Optic Nerve Compromise Research Articles

A Unique Presentation of Metastatic Follicular Thyroid Cancer Associated with Hyperthyroidism and an Active Graves’ Orbitopathy

Background: Graves orbitopathy (GO) developing in a thyroidectomized patient with hormonally active metastatic follicular thyroid cancer (FTC) is an extremely rare event. We report a unique patient with GO and hyperthyroidism developing 13 years after FTC diagnosis. Case: A 79-year-old Caucasian female diagnosed with FTC T3N0M1 with lung metastases in 2005, was treated with total thyroidectomy and cumulative radioiodine (RAI) activity of 700 mCi between 2005 and 2010, with post-treatment scans revealing RAI-avid disease. Despite RAI treatment-associated stable disease in the lungs, the patient developed bone metastases and required external beam radiation (EBRT; 30 Gy in 10 fractions) to the left acetabular lesion in 2011. In 2015, she presented with clinically symptomatic tumor growth in the lungs and bones and biochemical disease progression with thyroglobulin levels rising from 255 ng/ml in 2014 to 273141 ng/mL in 2019. The patient completed repeat EBRT to the left iliac bone in December 2019 (30 Gy in 10 fractions). She was on weight-based suppressive levothyroxine treatment between 2005 and 2019 until she developed atrial fibrillation with a rapid ventricular response and was diagnosed with thyrotoxicosis with TSH < 0.01 mIU/mL (normal0.36 - 5.60) and free T4 5.93 ng/dL (normal 0.9 - 1.7). An iatrogenic cause of thyrotoxicosis was ruled out on the basis of persistent clinical and biochemical hyperthyroidism after reduction, and subsequently, cessation of levothyroxine treatment. Further workup was significant for elevated thyroid stimulated immunoglobulin (TSI) of 23.9 IU/l (normal: < 1.3) and thyrotropin receptor antibodies (TRAb) of 10.39 IU/L (< or =1.75), consistent with Graves’ disease. The patient achieved and maintained euthyroidism on methimazole treatment. In April 2019, she was diagnosed with active GO and was treated with intravenous methylprednisolone, which was discontinued four weeks later due to steroids-induced severe myopathy. Given a high clinical activity score of 6 and magnetic resonance imaging of the orbits revealing a significant bilateral symmetric extraocular muscle enlargement and increased retro-orbital fat with no evidence of optic nerve compromise, she underwent radiation therapy to the orbits (20 Gy in 10 fractions), which was completed in December 2019. Subsequently, in 2020, the patient underwent 8 cycles of treatment with a monoclonal antibody against insulin-like growth factor I receptor - teprotumumab. Subjectively, she reported improved eye swelling and no vision changes, but developed drug-induced partial hearing loss, which is thought to be reversible. Conclusion: Metastatic, progressive FTC can be associated with an autoimmune response, leading to stimulation of well-differentiated cancer tissue to overproduce thyroid hormones resulting in overt hyperthyroidism, as well as retroorbital fibroblasts activation leading to GO.

Man with a Swollen Eye: Nonspecific Orbital Inflammation in an Adult in the Emergency Department

BackgroundNonspecific orbital inflammation (NSOI) is a rare idiopathic ocular pathology characterized by unilateral, painful orbital swelling without identifiable infectious or systemic disorders, which can be complicated by optic nerve compromise. Case ReportA 50-year-old man presented to the Emergency Department with recurring, progressive painless left eye swelling, decreased visual acuity, and binocular diplopia in the absence of trauma, infection, or known malignancy. His physical examination was notable for left-sided decreased visual acuity, an afferent pupillary defect, severe left eye proptosis and chemosis, and restricted extraocular movements; his dilatated funduscopic examination was notable for ipsilateral retinal folds within the macula, concerning for a disruption between the sclera and the retina. Ocular examination of the right eye was unremarkable. Laboratory data were unrevealing. Gadolinium-enhanced magnetic resonance imaging showed marked thickening of the left extraocular muscles associated with proptosis, dense inflammatory infiltration of the orbital fat, and characteristics consistent with perineuritis. The patient was diagnosed with NSOI with optic neuritis and admitted for systemic steroid therapy; he was discharged on hospital day 2 after receiving high-dose intravenous (i.v.) methylprednisolone with significant improvement. Why Should an Emergency Physician Be Aware of This?NSOI is a rare and idiopathic ocular emergency, with clinical mimicry resembling a broad spectrum of systemic diseases such as malignancy, autoimmune diseases, endocrine disorders, and infection. Initial work-up for new-onset ocular proptosis should include comprehensive laboratory testing and gadolinium-enhanced magnetic resonance imaging. Timely evaluation by an ophthalmologist is crucial to assess for optic nerve involvement. Signs of optic nerve compromise include decreased visual acuity, afferent pupillary defect, or decreased color saturation. Patients with optic nerve compromise require admission for aggressive anti-inflammatory therapy with i.v. steroids in an attempt to reduce risk of long-term visual sequelae. Our case demonstrates a severe presentation of this disorder and exhibits remarkable visual recovery after 48 h of systemic i.v. steroid treatment.

