vessels very Idle in IhlS ,tudy-Jnd filling even more bril\htly IhJn the other vein. Hgur~ 7. CJse 3. Left .ide of photo shuws Ihe normJI flghl oplic disc. Righi. ide of this photo shows the choked left optic di!-c Case 3 A 29-yedr-old womdn was seen in 1978 complaining of transient obscurations of vision in the left eye for I year. In April 1978 the left disc had been noted to be swollen. A CT scan showed t6 enlargement of the left optic nerve. On examination June 13, 1978. visual acuity was 20/15 in the right eye and 20/20 in the left eye. The right disc was normal. and the left disc was choked. Ultrasound revealed questionable enlargement of the Journal of Clinical Neuro-ophthalmology left l'pti.: nerve. Because there was no afferent pupillary defect, the initial diagnosis was proba~lC' optic nerve sheath cyst. A sheath decompression was performed by Dr. Richard Tenzel on June 10. 1978. but no gushing of fluid occurred, the nerve appeared quite norm.ll, and biopsy of the she.lth revealed norm.,1 dur.l. Visual .Icuity postl'per.ltively W,IS 20/25. She returned on July o. IQ 7t\ because of furthN visual loss. Vision in the left eye then was 20/50 and thNe was progression of .1 field defect in the left eye. The discs are seen in Figure 7. Review of the complex motion basE' optic (.In.11 tomogr.lms reveitled an abnormality at the intracraniJI end of the left optic cdnal (Fig. 8) with slight hyperostosis, consistent with" meningioma. She underwent left frontal craniotomy by Dr. Yat s ~m August 10, 1978. A small tumor was found at the intr.lCranial E'nd of the left optic canal (Fig. 9). which histologicdlly was a psammomatous meningotheli. 11 meningioma (Fig. 10). A fluorescein dngiogram (June 14, 1978) showed the presence of a small vessel loop at the 3 o'clock position (Fig. II <1). This vessel filled in the arteri.lJ pha e (12 seconds) and was still bright 57 seconds Figurr 8. Case 3. Complex motion base view optic canal polylomog..phy <hows eJlciflCJtion at ,nl..e..n..1end of the tefl ednal (larger arrow) and also relallve hypero<tosis of left anleri", linoid (smaller arrow) as compared to the other side. figure 9. Case 3. ~mall meningioma at intracranial end of canal JI surgery. March 1981 17 FJuor{'scein Angiogr.lphy of Optocilidry Shunt Vessels after injection (Fig. II b). Some might have reservations about considering this vessel an optociliary vessel, but because of the early pictures in case 1 made 4 yetHs before definite optociliary vessels were seen, thl!' lime pattern of filling noted, and the histologic di.lgnosis of optic nerve sheath men ingiom, l in this patient, this case was included beCduse of its p,uticular interest. Case 4 This 61-year-old woman was seen in August 1979 for evaluation of a suspected central vein occlusion occurring in a blind eye. She had been first seen 10 years earlier with a history of transient obscurations of vision in the right eye for 7 months. Visual acuity in January 1969 was 20/50 in the 18 Figure 10. Histology of this leSion in case 3. Meningioma. ·~8ure J la. LJs<, J. Fluor<'scein angiogram shows a small vessel loop at J tl dock filling in Jrt<'riJI ph••<'. Journal of Clinical Neuro-ophthalmology Figur~]2. Case 4. Pale swollen optic disc in blind right eye. Note. small loop th.t IS difficult to see (arrow). Compa re with smaller arrow in Fig. 14 d. right eye and 20/15 in the left eye. The right optic disc was choked. Subsequent evaluation led to a diagnosis of right optic nerve sheath cyst. An anterolateral Kronlein orbitotomy was performed on January 31, 1969. A small incision was made through the sheath and a paste-like material came out. The papilledema cleared, but her acuity continued to decrease. By May 1972 she had no light perception in the right eye. She was followed yearly by her ophthalmologist, but in June 1979 he questioned whether a central retinal vein occlusion had occurred in her blind right eye. The right fundus showed a pale swollen disc (Fig. 12) and scattered small retinal hemorrhages all throughout March 1981 