Optic neuropathy produced by a compressed mucocele in an Onodi cell

PURPOSE: To describe a patient with compressive optic neuropathy caused by a mucocele in an Onodi cell. DESIGN: Interventional case report. METHODS: A 73-year-old man complained of sudden visual loss in the left eye 10 days after cataract surgery. Coronal computed tomography showed a homogeneous mass in an Onodi cell. Magnetic resonance imaging revealed an oval-shaped lesion that compressed the left optic nerve. RESULTS: After endoscopic microsurgery of the paranasal sinus, visual acuity in the left eye improved. Histopathological examination of the excised specimen showed a mucocele. CONCLUSIONS: Ophthalmologists should be aware that the mucocele in the Onodi cell, an anatomical variation of the paranasal sinus, may compress the optic nerve.     

Orbital complications of paranasal sinus surgery

Despite the low complication rate from surgery of the paranasal sinuses, orbital injury may be seen in up to 3% of all procedures. These complications include orbital edema, orbital hemorrhage, enophthalmos, extraocular muscle injury, and nasolacrimal duct obstruction. The most devastating complication is blindness, usually resulting from optic nerve compression with central retinal artery occlusion, or direct injury to the nerve itself. Early recognition of orbital injury during sinus surgery and appropriate intervention may prevent later, more serious ophthalmic complications.     

Major orbital complications of endoscopic sinus surgery

BACKGROUND: The paranasal sinuses are intimately related to the orbit and consequently sinus disease or surgery may cause severe orbital complications. Complications are rare but can result in serious morbidity, the most devastating of which is severe visual loss. METHODS: A retrospective review was undertaken of four cases of severe orbital trauma during endoscopic sinus surgery. RESULTS: All the cases suffered medial rectus damage, one had additional injury to the inferior rectus and oblique, and two patients were blinded as a result of direct damage to the optic nerve or its blood supply. CONCLUSION: Some ophthalmic complications of endoscopic sinus surgery are highlighted, the mechanisms responsible are discussed, and recommendations for prevention, early recognition, and management are proposed.     

经颅视神经减压开放术治疗外伤后迟发失明

目的 :报告 2 0例经颅视神经减压开放术治疗外伤后迟发失明。方法 :经冠状切口额部开颅硬膜下入路 ,视神经管上壁骨性减压 ,并剪开视神经鞘膜。评价手术后视力恢复的标准为 :失明、眼前手动、眼前数指、光感、能见视力表符号 5个级别。术后视力提高 1个级别以上者为有效 ,否则为无效。结果 :2 0例患者共 9例术后恢复了视力 ,有效率为 45 %。结论 :迟发性失明的患者应行急诊手术治疗 ,术后视力恢复与损伤后至手术时间、手术方法相关 ,也与视神经损伤程度密切相关     

鼻内镜手术致视神经损伤的临床研究

目的探讨应用鼻内镜行鼻窦手术的眼并发症发生原因及治疗方法。方法回顾性分析3例鼻内镜术后出现不同程度视功能损害者,对其视力、视野、眼电生理、对比敏感度等检查及治疗进行分析。结果鼻内镜手术操作不当可以引起视功能损伤。3例中1例经皮质类固醇冲击等治疗后视力及视野明显改善,另2例经治疗后改善不明显。结论鼻内镜手术因局部解剖位置的原因容易引起视功能损害,对于视力正常但仍主觉视力下降的患者,应行对比敏感度检查。鼻科医生必须熟练掌握相关解剖,对可能发生的眼部并发症予以足够的重视。     

Ophthalmic complications of endoscopic sinus surgery

The intimate anatomical relationship between the orbit and the paranasal sinuses places the orbit and its contents at risk of harm from primary pathologic processes of the sinuses. In the absence of ophthalmic signs or symptoms, ophthalmologists are not routinely involved in the management of patients with sinus disease. Occasionally, some patients may develop ophthalmic complaints after surgical intervention. The orbit, optic nerve, extraocular muscles, and lacrimal drainage system are susceptible to injury during endoscopic sinus surgery. The risk of injury is related to the skill of the sinus surgeon, history of previous surgery, extent and severity of disease, and anatomic variation. Furthermore, recent advances in endoscopic sinus surgery, in particular the use of powered cutting instruments, has resulted in a novel mechanism of injury to the ocular structures.     

