Elsevier

Survey of Ophthalmology

Volume 52, Issue 1, January–February 2007, Pages 106-110
Survey of Ophthalmology

Clinical Challenges
Optic Neuritis Is Nothing to Sneeze At

https://doi.org/10.1016/j.survophthal.2006.10.008Get rights and content

Abstract

A 36-year-old man developed acute visual loss, mimicking an optic neuritis in the left eye. Cranial magnetic resonance imaging revealed a sphenoid sinus mucocele with extension into the anterior clinoid process abutting the left optic nerve. Endoscopic marsupialization of the mucocele led to marked improvement of vision. Sphenoid sinus mucocele is discussed, as is the differential diagnosis of optic neuritis.

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Comments

Comments by Dale Meyer, MD, and David M. Mills, MD

The patient is a young adult male presenting with painless, acute unilateral vision loss with signs and symptoms of an optic neuropathy. Statistically, in this age group optic neuritis, typically due to demyelinating disease, would be high on the differential. Typically, these patients have pain, especially with eye movement, but this symptom is not always present. It is also important to note that optic neuritis can be related to other causes

Case Report (Continued)

The diagnosis of probable optic neuritis was made and cranial MRI was ordered to evaluate for optic nerve enhancement and demyelinating plaques. The brain and orbit MRI scan showed a non-enhancing mass in the sphenoid sinus with extension into the anterior clinoid process abutting the left optic nerve (Fig. 3). There was no optic nerve enhancement. Computed tomography (CT) scan showed the mass causing destruction of the left optic canal, consistent with a chronic mucocele (Fig. 4).

How would you

Comments (Continued)

Comments by Dr. Meyer and Dr. Mills

The imaging showed a mass in the superolateral wall of the sphenoid sinus adjacent to the optic nerve. The MRI shows the soft-tissue characteristics of the lesion well, and in this case the addition of CT is helpful as it better demonstrates the erosion of the bone in the area along the optic canal. The radiologic features are consistent with the features of a sphenoid sinus mucocele.

Surgical intervention seems clearly indicated for definitive treatment, as

Case Report (Concluded)

The patient underwent endoscopic marsupialization of the mucocele. Two weeks after surgery, the vision OS had improved to 20/25. Color vision was 3/14 Ishihara pseudo-isochromatic plates OS and the automated visual field OS had also improved (Fig. 5). There was a residual 0.3 log unit RAPD OS.

Authors' Discussion

The term optic neuritis denotes primary inflammation of the optic nerve, usually accompanying demyelinating disease. Sphenoid sinus mucocele is not generally listed in the differential diagnosis of optic neuritis.

Mucoceles are cyst-like lesions lined with respiratory epithelium; retention of mucoid secretions leads to thinning and erosion of the sinus bony walls.1, 7 More than half of these lesions are located in the frontal sinuses, most of the remainder being in the ethmoid sinuses. Sphenoid

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      Patients may present with ophthalmic symptoms attributable to II to VI cranial nerve palsies, for instance optic neuropathy, exophthalmos, visual field defects, extraocular palsies, retro-orbital pain. Most frequent symptom is headache, followed by ocular symptoms [8–11]. Anterior clinoid mucoceles are visualized with both CT and MRI.

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      The primary treatment for mucoceles is surgical excision. Because of their compressive nature, most authors advocate early surgical decompression of the cystic lesion via an endoscopic transnasal approach [11,12,14,15,18,19,22] or a transcranial approach [4,9,10,13,16,17]. A large marsupialization of the mucocele is generally definitive and complete removal of the cyst wall should be performed whenever possible [23].

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    The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article. This work was supported in part by an unrestricted grant from the Research to Prevent Blindness, Inc. NY, NY (University of Alabama at Birmingham).

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