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59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

  • 1.  59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-26-2025 19:58
    This is Dr Anthony Fok - neuro-ophthalmologist from Melbourne, Australia. 

    Case - 59yo with right optic disc swelling that has responded to ONSF and diamox but cannot move forward with diamox or topirimate because of CKD egfr 51 CR 130 and these medications drops his egfr.
    Questions - should I repeat ONSF or consider a trial of steroids if there is an autoimmune process? I am yet to embark of an autoimmune panel. 


    I inherited a patient this year and was prev seen by a now retired neuro-ophthalmologist.

    59yo male with pauci symptomatic right optic disc swelling cause nyd 

    Background: Chronic kidney disease, HTN, dyslipidemia, umbilical hernia, kidney stones 2021 req ureteric stent now removed.  

    Medications: perindopril 10mg daily, atorvastatin 20mg daily. 

     

    2016 found to have right optic disc swelling on routine opt. He has metamorphopsia centrally od. Normal os.  

    Exam: 88kg  BMI 26 

    VA 6/9.6cc PH 6/7.5 od 6/6cc os CP 7/7 ou, pupils 3mm ou in light 4mm ou in dark. Small right RAPD. Fundoscopy: grade 2 disc swelling od normal os. Full eye movements, orthophoric in all gaze positions. 

    HVF: 30-2:  enlarged blind spot od normal os 

    image.pngimage.png 

     

    Autoflorescence –ve for drusen 

    9Feb2017: LP opening pressure 21cmCSF. <1 leucocytes, <1 erythrocytes protein 0.48, glucose 3.3 no organisms, no malignant cells 

    14May18 LP opening pressure 20cmCSF: leucocytes 4 rbc 1 protein 0.44 glucose 3.1. Cytology negative 

    MRI brain and orbits x 5 normal. 2017 2018 2018 2024 2025: prominence of the left optic nerve sheath 

      

    Presumptive diagnosis from my colleague was unilateral papilledema. Tried diamox 250mg Feb2017 qid but caused renal impairment egfr 69 down to 55.  

    Overall diamox seems to be able to reduce the RNFL. 

    Diamox was ceased and disc swelling recurred and had Optic nerve sheath fenestration  25Sep2018 od The oculoplastics surgeon states when he cut into the sheath – CSF flowed freely like 'Niagra falls'.  

    image.png  

     

    image.pngimage.png17May18 (pre ONSF) OCT RNFL 125um od 100 um os      6Nov18 Post ONSF OCT RNFL 93 um od 107um os             

     

    image.png  

    25Nov2024 OCT RNFL 172um od 102um os  

    image.png image.png  

    7Jan25 MRI – Hypoplasia of the left transverse sigmoid sinus with possible narrowing at the right sigmoid transverse junction. Flattening of the posterior sclera right >left . Has moderate fluid within the optic nerve sheath,.  

    image.png  

    image.png  

     

    16May25 od 

    image.png  



  • 2.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-26-2025 20:12

    Hi Anthony,

    What a unique and interesting case.

    I would favor confirmation of a diagnosis before proceeding with any further invasive treatments. The Emory group has an excellent paper on this specific topic in 2021 JNO: Hawy E, Sharma RA, Peragallo JH, Dattilo M, Newman NJ, Biousse V. Unilateral Isolated Paucisymptomatic Optic Disc Edema. J Neuroophthalmol. 2021 Dec 1;41(4):e523-e534. doi: 10.1097/WNO.0000000000001136. PMID: 33394642.

    1. Do you have a contrasted MRI to look for nerve sheath enhancement or a meningioma in the apex / canal blocking CSF egress from the orbit?
    2. How about a fluorescein angiogram to look for signs of uveitis?
    3. Is there vitreopapillary traction on the OCT?
    4. I would discuss ICP monitoring or venous sinus manometry to confirm elevated ICP before repeating an ONSF.

    If there is no progressive field loss and the patient is minimally symptomatic, with only mild disc edema, what is wrong with monitoring?

    Best,


    Drew



    ------------------------------
    Andrew Carey
    Associate Professor
    Wilmer Eye Institute, Johns Hopkins Medicine
    Baltimore MD
    ------------------------------



  • 3.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-26-2025 20:25
    Thanks for your prompt replies.

    There are no symptoms of raised ICP. No TVO, nil pulsatile tinnitus and no headache. 

    Good question -i.e intracranial venous pressures and ICP monitoring. I have attached the MRV TOF. I can refer to neurointervention about this

    Vitreopapillary traction on OCT - I cant see any but I might refer to someone who can check for this and can do FA as well.  

    MRI Feb2024 was with contrast with post con sequences. Nothing significant.
    Feb2025 MRI MRV was done - TOF .
    Left image  is post con, right image is TOF
    image.png
    image.png





    Original Message


  • 4.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-26-2025 20:35
    Can you post a higher resolution disk photo? It doesn’t look too impressive when I blow that one up. I’d be inclined to just watch.

    Mitch G


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  • 5.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-26-2025 20:43
    The fields are stable (improved?), good rnfl, asymptomatic. I would observe and limit further evaluation to low and zero risk testing.

    Russ Edwards




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  • 6.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-26-2025 21:47



    Original Message


  • 7.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-27-2025 04:05
    This may be optic disc gliosis following papilledema that happens to be asymmetrical with good fields and normal ICP no ONSD is required , also other causes of unilateral disc swelling , I mean a new pathology , a new unilateral optic neuropathy or different causes , however it seems unlikely 



    Original Message


  • 8.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-27-2025 07:16
    Why not simply perform a fluorescein angiogram to determine if there is truly leakage of the optic nerve confirming True disk swelling versus late staining which would not require any further investigations or treatment.

    Matt

    Sent via the Samsung Galaxy S21 5G, an AT&T 5G smartphone




    Original Message


  • 9.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-27-2025 14:01

    We can also do just optic nerve head photo , with suitable magnification and focus on the optic nerve only , not the usual Fundus photo that display the optic nerve as a side shadow , I guess with suitable focus and magnification we can get an image that equals the 90-70 D biomicroscooy , details may solve the problem without dye injection 




    Original Message


  • 10.  RE: 59yo mane with pauci symptomatic right optic disc swelling for ~10 years with prev ONSF

    Posted 08-26-2025 20:19
    Are there symptoms aside from the eye consistent with elevated intracranial pressure?

    And when you report the MRI findings, was an MR Venogram done?  Is a sampling of the intracranial venous pressures indicated?
    Sent from my iPhone





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