Dean McGee Eye Institute, Department of Ophthalmology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA.
J Neuroophthalmol. 2009 Dec;29(4):281-3. doi: 10.1097/WNO.0b013e3181c2530b.
A 16-year-old woman complaining of headache and declining vision in both eyes had papilledema, normal brain imaging, and a lumbar puncture showing a moderately high opening pressure (35 cm H2O) and normal cerebrospinal fluid constituents. For a diagnosis of idiopathic intracranial hypertension (IIH), she was treated with acetazolamide and methylprednisolone, but vision worsened, so she underwent bilateral optic sheath fenestration (ONSF). Within the 1st postoperative week, vision had improved and papilledema was less prominent. However, by the 14th postoperative day, vision had worsened and headache persisted. Lumbar puncture showed a very high opening pressure (65 cm H2O), so she underwent ventriculoperitoneal shunting. Although there was a slight initial improvement in vision, it eventually declined further. This case emphasizes that ONSF may yield initial improvement in vision and reduction in papilledema yet not prevent eventual visual loss in IIH. Whether the visual loss in this patient resulted from persistently elevated intracranial pressure after ONSF or was prefigured before ONSF occurred is unresolved. It is a reminder that patients with IIH must be monitored carefully after ONSF. If there is a suggestion of further visual loss, shunting should be considered if intracranial pressure is high.
一位 16 岁的女性患者主诉头痛和双眼视力下降，出现视乳头水肿，脑影像学检查正常，腰椎穿刺显示颅内压中度升高（35cmH₂O），脑脊液成分正常。为了诊断特发性颅内高压（IIH），给予乙酰唑胺和甲泼尼龙治疗，但视力恶化，因此进行了双侧视神经鞘减压术（ONSF）。术后 1 周内，视力有所改善，视乳头水肿减轻。然而，术后第 14 天，视力再次恶化，头痛持续存在。腰椎穿刺显示颅内压非常高（65cmH₂O），于是进行了脑室-腹腔分流术。尽管视力有轻微的初始改善，但最终进一步下降。这个病例强调了 ONSF 可能会导致初始的视力改善和视乳头水肿减轻，但不能预防 IIH 最终的视力丧失。该患者的视力丧失是由于 ONSF 后颅内压持续升高所致，还是在 ONSF 发生之前就已经出现，目前尚无定论。这提醒我们，IIH 患者在接受 ONSF 后必须密切监测。如果有进一步视力丧失的迹象，且颅内压升高，则应考虑分流。
