Optic nerve sheath fenestration for cerebral venous thrombosis

This case report demonstrates the successful use of bilateral optic nerve sheath fenestration (ONSF) to treat papilledema due to cerebral venous thrombosis (CVT) after the failure of medical treatment.

Patients with CVT and increased intracranial pressure with persistent visual loss despite initiation of maximum medical therapy, including anti-coagulation medication, present a unique challenge. ONSF represents a treatment option in such a setting.

A 16-year-old girl with CVT involving the left transverse and sigmoid sinuses and left internal jugular vein presented with acute onset of headache, decreased vision and papilledema.

She had an unusual combination of risk factors for CVT, including the use of oral contraceptives and positive lab values for Factor V Leiden mutation, prothrombin G20210A mutation, Factor XII deficiency, decreased antithrombin III and protein S levels.

Her condition progressed despite initiation of both enoxaparin and acetazolamide.

Two months after bilateral ONSF her vision improved from 20/100 OD and 20/200 OS to 20/40 OU. At four months, visual fields were stable, with complete resolution of papilledema.The authors note that the use of anticoagulation complicates ONSF due to the increased risk of bleeding during surgery. They say that careful dissection during the procedure is essential to maintain hemostasis with the orbit. They recommend working closely with a hematologist and overnight monitoring postoperatively. They note that switching a patient to enoxaparin sodium, which has a shorter half-life than heparin, may decrease the risk of hemorrhage.