the posterior pole. A CT scan on August 22, 1979, showed enlargement of the right optic nerve (Fig. 13) compatible with the diagnosis of optic nerve sheath meningioma. On fluorescein dngiography (Figs. 14d-14c) an drteriovenous connection WdS seen at 10-11 o'clock. The vessel filled in the edrly arteriovenous stage and was hyperfluorescent in the venous stages when compared to other veins on the disc (Fig. 14 d). CaseS This 76-year-old woman was seen in the Bascom Palmer Institute on MdY 9, 1978, complaining of a 19 F1uore cein AngioKr,lphy of Optocili,lry Shunt Ves els {.'gure 1_". L T ..,.In (\\)r \nJI' VI('W) ... h..wv" ('nl"uf,('d n~hl llrtn o('r"\-r (.Hfll\'\" "1".....I,,'nt with ..'ph, nl'r\'\' ..h("Jtn n'll"J'ln>,IVmJ Figure 14 ... Fluorescein angiogrdm made August 15. 107". on Cdse~. I':ole dbsence of filling of vessel mMked with ",row Jnd ,-ompdre with IJter pictures sudden loss of vision in the left eye which occurred 6 weeks prior to examindtion. Visual acuity WdS 20/40 in the right eye and 8/200 in the left eye, and there WdS an dfferent pupillary defect in the left eye. Fluorescein angiography at thdt time showed dilated shunt vessels in the nerve head (Figs. I5d-ISe). The clinical diagnosis in this pdtient was central vein occlusion. In the initial stages of the fluorescein angiogram, the arterial system filled, but there was no evident fluorescence of the 20 shunts (Figs. Ish and ISc). However, once in the venous stage (Fig. 15 cf), the shunts filled at the same time as the veins. In the late venous stages (Fig. IS e), the shunts remained at the same intensity dS the veins (eufluorescent). Case 6 A 42-year-old woman came for a routine examination to the Bascom Palmer Institute in January Journal of Clinical Neuro-ophthalmology March 1981 ri~ur\~ 1.& It. \n"':h'~r.Hl1 1.,l...t·" ~I ·1 "'nt1lh.t ...lttl'f 1111l'lo.l1PI1 (1.111" MIl·fl ..11 ph.l"('l ... h~I\\" ".trl\" Idl..,~ ,II .\nt.'r\l,,'\'\·lh~U"\,~I\Il"\11 III (JrrtlwJ figure 14 d. Nol~ th.t ~ven .her • monute .nd • h.lf on 0 I.t~ phos~ ther~ is hyperfluorescenc~ of this vessel (lorger orrowlos campored to other v~in . C(>mp..~ the loop (sm.ller .rrow) with poorer visibility in Fig. 12 ond note hdl'fuln~ss of fluorescein study in this c.s~. 21 22 Figure ISb. Ang,ogrJffi ttlJ...('n 17 ~r(onds Jftr-r ,nlc~·t1('ln (JrtC'flJI pn.bC) 5h\.'w~ n...' tiling of th~s~ v~.. Is ("",wI. Figure ISc. Ar'eri"v~nous phdS~ (cdse 41: optocilidry vessels still do not fill. Journal of Clirtical Neuro-ophthalmology t-i~ur~ I=' J. ,'\t .l; ".·uJlhl... III \'4,'11\.1'10" phJ"~', th4,' ~lphl\.dIJrv 4,llfl.lter..ll.... Jrl,' n'.JJ.lv " ..' ..';1 1.1rr\.'\\ I Figur~ IS ... Not" that 100 seconds after injection (in a very lale stage). the optodliary veins stain to tho same degroe as other disc veins (eufluorescent). 1978. Visual acuity was 20/20 slowly in her right eye and 20/20 in the left eye. The right fundus showed vessel abnonnalities in the disc compatible with an old central retinal vein occlusion. A large loop was seen on the disc surface at the 9-10 o'clock position (Fig. 16). During fluorescein angiography, the arterial system filled first (Figs. 17a-17 c). There was no evidence of perfusion of this large loop until the venous stage (Fig. 17d). There was also a smaller tortuous loop (1-3 o'clock), which filled at the late arteriovenous stage (Fig. 17c). It remained filled during the venous stage but its fluorescence was of the same intensity as the veins (Fig. 17d). March 1981 Case 7 A 53-year-old man was seen in July 1977 complaining of decreased vision in the left eye for 4 months. Visual acuity was 20/20 in the right eye and 20/200 in the left eye. The left disc (Fig. 18) h.ld prominent vessels over its surface. The temporal half of the disc had fine vessels and the nasal side had large venous collaterals. The inferior fundus showed many hemorrhages consistent with a vein occlusion. The shunt vessels on the disc were tortuous and were located mainly near the disc margin. These vessels did not fill until the venous stage (Figs. 19a and 19b). At the venous stage (Fig. 23 Fluores ein Angiogrdphy of Oplociliuy Shunt Vessels Hgur~ 17 b. This I""p does not fill in dn~riovenous phds~. 