Outcomes of endoscopic optic nerve decompression in patients with idiopathic intracranial hypertension

Abstract

Background The conventional treatment for idiopathic intracranial hypertension involves weight loss, steroids, diuretics, and/or serial lumbar punctures; however, if the symptoms persist or worsen, surgical intervention is recommended. Surgical options include cerebrospinal fluid diversion procedures, such as ventriculoperitoneal and lumboperitoneal shunts, and optic nerve decompression with nerve sheath fenestration. The latter can be carried out using an endoscopic approach, but the outcomes of this technique have not been firmly established. Methods This systematic review examined the outcomes of performing endoscopic optic nerve decompression (EOND) in patients with idiopathic intracranial hypertension (IIH). Six studies were included for a total of 34 patients. Results The patients presented with visual field disturbances [32 of 32 (100%)], visual acuity disruptions [33 of 34 (97.1%)], papilledema [26 of 34 (76.5%)], and persistent headache [30 of 33 (90.1%)]. The mean duration of the symptoms ranged from 7 to 32 months. Overall, the patients showed post-EOND improvement of the signs and symptoms associated with IIH, specifically visual field deficits (93.8%), visual acuity (85.3%), papilledema (81.4%), and headaches (81.8%). Interestingly, 11 cases showed postoperative improvement in their symptoms with bony decompression of the optic canal alone, without nerve sheath fenestration. The authors did not report any major adverse events or complications with this approach. Conclusion EOND appears to be a promising and safe surgical alternative for patients with IIH who fail to respond to medical treatment. Further studies are needed before we can attest to the clinical validity of this procedure.

Noninvasive Monitoring and Neurointerventional Management of Idiopathic Intracranial Hypertension

“…56 While the former study did not perform analysis of visual improvement, other meta-analyses have demonstrated an improvement in visual acuity, papilledema, and headache in an average of 47 to 84%, 83 to 97%, and 78 to 88% of IIH patients undergoing transverse venous sinus stenting, respectively (►Tables 3-5). 17,18,[54][55][56][57][58] It should be mentioned that one potential limitation of these findings is that these results are largely only applicable to those with patients who would have been documented with venous stenosis whereas those treated with ONSF or CSF shunting may or may not have demonstrated venous stenosis. Additional studies show venous stenting effectively reduces ICP immediately following the procedure and results in a significantly decreased CSF opening pressure for up to 3 months during the postoperative period.…”

“…These findings can be compared with the results of four meta-analyses from 2007 to 2017 that calculated average improvement in visual acuity ranging from 59 to 85% of IIH patients undergoing ONSF (►Table 3). 17,18,54,55 Additionally, results of the meta-analyses showed average improvement in papilledema and headaches ranged from 80 to 81% and 44 to 81% of IIH patients undergoing ONSF, respectively (►Tables 4 and 5 ). 18,[54][55][56][57][58] While there are few reports of major complications due to ONSF, common minor complications include diplopia, corneal dellen, and tonic pupil.…”

“…17,18,54,55 Additionally, results of the meta-analyses showed average improvement in papilledema and headaches ranged from 80 to 81% and 44 to 81% of IIH patients undergoing ONSF, respectively (►Tables 4 and 5 ). 18,[54][55][56][57][58] While there are few reports of major complications due to ONSF, common minor complications include diplopia, corneal dellen, and tonic pupil. 59 Several risk factors have been identified for ONSF failure and include CSF opening pressure of > 50 cm H 2 O, male sex, poor visual acuity at presentation, and longer duration of symptoms before surgery.…”

“…61 Meta-analyses conducted from 2007 to 2019 demonstrate that shunting, whether VP or LP, show improvement in visual acuity, papilledema, and headaches in an average of 38 to 56%, 70%, and 62 to 80% of patients with IIH, respectively (►Tables 3, 4 and 5). 17,18,[54][55][56][57][58] In consideration of the differential efficacy of VP versus LP shunts, one analysis reports that LP shunts are associated with a significantly increased likelihood of shunt revision and subsequent greater healthcare costs ($3.7 vs. $5.4 million) as compared with VP shunts. 62 A more recent study, however, demonstrates statistically similar rates of shunt failure and complication between VP and LP shunts.…”

Endoscopic Bilateral Optic Nerve Decompression for Treatment of Idiopathic Intracranial Hypertension

“…To the best of our knowledge, the endoscopic bilateral optic nerve decompression technique is the least used technique in the literature. [ 9 , 10 ]…”