Safety and efficacy of bilateral same-day optic nerve sheath fenestration

To evaluate the safety and efficacy of bilateral same-day optic nerve sheath fenestration (ONSF) in patients with vision-threatening papilledema.

This multi-institutional study included 119 patients with bilateral papilledema who underwent same-day bilateral ONSF. Clinical data collected included: visual acuity (VA), visual field mean deviation (MD) and index (VFI), retinal nerve fiber layer (RNFL) thickness, and intraocular pressure (IOP). Pre- and postoperative outcomes and complications were evaluated with a Generalized Estimating Equation (GEE) using Statistical Analysis System (SAS) for analysis.

This cohort included 119 patients (87% female, mean age 43 years), with idiopathic intracranial hypertension (75%) as the most common cause of papilledema. The median follow-up was 12.5 months. Approximately 20% (40/198) of eyes had improvements in visual acuity >2 Snellen lines, 58% (114/198) had no change in vision, and 22% (44/198) had a decrease in vision >2 lines following ONSF. Visual field MD improved from -17.2 dB to -14.3 dB (p = 0.09). RNFL thickness decreased from 224.7 µm to 146.9 µm (p < 0.001). Two planned bilateral procedures were aborted intraoperatively due to safety concerns; no intraoperative complications occurred among completed bilateral procedures. Additional cerebrospinal fluid diversion procedures were required in 7% of patients.

Same-day bilateral ONSF is a safe and effective option for patients with bilateral vision-threatening papilledema, demonstrating improvement in RNFL thickness while minimizing surgical risk and treatment delays.