Changes in Choroidal Perfusion after Orbital Decompression Surgery for Graves' Ophthalmopathy.

Purpose:To assess choroidal perfusion before and after orbital decompression surgery in patients with Graves' ophthalmopathy.Methods:In this interventional case series, surgical decompression for optic nerve compromise was performed on four eyes of three patients with Graves' disease. Complete ophthalmic examination including visual acuity, color vision, and intraocular pressure assessment were done pre- and postoperatively. High-speed indocyanine green angiography was performed prior to surgery and was repeated one year after surgery.Results:In all three patients, choroidal perfusion defects were noted pre-operatively in the eyes with the compressive optic neuropathy. At 1 year after orbital decompression surgery, the defects improved or completely resolved. Improved visual acuity and color perception, as well as decreased intraocular pressure, were also noted postoperatively.Conclusion:Patients with Graves' orbitopathy may have abnormal choroidal perfusion even in the absence of optic neuropathy. Orbital decompression may improve choroidal circulation in these patients.

Complete Vision Loss following Orbital Cellulitis Secondary to Acute Dacryocystitis.

We present a case of a 50-year-old woman with acute dacryocystitis that was complicated by posterior rupture of the lacrimal sac causing an orbital cellulitis with subsequent visual acuity of no light perception. Upon presentation, she was immediately started on broad-spectrum antibiotics and underwent surgical incision and drainage of the lacrimal sac abscess but never regained vision. There are 4 cases in the literature of permanent severe vision loss from acute dacryocystitis. Prompt diagnosis and close monitoring of acute dacryocystitis are therefore essential to prevent extension into the orbit and possible optic nerve compromise.

Nontraumatic Subperiosteal Bilateral Orbital Hemorrhages After Mitral Valve Repair

Nontraumatic subperiosteal orbital hemorrhages (NTSOHs) are rare events, but pose a grave risk of vision loss and must be evaluated carefully for optic nerve compromise. To the author's knowledge, only 2 cases of NTSOH after cardiovascular procedures have been reported. The authors report a unique case of bilateral NTSOH with optic neuropathy that developed after cardiothoracic surgery and reaccumulated after orbitotomy. The case presentation conforms to the tenets of the Declaration of Helsinki and is Health Insurance Portability and Accountability Act compliant. The etiology and management of this uncommon and dangerous entity will be discussed.

Medical versus surgical management of pediatric orbital subperiosteal abscesses

Medical versus surgical management of pediatric orbital subperiosteal abscesses

Endoscopic Resection of Tuberculum Sellae Meningiomas

Objective To evaluate the results of endoscopic transnasal resection of tuberculum sellae meningiomas (TSMs) as compared with transcranial approaches. Design We retrospectively analyzed five patients who underwent endoscopic endonasal resection of TSM and performed a comprehensive review of articles published between 2000 and 2012 describing the operative treatment of TSMs. Results Gross total resection (GTR) was achieved in four patients (80%). Transient diabetes insipidus occurred in three patients (60%). Preoperative visual field deficit resolved in all patients. Cerebrospinal fluid (CSF) leak occurred in one patient. Analysis of published studies included 1,026 transcranial and 144 transnasal cases. GTR was achieved in 85% of transcranial and 72% of transnasal cases. Visual field deficit improved in 65% of transcranial and 82% of transnasal cases. Rate of diabetes insipidus and CSF leak was higher in the transnasal series. Rate of GTR and visual improvement was higher in endoscopic endonasal as compared with microsurgical transnasal series. Conclusion The literature supports transsphenoidal surgery for the resection of TSMs with significant optic nerve compromise and limited lateral extension. This approach may have an equivalent if not superior outcome over transcranial surgery in visual outcome. CSF leaks are still a challenge but may improve with the use of vascularized nasoseptal flaps.

Management of acute traumatic retrobulbar haematomas: A 10-year retrospective review

Retrobulbar haematoma formation is a known complication following facial trauma involving the orbits. This is an important clinical entity as it can lead to permanent vision loss if not appropriately managed in the acute setting. From 1999 to 2009, 2586 patients presented to the Chang Gung Memorial Hospital with orbital fractures. Eight patients presented with nine retrobulbar haematomas. A retrospective review of the patient's medical records was performed. Analysis of visual outcomes was performed based on the improvement degree (ID) formula. The average age of our patients is 24.5 years with the most common cause of trauma being motor vehicle (motorcycle) collisions. Visual acuity and the light reflex were abnormal in all patients. Five patients (case #1-5) demonstrated an absent relative afferent pupillary defect (RAPD). Computed tomography imaging confirmed the presence of a retrobulbar haematoma in all patients. The average follow-up was 14.5 months (range: 6-20 months). Management was divided into three cohorts: observation alone, medical therapy alone or a combined surgical and medical therapy. The best visual outcomes (ID=82%) were achieved in the combined treatment group. The worst outcomes (ID=42%) were in the medical therapy alone group. In review of our experience, we have found that the presence or absence of an RAPD is the most sensitive indicator of optic nerve compromise and necessity for intervention. An algorithm was also developed based on this study. Once a decision is made to intervene on a retrobulbar haematoma, both medical and surgical therapies should be instituted with a priority given to timely decompression of the orbit.

