Journal of Neuro-Ophthalmology, June 2013, Volume 33, Issue 2

A Case of Extraocular Muscle Enlargement Causing Diplopia: Thinking Beyond Thyroid Eye Disease

Although most patients with idiopathic intracranial hypertension (IIH) can be effectively treated with conservative measures, such as lumbar puncture, weight loss, acetazolamide, medical treatment of headaches, surgery is sometimes necessary, particularly in patients with visual loss secondary to chronic papilledema (1-4). Recently, endovascular venous stenting of a stenosed dominant intracranial transverse venous sinus has been proposed as a possible treatment (5); however, cerebrospinal fluid (CSF) shunting and optic nerve sheath fenestration (ONSF) remain among the most commonly used surgical procedures to treat IIH in the United States (6). In the absence of any prospective, randomized clinical trials comparing these procedures for the treatment of IIH, opinions vary greatly between ONSF and CSF shunting procedures as the most appropriate recommended surgical treatment (7,8). The decision to use one or the other is often based on local preferences and the availability of specific surgeons; some centers al ys perform ONSF as a first-line treatment, some use both procedures based on patient's symptoms and signs (ONSF for visual loss and shunts for headaches), while others exclusively recommend lumboperitoneal shunt (LPS) or ventriculoperitoneal shunt (VPS) when surgery is necessary (9).