24 Journal of Clinical Neuro-ophthalmology Figure 17 d. This loop is readily se('n in lale venous phdse and f1uor('sces 10 same degree dS Ihe other veins (eufluOrescenl). Figure 18. CdSe 7. Vessel loops on disc after centrdl vein occlusion. Note chdnges primdfily involved lower venous branch. March 1981 19 b) the shunt remains as fluorescent as the veins (eufl uorescent). Case 8 A 53-year-old man had the sudden onset of blurred vision in the left eye in 1954. A branch vein occlusion was diagnosed at that time. He then did well until July 1971, when he noted painless blurring of vision in the same eye. Examination in the Bascom Palmer Institute revealed a central vein occlusion in the left eye. Visual acuity was 20/20 in the right eye and 20/200 in the left eye. The left disc showed marked neovascul.HiZcltion and the veins were dilated and tortuous. In October 1971 optociliary shunt vessels were present (Fig. 20). Fluorescein angiography in April 1972 showed no evident fluorescence of these shunts in the early stages of the study (Figs. 21 a and 21 b). The shunts filled at the venous stage (Figs. 21 c and 21 d) and 25 Fluorescein Angiography of Oplociliary Shunt Vessels Figur~ 19b, Arr\.'lW ...h(l\v!' Ihr l\ph."'I~111.11'"\' l'\..,11Jhn.lI kl~'r dlll~~ till ,n l.He \'t'nl'U~ ph.l'-';C' In.d L cuftu\'")r{'~((l'nl wIth lhe \,Itheor dl~\' v('ln~ Figure 20. l'Jse 8. OplllCiliJry shunt vessels after central vein occlusion. 26 Journal of Clinical Neuro-ophthalmology March 1981 Figure 21 b. Even In early venous phase these vessels do not fill Figure 21 c. The optociliary veins are readily seen in later venous phase. however. 27 Fluorescein An~logr.,phy of OplociliMY Shunt Ves,pls Figure 21 d. Nutl' thai the,e oplonl.ary vessels fill dt .me Int"n5lt (Pufluor(" sc~nc~) J other vrmS In a very Idle picture. how("ver TABLE I Oplocilidry Shunt Vessels TABLE 2. Oplocilidfy Shunt Vessels: Differences in Fluoresc"in Angiog", ms A. Cogen,t.l o B. Acqulfed } Optic n("rv(" she.llh meninglom~sl"""ill.:t.e 2. Cpntral ('tlnal vein occlu.slon~ 3. OptiC nerve ghom.'· ~. Chronic dtrophic p.pill"demd' 5. GI.u om.tous optic dlrophy 6. Ardchno,d cyst of optoc n"rv,,' 7 Phacomdtosis: ci rcumferential tumor compression. For the present study, the fluorescein angiograms of four patients with optic nerve sheath meningiomas and four patients with central retinal vein occlusions were reviewed. All of these cases showed optociliary shunt vessels on the discs. The results are summarized in Table 2. The fundus photographs and fluorescein angiograms of these two groups of patients were quite interesting. At the outset, it should be stated that ute-in v~nous phdse St.ble to deere.s· ing- "ufluor" sc"nl to other veins Dr.ins to outer disc or to coll.ler.ls Cc-ntr41 Retln~1 '"t'ln O<cluslon ptl' f'r\'(' Sh".lth ~1rnln1CI\'m .. [onlY-in JrltJr1f)\·entlU$ ph.Jse Stal>le to ,"crus· inj:- hyp"rflu,'" r('~Cl!nt to other \,(I'ln5 Dr.lIns to l'entr.al V(I'n..." luS tributJ.ries FI('lw lAte St.ining Shunl FIlls Discussion Optociliary shunt vesselsH have been described in several conditions (Table 1), the most common being optic nerve sheath meningiomasI. 9-28 and central vein occlusions. These shunt vessels have been termed the Hoyt-Spencer syndrome.~ Optociliary shunt vessels have been considered to be abnormal communications between the retinal and ciliary systems. The pathogenesis of these vessels remains a subject of discussion. In the case of optic nerve sheath meningiomas, these vessels have been considered to connect the central retinal vein with peripapillary choroidal veins, and to represent tumor compression of the retrobulbar portion of the central retinal vein.1.S An alternate explanation may be that the shunts represent enlargement of preformed capillary vessels which occur when normal drainage routes are obstructed ."' '" Rodrigues, Savino, and SchatzlU reported