Optic Nerve Sheath Fenestration in Cancer Patients: Indications and Surgical Technique

  • Thomas E. JohnsonEmail author
Part of the M.D. Anderson Solid Tumor Oncology Series book series (MDA, volume 6)


Optic nerve sheath fenestration (ONSF) entails cutting a window or making linear fenestrations in the retrobulbar optic nerve sheath, which releases pressure and often allows stabilization or improvement of vision. Indications for ONSF include visual loss due to pseudotumor cerebri, optic nerve sheath hemorrhage, dural sinus thrombosis, subdural hematoma, intradural arteriovenous malformation, arachnoiditis with increased intracranial pressure, and cryptococcal meningitis with papilledema due to AIDS. Indications for ONSF in cancer patients are not well established, but a few case reports have shown success of ONSF in patients with perineural metastasis of breast cancer, increased intracranial pressure with papilledema due to a brain tumor, lymphomatous infiltration of the optic nerve, and optic nerve sheath meningioma. ONSF can be performed with a medial orbitotomy approach with disinsertion of the medial rectus muscle, a superomedial eyelid crease incision without extraocular muscle disinsertion, a lateral orbitotomy approach with bone removal, or a lateral canthotomy incision without bone removal. ONSF is considered relatively safe when performed carefully; serious complications occur in about 1% of patients.


Optic Nerve Optic Neuropathy Optic Nerve Sheath Medial Rectus Retinal Artery Occlusion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Keltner JL. Optic nerve sheath decompression: how does it work? Has its time come? Arch Ophthalmol 1988;106:1365–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Hamad LM, Tse DT, Glaser JS, et al. Neuroimaging of the optic nerve after fenestration for management of pseudotumor cerebri. Arch Ophthalmol 1992;110:636–9.CrossRefGoogle Scholar
  3. 3.
    Sergott RC, Savino PJ, Bosley TM. Modified optic nerve sheath decompression provides long-term visual improvement for pseudotumor cerebri. Arch Ophthalmol 1988;106:1384–90.PubMedCrossRefGoogle Scholar
  4. 4.
    Corbett JJ, Nerad JA, Tse DT, et al. Results of optic nerve sheath fenestration for pseudotumor cerebri: the lateral orbitotomy approach. Arch Ophthalmol 1988;106:1391–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Spoor TC, McHenry JG. Long-term effectiveness of optic nerve sheath decompression for pseudotumor cerebri. Arch Ophthalmol 1993;111:632–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Horton JC, Seiff SR, Pitts LH, et al. Decompression of the optic nerve sheath for vision-threatening papilledema caused by dural sinus occlusion. Neurosurgery 1992;31:203–12.PubMedCrossRefGoogle Scholar
  7. 7.
    Garrity JA, Herman DC, Imes R, et al. Optic nerve sheath decompression for visual loss in patients with acquired immunodeficiency syndrome and cryptococcal meningitis with papilledema. Am J Ophthalmol 1993;116:472–8.PubMedGoogle Scholar
  8. 8.
    Ischemic Optic Neuropathy Decompression Trial Research Group. Optic nerve decompression surgery for nonarteritic ischemic optic neuropathy (NAION) is not effective and may be harmful. JAMA 1995;273:625–32.Google Scholar
  9. 9.
    Gasperini J, Black E, Van Stavern G. Perineural metastasis of breast cancer treated with optic nerve sheath fenestration. Ophthal Plast Reconstr Surg 2007;23:331–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Dayan MR, Elston JS, McDonald B. Bilateral lymphomatous optic neuropathy diagnosed on optic nerve biopsy. Arch Ophthalmol 2000;188:1455–7.Google Scholar
  11. 11.
    Kitzmann AS, Pulido JS, Garrity JA, et al. Histologic findings in T-cell lymphoma infiltration of the optic nerve. Ophthalmology 2008;115:e1–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Kersten RC, Kulwin DR. Optic nerve sheath fenestration through a lateral canthotomy incision. Arch Ophthalmol 1993;111:870–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Turbin RE, Wladis EJ, Frohman LP, et al. Role for surgery as adjuvant therapy in optic nerve sheath meningioma. Ophthal Plast Reconstr Surg 2006;22:278–82.PubMedCrossRefGoogle Scholar
  14. 14.
    De Wecker L. On incision of the optic nerve in cases of neuroretinitis. Int Ophthalmol Congr Rep 1872;4:11–14.Google Scholar
  15. 15.
    Pelton RW, Patel BC. Superomedial lid crease approach to the medial intraconal space: a new technique for access to the optic nerve and central space. Ophthal Plast Reconstr Surg 2001;17:241–53.PubMedCrossRefGoogle Scholar
  16. 16.
    Tse DT, Nerad JA, Anderson RL, et al. Optic nerve sheath fenestration in pseudotumor cerebri: a lateral orbitotomy approach. Arch Ophthalmol 1988;106:1458–62.PubMedCrossRefGoogle Scholar
  17. 17.
    Mohamed IG, Roa W, Fulton D, et al. Optic nerve sheath fenestration for a reversible optic neuropathy in radiation oncology. Am J Clin Oncol 2000;23:401–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Banta JT, Farris BK. Pseudotumor cerebri and optic nerve sheath decompression. Ophthalmology 2000;107:1907–12.PubMedCrossRefGoogle Scholar
  19. 19.
    Hupp SL, Glaser JS, Frazier-Byrne S. Optic nerve sheath decompression: review of 17 cases. Arch Ophthalmol 1987;105:386–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Brodsky MC. Protracted postsurgical blindness with visual recovery following optic nerve sheath fenestration. Arch Ophthalmol 1998;116:107–9.PubMedGoogle Scholar
  21. 21.
    Joos KM, Shah RJ, Robinson RD, et al. Optic nerve sheath fenestration with endoscopic accessory instruments versus the free electron laser (FEL). Lasers Surg Med 2006;38:846–51.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of Ophthalmology, Bascom Palmer Eye InstituteUniversity of Miami Miller School of MedicineMiamiUSA

Personalised recommendations