Progressive and static nonarteritic ischemic optic neuropathy treated by optic nerve sheath decompression

Optic nerve sheath fenestration has been advocated as an effective treatment for progressive nonarteritic ischemic optic neuropathy (NAION) and anecdotally effective for selected patients with NAION who have not had progressive visual loss. To determine whether optic nerve sheath decompression is of any benefit in patients with NAION, the authors reviewed their experience, surgically treating 23 patients with progressive NAION and 15 patients with static or nonprogressive NAION.

Patients with progressive NAION had a significant improvement in visual function as measured by Snellen visual acuity after optic nerve sheath decompression (P = 0.0005). There was no statistically significant improvement in visual field mean deviation (P = 0.11). The 15 patients undergoing optic nerve sheath decompression for static NAION failed to demonstrate significant improvement in either visual acuity (P = 0.90) or visual field mean deviation (P = 0.87). Preoperative standardized echography was used to measure the optic nerve sheath diameter and ascertain its compressibility (30 degrees test). There was a significant difference in compressibility between eyes with static NAION and eyes with progressive NAION (P = 0.001). Accumulation of optic nerve sheath fluid was documented in three eyes initially presenting with NAION and then with development of progressive visual dysfunction.

Optic nerve sheath decompression improves visual acuity but has little effect on overall visual function in patients with progressive NAION. Optic nerve sheath decompression does not improve visual field or acuity in patients with static NAION. Detection of significant intrasheath fluid by standardized echography helps to objectively differentiate patients with NAION who may benefit from optic nerve sheath decompression.