Unusual Optic Nerve Sheath Meningioma (Kennerdell Case 12)

John S. Kennerdell, MD

Chair, Department of Ophthalmology Allegheny General Hospital Professor, Ophthalmology

Drexel University College of Medicine

Unusual Optic Nerve Sheath Meningioma Slide 1/18

Case Presentation

• 39-year-old female c/o 6 year history of blurred vision OS, Darkening of vision in eccentric gaze OS, dark lines in vision OS

• Vision: 20/20 OD 20/25 OS 9/1996

• Ishihara: 12/12 OD 10/12 OS

• Pupils: 3/3 RRL 2+ RAPD OS

• Motility: 2+ abduction deficit OS,

8∆ esotropia, 20∆ esotropia L gaze

Unusual Optic Nerve Sheath Meningioma Slide 2/18

Case Presentation

• Exophthalmometry: No proptosis

• SLE: Normal

• DFE: OD: Disc Normal

OS: Moderate chronic disc edema

• Macula/Retina: OD: Normal

OS: Choroidal folds

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An enlarged blind spot caused by the meningioma choking the left optic nerve.

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The left orbital meningioma non-contrast scan (right on this slide).

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The coronal view of the enhancing meningioma (right on this slide).

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Treatment

• 10/7/96 to 11/13/96 Stereotactic XRT

28 fractions 5040 cGy

Intraorbital and intracranial ON

4MV Ph

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Clinical Followup

• 8/1997: Followup Exam: 20/20 OU

“Disc pale”, choroidal folds

• 5/1998: C/O enlarging scotoma, dim vision

20/20 OD 20/200 OS 0/12 plates

Persistent RAPD OS

Severe disc edema with macular and peripapillary exudates

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Clinical Followup

• 9/1998: Persistent poor vision

20/20 OD, 20/200 OS

Florid disc edema with macular

exudates OS, choroidal folds

• MRI repeated, no radiographic progression

no new enhancement

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The severe disc edema that recurred.

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The severe central visual field defect of the left eye.

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The enhancing left optic nerve meningioma lesion with apparent fluid distal to the lesion abutting the globe (right side of slide).

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Surgical Therapy

• 9/17/98 Left lateral optic nerve sheath biopsy and fenestration

• 6 hours post op: 20/20 OD, NLP OS

Pupil: dilated, nonreactive

• Hospitalized for observation

solumedrol 250mg IV q6, 80mg pred taper

• POD #1: 20/20 OD, 10/400 OS

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The lateral approach to the lesion without removing the left orbital rim.

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Post Operative Followup

• POW #5: 20/20 OD, 20/25 OS

Persistent florid edema, macular exudates OS

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The post operative appearance of the lesion which is much smaller now. Note the slight adhesion of the optic nerve lesion to the lateral orbitotomy site (right on this slide).

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The post operative appearance of the patient.

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The marked improvement of the visual field with the vision returning again to 20/20.

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The marked reduction in temporal edema following the left optic nerve sheath decompression anterior to the lesion.