Optic nerve sheath fenestration in patients with visual failure associated with vestibular schwannoma

Background: Papilloedema and visual failure can occur as a consequence of vestibular schwannoma without evidence of hydrocephalus on imaging. Conventional treatment usually includes CSF diversion procedures. We describe here the novel use of optic nerve sheath fenestration in these patients. Methods: A case series of three patients who underwent optic nerve sheath fenestration for visual complications of vestibular schwannoma. Results: Patients A and B were both 23 year old females, with visual symptoms and papilloedema at the time of presentation with a large vestibular schwannoma. Patient A had progressive, severe visual failure despite treatment with an external ventricular drain and tumour resection. She therefore went on to have bilateral optic nerve sheath fenestration surgery, which restored central vision, improved peripheral vision and resolved papilloedema. Patient B underwent optic nerve sheath fenestration as first line surgical management for visual symptoms from a large vestibular schwannoma. This resulted in resolution of visual symptoms and papilloedema and she went on to have the lesion resected at a later date. Patient C was a 54 year old male who developed visual symptoms and papilloedema following the resection of a vestibular schwannoma. This was found to be secondary to a transverse venous sinus thrombosis and he underwent an optic nerve sheath fenestration to treat the complications of this. He also had restored vision and resolution of papilloedema. Conclusion: We demonstrate, with 3 differing cases, that optic nerve sheath fenestration can be a useful and safe treatment choice for patients with visual failure and papilloedema secondary to vestibular schwannoma.