Bilateral consecutive blindness due to sphenoid sinus mucocele with unilateral partial recovery

BACKGROUND: We present an interventional case report of a rare occurrence of sphenoid sinus mucocele causing bilateral consecutive blindness with unilateral partial recovery after endoscopic surgery. METHODS: A 64-year-old woman with known sphenoid sinus mucocele and right blindness was referred because of an acute drop of vision to hand motion in her only-seeing left eye over 5 days. Imaging revealed a large mucocele enlarging the sphenoid sinus, eroding the base of the skull, protruding into the cranial cavity, and compressing the left optic nerve. RESULTS: Urgent endoscopic sphenoidotomy was performed. Several hours after the procedure, visual acuity was partially recovered in the left eye. INTERPRETATION: Sphenoid sinus mucoceles can cause bilateral blindness. A high index of suspicion and urgent imaging studies are necessary. Because visual recovery depends on prompt diagnosis and surgical intervention, a close collaboration between otolaryngologists and ophthalmologists is crucial.     

Optic Nerve Blindness Following Blunt Forehead Trauma

Seven cases of sudden monocular blindness following frontal head trauma are presented. The average age of these patients was 18 years. Four of the seven patients underwent transethmoid-sphenoid nerve decompression with only one of the four achieving a minor return of vision. None of the three out of six patients who failed to respond to megadose steroids regained vision with optic nerve decompression. Three out of six patients had return of good vision with megadose steroids without optic nerve decompression. Two of these three patients had a delayed loss of vision. One of the three patients with visual return developed visual loss again following a facial fracture reduction, which again responded to megadose steroids without optic nerve decompression. Another patient had visual return on steroids but also required removal of a subperiosteal hematoma to obtain near normal vision. This case differs from our other cases in that subperiosteal hematoma is an unusual complication of these injuries and caused the optic nerve compression in the orbital apex in this case. Review of the literature and our clinical and experimental findings suggest that the etiology of the indirect optic nerve injury is secondary to a stretching, tearing, torsion, or contusion of the nerve caused not only from the momentum of the eyeball and orbital contents being absorbed by the fixed canalicular portion of the optic nerve but also by skeletal distortion caused by forces remote from the initial impact. This is well illustrated by the holographic findings. These injuries cause direct injury to the nerve or vascular compromise from tearing, thrombosis, hematoma, or compression of the small nutrient vessels supplying the optic nerve. Megadose steroids appear to be useful in some cases of traumatic monocular blindness secondary to blunt facial trauma and as an adjunct to or an indication for surgery in others. The authors' recommended indications for optic nerve decompression (transethmoid-sphenoidotomy with removal of the medial wall of the optic canal) following blunt trauma are (1) delayed visual loss following frontal head trauma unresponsive to 12 hours of megadose steroid therapy and (2) initial return of vision with megadose steroids followed by visual decrease while on steroids or with the tapering of steroids.     

Loss of electroretinographic oscillatory potentials, optic atrophy, and dysplasia in congenital stationary night blindness

New criteria for diagnosing congenital stationary night blindness include loss of the oscillatory potentials in the photopic and bright-flash dark-adapted electroretinogram, and atrophy or dysplastic changes, or both, in the optic nerve head. Ten patients (seven male and three female, ranging in age from 6 to 19 years) had typical findings of congenital stationary night blindness including congenital nonprogressive nyctalopia, no pigmentary retinopathy, and full visual fields consistent with myopia. Visual acuities ranged from 20/30 to 20/60, though one patient had a visual acuity of 20/200. Most patients had histories of strabismus. The photopic electroretinograms were subnormal. Of the male patients, five had tilted optic disks with temporal portions of the nerve missing, and two had misshapen nerve heads. The three female patients had pallor of the optic disk without evidence of tilt.     

Spheniodal mucocele causing bilateral optic neuropathy and ophthalmoplegia

Sphenoid sinus mucocele comprises only 2% of all paranasal sinus mucoceles. In literature, there is a case report on sphenoidal mucocele causing bilateral optic neuropathy, with unilateral partial recovery and cranial nerve palsy, but we did not come across any literature with bilateral optic neuropathy and ophthalmoplegia together caused by spheno-ethmoidal mucocele. We present such a rare case of spheno-ethmoidal mucocele causing bilateral optic neuropathy and unilateral sixth nerve palsy who had postsurgery, unilateral good vision recovery, and complete resolution of sixth nerve palsy.     

颅外伤合并间接性视神经损伤

目的 探讨颅外伤合并间接性视神经损伤的临床诊断和治疗。方法 回顾分析了颅外伤合并间接性视神经损伤36例（36眼）的临床资料。11例行视神经减压术，25例接受药物治疗。结果 全部患者伤侧眼的相对瞳孔传入障碍（RAPD）阳性；眼眶CT扫描显示有眶壁和／或鼻窦骨折。药物治疗组有8例（32．00％）视力提高1行，其余17例（68．00％）视力无改善，手术治疗组有1例（909％）由数指／1．5m提高到03，5例（45．46％）恢复了瞳孔直接对光反应，1例（9．09％）恢复了VEP波，其余4例（36．36％）视力无改善。结论 对颅外伤患者应进行RAPD检查及眼眶CT扫描，确定有无间接性视神经损伤。皮质类固醇和视神经减压联合应用可能更有利于视功能的恢复。     

Fronto-ethmoid sinus mucocele: a case report.

