Controversies: Optic nerve sheath fenestration versus shunt placement for the treatment of idiopathic intracranial hypertension

• Published in: Indian journal of ophthalmology 2014-10, Vol.62 (10), p.1015-1021
• Main Authors: Spitze, Arielle, Lam, Peter, Al-Zubidi, Nagham, Yalamanchili, Sushma, Lee, Andrew
• Format: Article
• Language: English
• Subjects: Abducens palsy; Acetylcholine; Anastomosis; Atypical optic neuritis; autoimmune; autoimmunity; Care and treatment; Cerebrospinal Fluid Shunts; Chemosis; Childhood optic atrophy; clinical profile; Comparative analysis; computed tomography; Cortical visual impairment; cranial nerve palsy; Drug therapy; etiology; Eye; Fellowship; Humans; hypoglycemia; hypoxia; Idiopathic intracranial hypertension; India; Intracranial hypertension; lumbo-peritoneal shunt; magnetic resonance imaging; mononeuropathy; multiple sclerosis; neuro-muscular junction; neuro-ophthalmology; neuroimaging; neuromyelitis optica; neuroretinitis; ocular myasthenia gravis; ophthalmology; Ophthalmology Practice; optic atrophy; Optic Nerve - surgery; optic nerve sheath fenestration; optic neuritis; optic neuropathy; periventricular leukomalacia; prematurity; pseudotumor cerebri; Pseudotumor Cerebri - surgery; sixth nerve palsy; strabismus; sub-specialty; Surgery; Surgical anastomosis; thyroid eye disease; treatment; ventriculo-peritoneal shunt
• ISSN: 0301-4738; 1998-3689
• DOI: 10.4103/0301-4738.146012

Background: Idiopathic intracranial hypertension (IIH) has been increasing in prevalence in the past decade, following the obesity epidemic. When medical treatment fails, surgical treatment options must be considered. However, controversy remains as to which surgical procedure is the preferred surgical option - optic nerve sheath fenestration (ONSF) or cerebrospinal fluid (CSF) shunting - for the long-term treatment of this syndrome. Purpose: To provide a clinical update of the pros and cons of ONSF versus shunt placement for the treatment of IIH. Design: This was a retrospective review of the current literature in the English language indexed in PubMed. Methods: The authors conducted a PubMed search using the following terms: Idiopathic IIH, pseudotumor cerebri, ONSF, CSF shunts, vetriculo-peritoneal shunting, and lumbo-peritoneal shunting. The authors included pertinent and significant original articles, review articles, and case reports, which revealed the new aspects and updates in these topics. Results: The treatment of IIH remains controversial and lacks randomized controlled clinical trial data. Treatment of IIH rests with the determination of the severity of IIH-related visual loss and headache. Conclusion: The decision for ONSF versus shunting is somewhat institution and surgeon dependent. ONSF is preferred for patients with visual symptoms whereas shunting is reserved for patients with headache. There are positive and negative aspects of both procedures, and a prospective, randomized, controlled trial is needed (currently underway). This article will hopefully be helpful in allowing the reader to make a more informed decision until that time.