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  • 1.  Optic Nerve Sheath Meningioma after radiation

    Posted 2 days ago
    A 70 yo woman with optic nerve sheath meningioma had improved vision for 12 years post radiation. She is post cataract extraction without radiation retinopathy and has noticed 20% gradual decrement in vision this month. There is disc pallor without optochoroidal collaterals. Repeat imaging is pending.

    Is there anything to offer post rads?

    --
    Edsel Ing  MD PhD FRCSC DABO MPH CPH MIAD MEd MBA
    Chair of Ophthalmology, Univ.of Alberta, Royal Alexandra Hospital  
    Professor DOVS, Univ. of Alberta and Univ. of Toronto
    Oculoplastics, Strabismus & Neuro-ophthalmology 
    Pronouns:  (he-him) (il-lui)

    fax 416) 385 3880

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  • 2.  RE: Optic Nerve Sheath Meningioma after radiation

    Posted 2 days ago
    (The cataract extraction was completed a few years ago.)

    --
    Edsel Ing  MD PhD FRCSC DABO MPH CPH MIAD MEd MBA
    Chair of Ophthalmology, Univ.of Alberta, Royal Alexandra Hospital  
    Professor DOVS, Univ. of Alberta and Univ. of Toronto
    Oculoplastics, Strabismus & Neuro-ophthalmology 
    Pronouns:  (he-him) (il-lui)

    fax 416) 385 3880

    This email may contain confidential, personal and or health information (information which may be subject to legal restrictions on use, retention and /or disclosure) for the sole use of the intended recipient.  Any review or distribution by anyone other than the person for whom it was originally intended is strictly prohibited.  If you have received this email in error, please contact the sender and delete all copies.  




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  • 3.  RE: Optic Nerve Sheath Meningioma after radiation

    Posted 2 days ago
    Does she have any previous visual field to compare with a new one this may give some clues about the cause , something else than the tumour 



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  • 4.  RE: Optic Nerve Sheath Meningioma after radiation

    Posted 2 days ago
    Depends on what the MRI shows:
    1) progression of meningioma is a rock and a hard place, you could consider repeat radiation although the risk of radiation optic neuropathy will be higher and different to quantify, you could try a course of IV steroids, or talk to neuro-oncology about 3rd line options for meningioma (usually temozolamide...)

    2) radiation optic neuropathy (usually occurring to the pre-chiasmal intracranial segment) can offer IV bevacizumab, most patients will not have improved vision but in our retrospective series we were able to prevent further vision decline in ~67% of cases which is a lot better than going blind!
    AlAmeer AM, Davis JB, Carey AR, Henderson AD. Outcomes of systemic bevacizumab in radiation-induced optic neuropathy, case series. J Neurooncol. 2023 Jun;163(2):439-446. doi: 10.1007/s11060-023-04346-y. Epub 2023 May 25. PMID: 37227651.

    I think the evidence for steroids, HBO, and Pentoxifylline is less convincing.
    If there is MRI involvement of the contralateral pre-chiasmal optic nerve before I would try to get IV bevacizumab started ASAP!

    Best,

    Drew



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  • 5.  RE: Optic Nerve Sheath Meningioma after radiation

    Posted 2 days ago
    Assuming that this is growth of residual meningioma rather than radiation-induced optic neuropathy, it is reasonable to consider repeat radiation, although whether to give protons or photons depends on the extent of the process. 

    N



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  • 6.  RE: Optic Nerve Sheath Meningioma after radiation

    Posted yesterday
    My notice is to check about a new pathology like NAION , example , rather than assuming recurrence or radiation neuropathy after those years 



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  • 7.  RE: Optic Nerve Sheath Meningioma after radiation

    Posted yesterday
    Hi 

    You may be assuming it is either recurrent growth of the meningioma or radiation. You have not given us her visual acuities or visual fields or color vision or RAPD with neutral density filters. Is there any posterior subcapsular opacity or change in refraction. She needs a good look at her OCT and OCTA. 

    Dr Hoyt in the early 70s called our attention to signs of radiation optic neuropathy
    Subacute loss of vision
    Relative early development of pallor
    Arteriolar  narrowing

    Do you have  fundus photos at prior visits. 

    The discs become pale or paler frequently before the vision loss

    Jeff Odel




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  • 8.  RE: Optic Nerve Sheath Meningioma after radiation

    Posted 23 hours ago
    Thanx to all for input.
    This patient was lost to follow-up for about 7 years.
    If MRI shows recurrence of optic nerve sheath meningioma will see if rad onc will repeat radiation. I was not aware of this option so thank you Dr. Miller.

    As mentioned no radiation retinopathy.  Await MRI to see if ONSM recurrence or radiation optic neuropathy. 

    VA cc near 20/50, 20/200 NIPH
    Pupil 4->3 OU 2+ RAPD OS
    Troubles seeing control plate from OS. Ishihara 11/12 OD
    IOP 15
    full EOM
    HVF 24-2 VFI OD 99% OD,
    94% generalized depression OS (no media opacity, but pattern deviation plot looks good with generalized depression on total deviation plot.
    PCIOL OU. No posterior capsular opacification.
    optic nerve OD 0.2, OS 0.55 w diffuse pallor, drusen OD, scattered small areas of RPE atrophy OS

    --
    Edsel Ing  MD PhD FRCSC DABO MPH CPH MIAD MEd MBA
    Chair of Ophthalmology, Univ.of Alberta, Royal Alexandra Hospital  
    Professor DOVS, Univ. of Alberta and Univ. of Toronto
    Oculoplastics, Strabismus & Neuro-ophthalmology 
    Pronouns:  (he-him) (il-lui)

    fax 416) 385 3880

    This email may contain confidential, personal and or health information (information which may be subject to legal restrictions on use, retention and /or disclosure) for the sole use of the intended recipient.  Any review or distribution by anyone other than the person for whom it was originally intended is strictly prohibited.  If you have received this email in error, please contact the sender and delete all copies.  




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