Journal of Neuro-Ophthalmology, March 2013, Volume 33, Issue 1

Untreated Bilateral Optic Nerve Sheath Meningiomas Observed for 27 Years

We describe a vision sparing surgical approach for optic nerve glioma. A 7-year-old girl experienced declining academic performance and social withdrawal attributed to progressive disfiguring proptosis. Three years earlier, she had undergone a limited biopsy, a course of chemotherapy, and orbital radiation therapy for a right optic nerve glioma with perineural arachnoidal gliomatosis (PAG). Because of marked proptosis, another surgery was performed via a lateral orbitotomy. After cutting a window in the thickened dura of the optic nerve, rouge colored spongy tissue was suctioned from the subarachnoid space. Small, more solidified areas were excised with unipolar cautery. Care was taken to avoid identifiable blood vessels and the optic nerve, and approximately 60%70% of the tumor was removed. The dural window was approximated with interrupted sutures. Postoperatively, there was 9 mm reduction in right proptosis and visual acuity improved to from 20/70 to 20/60. This case illustrates the possibility of debulki optic nerve gliomas without sacrificing vision. It should be stressed that this technique is only applicable to gliomas with PAG and the durability of the surgical benefit is unknown.

Untreated Bilateral Optic Nerve Sheath Meningiomas Observed for 27 Years Nikisha A. Kothari, BS, Kaushal M. Kulkarni, MD, Byron L. Lam, MD Abstract: A 48-year-old woman noted progressive, painless visual loss in her left eye. She was diagnosed with bilateral optic nerve sheath meningiomas (ONSMs), extending across the planum sphenoidale. Radiation was offered, but the patient declined. She has been followed for more than 27 years with stable visual function and neuroimaging findings. Bilateral ONSMs, although usually described as aggressive in nature, may follow a stable clinical course. Journal of Neuro-Ophthalmology 2013;33:45-47 doi: 10.1097/WNO.0b013e318267fc5e © 2012 by North American Neuro-Ophthalmology Society A75-year-old woman noted progressive, painless visual loss in her left eye that began at age 48. At that time, visual acuity was 20/30 in the right eye and no light per-ception (NLP) in the left eye. Neuroimaging revealed bilateral optic nerve sheath meningiomas (ONSMs), left greater than right, extending across the planum sphenoidale. She was given the options of surgery and stereotactic radio-therapy, but declined both. Serial examinations revealed stable visual acuity, visual fields, and neuroimaging findings. FIG. 1. A. At presentation, the right visual field (HVF: 24-2) shows an inferonasal defect (deviation, 26.49 dB; pattern standard deviation, 8.42 dB). B. Fourteen years later, the right visual field (HVF: 30-2) is unchanged (deviation, 26.58 dB; pattern standard deviation, 8.63 dB). HVF, Humphrey visual field. From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida. Supported in part by an unrestricted grant from Foundation to Prevent Blindness Inc. The authors report no conflicts of interest. Address correspondence to Kaushal M. Kulkarni, MD, Bascom Palmer Eye Institute, University of Miami School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA; E-mail: kaushal. [e-mail] Kothari et al: J Neuro-Ophthalmol 2013; 33: 45-47 45 Photo Essay Section Editor: Timothy J. McCulley, MD Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Her medical history was significant for hypertension treated with clonidine. Family history was noncontributory. She had a 20 pack-year smoking history and quit at age 40. A review of systems was negative for headaches or associated neurological symptoms. At age 61, she first presented to our institution with a visual acuity of 20/30 in the right eye and NLP in the left eye, and the left pupil was amaurotic. The patient identified 11/15 color plates with the right eye and there was 3 mm of left proptosis. Anterior segment examination was unremark-able. Both optic discs were pale, with an optic optociliary shunt vessels on the left. Automated visual field testing of the right eye showed inferonasal loss (Fig. 1A). Contrast-enhanced magnetic resonance imaging (MRI) of the brain and orbits were consistent with a bilateral ONSMs, left greater than right, with contiguous spread across the planum sphenoidale (Fig. 2A, B). The optic chi-asm was uninvolved. After more than 27 years of follow-up, the patient's