the histology of one case of optic nerve sheath meningioma. The microscopic study revealed invasion of the sclera and peripapillary choroid by an orbital meningioma, and the shunt vessels connected "the central retinal vein .md peripapillary choroid with adjacent nests of meningiomatous infiltration." Cogan" raised the question of whether the shunt vessels seen in the optic nerve sheath meningiomas represent drainage of the tumor itself. Our study was designed to see if a different f1uoroangiographic pattern existed between shunts developing secondary to relative obstruction of the axial venous system and those developing with followed the venous pattern, remaining eufluorescent in the late stages. There were also retinal arteriovenous shunts present. 28 Journal of Clinical Neura-ophthalmology one can usually readily differentiate between photographs of patients with optic nerve meningiomds and those who have had vein occlusions in that the fonner typically show more optic atrophy, and the latter usually have associated retinal hemorrhages when early or retinovascular aneurysmal changes later. However, our attention was focused strictly on the fluorescein changes in the optociliary disc vessels, and it was seen that the angiograms could indeed be divided into two major groups. In the optic nerve sheath meningioma patients (cases 14), the optociliary shunts filled early in the arteriovenous stage and remained staining in the late stages of angiography. However, in the late venous stages these shunts were hyperfluoresct:'nt when compared to the veins. On the other hand, in the vein occlusions (cases 5-8), there was no evident fluorescence of the optociliary vessels in the arteriovenous phase, and the shunts filled only as the venous system filled. Furthennore, the shunt vessels filled and emptied in a parallel fashion with the veins and remained eufluorescent with them in the late stages. As is commonly the case in medicine, one may agree on the data and disagree on the interpretation of the data. One interpretation of the angiographic findings in this study OOMG) is that the abnormal vessels are veins exiting from the optic nerve head presumably draining from the tumor behind the nerve head and leaving via the central retinal vein complex. There is no evidence that they are arteries and therefore they should not be called shunts. They are simply analogous to dilated epibulbar vessels, as may be seen overlying a ciliary body melanoma. These are therefore simply dilated existing venules occurring in the presence of a tumor mass. Another interpretation (EWON) is that since the abnormal vessels fill in the arterial phase at times, and more commonly in the arteriovenous phase, they may be arteriovenous shunts. However, if they are shunts, they have a very low perfusion pressure because the presence of late hyperfluorescence is consistent with a very stagnant flow. There is no staining as indicated by leakage in the late pictures. However one may interpret the pathophysiology of these abnormal vessels on the optic disc, the most significant observation of this study is that one can clinically differentiate optociliary vessels occurring with optic nerve sheath meningiomas from those due to central vein occlusions by a carefully performed timed optic nerve fluorescein angiogram. The abnormal vessels fill during the arteriovenous phase in the meningioma cases, whereas the ones with vein occlusions do not and fill only during the venous phase. Furthermore, in the late venous stages the abnormal vessels are hyperfluorescent in the meningioma cases, whereas following vein occlusions the vessels re- March 1981 Bo~(hdti, Smith, O~her, Gass, Norton mdined eufluorescent (same intensity as the veins). Fluorescein angiography can therefore be of value in the differenticll diagnosis of cases in which the history and findings are not conclusive. References l. Frisen, L., Hoyt, w.r., and Tengroth, B.: Optociliary veins, disc pallor and visual loss: A triad of signs indicclting spheno-orbital meningioma. Acta Ophth,,' mo/. 