BACKGROUND: Mucoceles are epithelium-lined cavities in the paranasal sinuses filled with mucus. They develop because of scarring and obstruction of the sinus ostium, whether from chronic sinusitis, trauma, or surgery. They commonly erode the bony sinus wall and can have serious complications of brain and orbital invasion, with potential for abscess and rupture. CASE REPORT: A 39-year-old woman had diplopia in left gaze and a hard nodule above the right eye for 1 year. She recently noted a bulging right eye, nasal congestion, and occasional headaches. She was 9 years post-sinus surgery. All aspects of the afferent optic nerve function were intact. Right-sided proptosis was evident as was a right adduction and supraduction deficit, prompting immediate imaging, both with a computed tomography scan and magnetic resonance imaging of the orbits. These results showed a large right ethmoid sinus mucocele, with bony erosion and orbital invasion, prompting an immediate surgical referral. CONCLUSION: Mucoceles may arise from any of the paranasal sinuses and, because of the close proximity of these spaces to the orbit, may initially manifest with visual and ocular signs and symptoms. Therefore, eye care providers need to be aware of this entity and the need for immediate referral or workup if a mucocele is suspected.     

Sphenoid sinus mucocele (anterior clinoid variant) mimicking diabetic ophthalmoplegia and retrobulbar neuritis

Two patients (two men, 56 and 59 years old) had sphenoid sinus mucocele originating in the anterior clinoid process. In one case the mucocele initially mimicked diabetic ophthalmoplegia with pupil-sparing palsy of the oculomotor (third) nerve. After resolution of the palsy, severe visual loss developed with minimal recovery of vision after surgery. The second patient had recurrent episodes of retrobulbar optic neuropathy with optic atrophy and decreased vision. Visual loss from sphenoid sinus mucoceles is usually associated with a poor prognosis if surgical treatment is delayed more than seven to ten days.     

A history of the optic nerve and its diseases

We will trace the history of ideas about optic nerve anatomy and function in the Western world from the ancient Greeks to the early 20th century and show how these influenced causal theories of optic nerve diseases. Greek and Roman humoral physiology needed a hollow optic nerve, the obstruction of which prevented the flow of visual spirit to and from the brain and resulted in blindness. Medieval physicians understood that the presence of a fixed dilated pupil indicated optic nerve obstruction, preventing the passage of visual spirit, and that cataract surgery in such cases would not restore sight. During the Renaissance, the organ of vision was transferred from the lens to the optic nerve, which was generally believed to be on the axis of the eye. The acuity of central vision (at the optic disc) was explained by the concentration of visual spirit where the optic nerve met the retina. The growth of anatomy and influence of mechanical philosophy from the 17th century led to visual spirit being replaced with the concept of nerve force, which later became associated with electricity travelling along nerve fibres. This coincided with discourse about the nature of the nervous system and a shift in orientation from understanding illness holistically in terms of an individual's humoral imbalance to the concept of organ-based diseases. Both the microscope and the ophthalmoscope allowed visualisation of the optic nerve, but problems of interpretation persisted until conceptual transformations in medical science were made.     

Orbital haemorrhage and prolonged blindness: a treatable posterior optic neuropathy.

Two patients developed traumatic orbital haemorrhage resulting in prolonged blindness. Orbital decompression successfully reversed the visual loss, though both eyes had no light perception for at least 3 1/2 hours. The clinical findings suggest damage to the posterior optic nerve as cause of the visual loss. The optic nerve tolerance time to ischaemic injury may be longer than previously thought.     

严重视神经损伤失明者行开颅手术治疗的探讨

目的 评价开颅视神经减压开放术在治疗严重视神经损伤失明病人的效果。方法 应用额部开颅视神经减压开放术治疗术治疗术前完全失明（无光感）患者31例,全程开放视神经管及视神经鞘膜,并取出眶尖的碎骨片。结果 术后恢复视力16例。效率51.5%。结论 开颅视神经减压开放术是唯一能彻底减压视神经的手术方式。     

Optic nerve sheath meningiomas.