vision is unchanged. The appearance of the optic discs (Fig. 3) and visual fields (Fig. 1B) remain stable, as do findings on MRI (Fig. 2C-E). FIG. 2. Three years after presentation to our institution, contrast-enhanced T1 axial (A) and coronal (B) magnetic resonance imaging (MRI) demonstrates bilateral optic nerve sheath meningiomas (ONSMs). Ten years later, the appearance of the ONSMs is unchanged on contrasted fat-suppressed T1 axial MRI (C, D) and on coronal view (E). FIG. 3. Bilateral optic disc pallor is present with an optociliary shunt vessel inferiorly on the left optic disc. 46 Kothari et al: J Neuro-Ophthalmol 2013; 33: 45-47 Photo Essay Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. ONSM is a slow-growing benign neoplasm arising from the arachnoid cap cells of the optic nerve sheath. A primary ONSM arises directly from the dural sheath of the optic nerve and is almost always unilateral, whereas secondary ONSM may arise from the dura adjacent to the planum sphenoidale and extend into one or both optic canals (1,2). Cases of bilateral ONSMs typically present initially with monocular vision loss with subsequent extension of the tumor to the contralateral optic canal or optic chiasm. While the typical natural history of ONSM is gradual pro-gressive visual loss over many years, some patients however exhibit rapid progression (3). To date, there is no means of predicting the clinical course in patients with ONSM. In a review of 477 cases, Dutton (4) found approxi-mately 5% of ONSMs are bilateral. It is unclear whether our case represents bilateral ONSMs with spread across the planum sphenoidale, or a secondary ONSM that originated from the dura on the planum and spread anteriorly to involve both nerves (5). In reviewing the literature, these types of ONSM usually are aggressive, leading to poor visual acuity and posterior extension, and should be treated (1-3,6,7). Management options include conventional or fractional stereotactic radiotherapy and surgical excision (4). Because of the aggressive appearance of our patient's tumor on neuroimaging, and loss of vision in her left eye, she was offered radiation treatment, but elected observation. There are limited data on the natural history of ONSM, particularly the bilateral form, and treatment remains controversial. Time intervals of up to 25 years from the onset of visual symptoms in one eye to involvement of the fellow eye have been reported in patients with bilateral ONSM (8-10). Our patient has been followed for more than 27 years, with stable clinical and neuroimaging findings. Our case highlights the variable natural history of ONSM. While a single case cannot be generalized, observation of patients whose visual function and neuroimaging studies are stable may spare the patient from sight-threatening compli-cations of treatments such as surgery or radiation therapy. REFERENCES 1. Miller NR. New concepts in the diagnosis and management of optic nerve sheath meningiomas. J Neuroophthalmol. 2006;26:200-208. 2. Dandy WE. Prechiasmal intracranial tumors of the optic nerves. Am J Ophthalmol. 1922;5:169-188. 3. Egan RA, Lessell S. A contribution to the natural history of optic nerve sheath meningiomas. Arch Ophthalmol. 2002;120:1505-1508. 4. Dutton JJ. Optic nerve sheath meningiomas. Surv Ophthalmol. 1992;37:167-183. 5. Craig WM, Gogela LJ. Meningioma of the optic foramen as a cause of slowly progressive blindness; report of three cases. J Neurosurg. 1950;7:44-48. 6. Turbin RE, Thompson CR, Kennerdell JS, Cockerham KP, Kupersmith MJ. A long-term visual outcome comparison in patients with optic nerve sheath meningioma managed with observation, surgery, radiotherapy, or surgery and radiotherapy. Ophthalmology. 2002;109:890-899. 7. James BP, Smith JL. Bilateral optic nerve sheath meningioma presenting as the chiasmal syndrome. In Smith JL (Ed), Neuro- Ophthalmology Update. New York, NY: Masson, 1977: 177-183. 8. Dunn SN, Walsh FB. Meningioma (dural endothelioma) of the optic nerve. AMA Arch Ophthalmol. 1956;56:702-707. 9. Trobe JD, Glaser JS, Post JD, Page LK. Bilateral optic canal meningiomas: a case report. Neurosurgery. 1978;3:68-74. 10. Hollenhorst RW Jr, Hollenhorst RW Sr, MacCarty CS. Visual prognosis of optic nerve sheath meningiomas producing shunt vessels on optic disk. Mayo Clin Proc. 1978;53:84-92. Kothari et al: J Neuro-Ophthalmol 2013; 33: 45-47 47 Photo Essay Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.