51: 241,1973. 2. S.:tnders, M.D.: Aclassification of papilledema based on .I fluorescein angiographic study of 69 cases. Trans. Ophthd/mo/. Soc. u.K. 89: 117, 1969. J. Braun: Ein beitrag zur kenntris optikociliarer gefasse. K/in. Mondtsbl. Augenhei/kd. 43: 579, 1905. 4. Hedges, T.P.: Papilledema. Its recognition to increased intracranial pressure. Surv. Ophthalmol. 19: 201, 1975. 5. Hoyt, W.F., and Beeston, D.: The Oculdr Fundus in Neurologic Disei/se. CV. Mosby, St. Louis, 1966, p. 42. 6. Miller, R., and Green, W.R.: Arachnoid cysts involving a portion of the intraorbital optic nerve. Arch. OphthalmoJ. 93: 1117, 1975. 7. Zaret, CR., Chromokos, E.A., and Meisler, D.M.: Cilio-optic vein associated with phacomatosis. Ophthalmology 87(4): 330-336, 1980. 8. Irvine, A.R., Shorb, S.R., and Morris, B.W.: Optociliary veins. Tri/ns. Am. ACi/d. Ophtha/mol. Otolaryngol. 83: OP-541, 1977. 9. Hollenhorst, R.W., Jr., HoUenhorst, R.W., Sr., and MacCarty, CS.: Visual prognosis of optic nerve sheath meningiomas producing shunt vessels of the optic disc: The Hoyt-Spencer syndrome. Trans. Am. Ophthalmol. Soc. 75: 141, 1977. 10. Rodrigues, M.M., Savino, P.I., and Schatz, N.J.: Spheno-orbital meningioma with optociliary veins. Am.]. Ophthalmo/. 81(5): 666, 1976. 11. Coston, T.O.: Primary tumor of the optic nervewith report of a case. Arch. Ophthi/lmol. 15: 696, 1936. 12. Craig, W.M., and Gogela, L.J.: Meningioma of the optic foramen as a cause of slowly progressive blindness. ]. Neurosurg. 7: 44, 1950. 13. Dandy, W.: Prechiasmal intracranial tumors of the optic nerve. Am.]. Ophthalmol. 5(3): 169, 1922. 14. lames, B.P., and Smith, J.L.: Bilateral optic nerve sheath meningiomas presenting as the chiasmaI syndrome. In Neuro-ophthi/lmology Update,].L. Smith, Ed. Masson Publishing USA, Inc., New York, 1977, p.177. 15. Karp, L.A., Zimmerman, L.E., Borit, A., and Spencer, W.: Primary intraorbital meningiomas. Arch. Ophthi/ lmo/. 91: 24, 1974. 16. Kearns, T.P., and Wagener, H.P.: Ophthalmologic diagnosis of meningiom.ls of the sphenoidal ridge. Am.]. Med. Sci. 226: 221, 1953. 17. Martin, V.A.F., and Schofield, P.P.: Meningioma invading the optic nerve. Br.]. Ophthalmol. 41: 161, 1957. 18. Moore, CE.: Sphenoidal ridge meningioma with optic nerve metastasis. Br.]. Ophthalmol. 52: 636, 1968. 19. Newell, r.w., and Beaman, T.C: Ocular signs of meningioma. Am.]. Ophtha/mol. 45: 30, 1958. 29 30 Fluorescein Angiography of Optociliary Shunt Vessels 20. Nicholson, D.H.: Tumors of the optic nerve. In Neuro-ophthd/mology Upddte, J.L Smith, Ed. Masson Publishing USA, Inc., New York, 1977, p. 131. 21. Schatz, H., Yannuzzi, L.A., ,md Rabb, M.F.: Interpretation of Fundus Fluorescein Angiography. c.v. Mosby, 51. Louis, 1978, p. 372. 22. Spencer, W.H.: Primary neoplasms of the optic nerve and its sheaths: Clinical features and current concepts of pathogenic mechanisms. Tr<ms. Am. Ophthd/mo/. Soc. 70: 518, 1972. 23. Susac, 10.. Martins, A.N., and Whaley. R.A.: Intracanalicular meningiomas with normal tomography. ]. Neurosurg. 46: 659, 1977. 24. Susac, j.O., Smith, J.L., and Walsh, F.B.: The impossible meningioma. Arch. Neurol. 34: 36, 1977. 25. Wilson, W.B., Gordon, M., and lehman, A.W.: Meningiomas confined to the optic canal and foramina. Surg. Neurol. 12: 21, 1979. 26. Walsh, F.B.: Meningiomas, primary within the orbit and optic canal. In Neuro-ophthd/mology Symposium of the University of Miami and the Bascom Palmer Eye Institute, Vol. S., J.l. Smith, Ed. Huffman Publishing Co., Hallandale, Fla., 1970, p. 240. 27. Wright, J.E.: Primary optic nerve meningiomas: clinical presentation and management. Trdns. Am. Acad. Ophthd/mol. Otolaryngol. 83: OP-617, 1977. 28. Zanka, K.A., Summerer, R.W., Yee, R.D., Foos, R.Y., and Kim, }.: Optociliary veins in a primary optic nerve sheath meningioma. Am. f. Ophtha/mol. 87: 91, 1979. Write for reprints to: J. Lawton Smith, M.D., Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, P.O. Box 016880, Miami, Florida 33101. Journal of Clinical Neuro-ophthalmology |