Meningiomas are benign neoplastic lesions arising from meningothelial cells of the meninges. Primary orbital meningiomas, originating in the optic nerve sheath, represent 1-2% of all meningiomas, and are the second most common optic nerve tumor after gliomas. They primarily affect middle-aged adults. Patients typically present with visual loss, frequently associated with optic atrophy and often with optociliary shunt vessels. The lesion is usually unilateral, but is bilateral in about 5% of cases. Meningiomas show characteristic indolent growth over years, progressing inexorably to blindness in the affected eye. Management should be conservative in most cases. In very rare situations, surgery has improved visual prognosis. In most patients, however, surgery offers no benefit, and should be reserved for those with blindness or severe proptosis, or when extension toward the optic canal is documented. Although preliminary results of radiotherapy are encouraging, very few patients have been treated using this modality, and the long-term advantage for vision remains unproven. Even when untreated, the prognosis for life is excellent, with an overall tumor-related mortality of 0%.     

Sphenoid sinus carcinoma mimicking retrobulbar optic neuritis

Sphenoid sinus carcinomas occur rarely compared with other sinonasal tumors. A case of sphenoid sinus squamous cell carcinoma presenting with acute, isolated optic neuropathy and visual loss is presented herein along with the related literature. A 37-year-old man with sudden decrease in visual acuity in his left eye of 15 days' duration was referred. He had received high-dose intravenous corticosteroid therapy with the provisional diagnosis of retrobulbar neuritis, and his visual acuity had temporarily improved at this time. Magnetic resonance study showed a space-occupying lesion in the left posterior ethmoid and sphenoid sinuses, adjacent to the intracanalicular optic nerve, and an increase in optic nerve signal intensity. An excisional biopsy of the sphenoid lesion revealed squamous cell carcinoma. After stereotactic radiotherapy and chemotherapy following surgery, a total loss of vision and optic atrophy developed in the left eye. No other complication, tumor recurrence, or metastasis occurred during 30 months of follow-up.     

Sphenoid Sinus Carcinoma Mimicking Retrobulbar Optic Neuritis

Sphenoid sinus carcinomas occur rarely compared with other sinonasal tumors. A case of sphenoid sinus squamous cell carcinoma presenting with acute, isolated optic neuropathy and visual loss is presented herein along with the related literature.

A 37-year-old man with sudden decrease in visual acuity in his left eye of 15 days’ duration was referred. He had received high-dose intravenous corticosteroid therapy with the provisional diagnosis of retrobulbar neuritis, and his visual acuity had temporarily improved at this time. Magnetic resonance study showed a space-occupying lesion in the left posterior ethmoid and sphenoid sinuses, adjacent to the intracanalicular optic nerve, and an increase in optic nerve signal intensity. An excisional biopsy of the sphenoid lesion revealed squamous cell carcinoma. After stereotactic radiotherapy and chemotherapy following surgery, a total loss of vision and optic atrophy developed in the left eye. No other complication, tumor recurrence, or metastasis occurred during 30 months of follow-up.     

Ophthalmic involvement as a presenting feature of nonorbital childhood parameningeal embryonal rhabdomyosarcoma

OBJECTIVE: To describe presenting ophthalmic signs and symptoms in children with parameningeal rhabdomyosarcoma. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-three children with parameningeal rhabdomyosarcoma treated from 1978 through 1998. MAIN OUTCOME MEASURES: Each patient's presenting symptoms and history, the ophthalmic signs at presentation, the location of the tumor on computed tomographic scanning, the pathologic diagnosis after tumor biopsy, and the child's outcome after chemotherapy and radiotherapy. RESULTS: Eight of 23 patients with parameningeal rhabdomyosarcoma had ophthalmologic signs at presentation. All patients had sixth nerve palsies, and four had additional third nerve palsies. Fifth and seventh nerve involvement was seen in three children each, and two manifested additional fourth nerve palsies. In two patients, invasion of the optic canals and posterior orbit resulted in unilateral blindness in one and marked unilateral visual loss in the other. In no patient was the symptomatic history longer than 12 weeks. Seven of eight patients were treated with a combination of surgery, chemotherapy, and radiotherapy. The mean survival time for five patients who died from parameningeal rhabdomyosarcoma associated with ophthalmic signs was 27.2 months. Three patients are currently alive, with a mean survival time of 33.7 months after diagnosis. The survival time of 12 patients with parameningeal rhabdomyosarcoma and without ophthalmologic signs at presentation was better, in that nine are alive, with a mean survival time of 54 months. CONCLUSIONS: Advanced parameningeal rhabdomyosarcoma with skull base invasion may present with ophthalmic signs. These patients sought treatment late and had advanced tumors because their initial signs and symptoms were often attributed to more common ailments. Usually, the onset of the cranial nerve palsy initiated referral to the tertiary care center. The sixth nerve was the most vulnerable. Further invasion of the skull base or cavernous sinus may cause additional third, fourth, and fifth nerve palsies. The optic nerve was involved when the optic canals and orbit were encroached on by the tumor. The prognosis for survival was poor when these tumors were accompanied by ophthalmic signs.