Orbital Floor Abscess Secondary to Sinusitis in an Immunocompromised Patient

A 65-year-old man with a history of renal transplantation presented with facial pain, purulent nasal discharge, and periorbital swelling. Signs of optic nerve compromise developed and persisted despite medial orbital wall decompression. Further imaging revealed an orbital floor abscess secondary to direct communication of a maxillary pseudomonal sinusitis. Full recovery was achieved after further surgical drainage via an endoscopic endonasal approach. Failure to improve after surgical decompression is an indication for repeat imaging. Immunocompromised patients can present atypically. Orbital floor abscess secondary to sinusitis without an underlying odontogenic or traumatic cause has not previously been reported. The authors highlight the importance of clinical vigilance, serial imaging, microbiological investigations, and early surgical intervention in high-risk patients.

Bilateral Spontaneous Subperiosteal Orbital Hemorrhages Following Endoscopic Retrograde Cholangiopancreatography

Spontaneous subperiosteal orbital hemorrhage is rare. The authors describe a case of acute bilateral eyelid swelling, eyelid ptosis, and double vision in a patient immediately following endoscopic retrograde cholangiopancreatography. CT revealed bilateral subperiosteal orbital hemorrhages. The patient demonstrated no signs of optic nerve compromise, and the hemorrhages resolved spontaneously without sequela. Previous reports in the literature have documented subperiosteal hemorrhages following increased intracranial venous pressure, coagulopathies, and prone positioning during procedures. To the authors' knowledge, subperiosteal orbital hemorrhages have not been previously described following endoscopic retrograde cholangiopancreatography. Ophthalmologists and gastroenterologists should be aware of this potential complication associated with this procedure.

The Role of Intravenous Methylprednisolone Immunosuppression in the Management of Active Thyroid Eye Disease

Purpose: To analyze the efficacy of intravenous methylprednisolone (IVMP) immunosuppression in the management of active thyroid eye disease (TED).Methods: This is a consecutive case series of 36 patients treated with 1 g of IVMP over 3 days, between January 2000 and January 2008. The indications for this treatment were moderate to severe active TED with or without optic nerve compression.Results: There were 32 hyperthyroid, 2 hypothyroid, and 2 euthyroid patients in this series. Nine patients presented with optic nerve compromise, 3 had severe active TED and 24 had moderately active TED. Twenty-seven patients received one course of IVMP and nine patients received two courses. All patients had tapering oral prednisolone over 1 month following the IVMP. The mean improvement in proptosis was 1.31 mm (range = 0–3 mm). Optic nerve function improved in seven of nine patients (77.8%). Extra ocular muscle movement improved in 18 patients (50%). Overall benefit from IVMP was seen at 1/12 in 27 patients (75%) and at 3/12 in 30 patients (83%). After IVMP one patient underwent radiotherapy and three patients had nonsteroidal immunosuppression.Conclusions: IVMP immunosuppression is effective in 83% of patients. The effect lasts from 3 months to 8 years, with a mean of 15 months in 30.5%. It remains a useful modality of treatment especially when the optic nerve or cornea is threatened because of moderate to severe active TED. We encountered no severe side effects of pulsed IVMP and 3 g over 3 days is a safe dose.

Orbital Subperiosteal Hematoma After Thrombolysis and Anticoagulation for Acute Myocardial Infarction

Orbital subperiosteal hematoma is a known complication of trauma (1). We are reporting for the first time its occurrence after the combination of thrombolysis and anticoagulation. A 44-year-old man presented with a head injury and brow laceration caused by syncope due to a myocardial infarction. No other ocular problems were noted. He underwent thrombolysis with 40 mg intravenous tenecteplase and was also treated with an infusion of intravenous heparin at a rate of 18 units/kg/h, 300 mg aspirin, 300 mg clopidogrel, and intravenous glyceryl trinitrate at an initial rate of 2.4 mL/h and titrated according to the patient's pain. Seven hours later he complained of headache and double vision. Visual acuity at the bedside was 20/25 in the right eye and 20/20 in the left eye. Ishihara plate color vision was normal. The pupils were of normal size and reactivity. The right eye appeared displaced inward and downward (Fig. 1). He had reduced supraduction and abduction of the right eye and normal ductions in the left eye. There was mild resistance to retropulsion, although no difference in globe displacement was found on Hertel exophthalmometry. He had some bruising and discoloration of his right upper lid. Intraocular pressure using a handheld applanation tonometer was 16 mm Hg in the right eye and 12 mm Hg in the left eye. Results of ophthalmoscopy were normal.FIG. 1: Seven hours after thrombolysis and anticoagulation, the patient complained of diplopia. In primary gaze position, the right eye is displaced downward and inward. The right upper lid is mildly ecchymotic.Brain and orbit CT revealed a frontal extradural hematoma, a temporal subdural hematoma, and a right orbital roof subperiosteal hematoma, with no evidence of an orbital roof fracture (Fig. 2). He was treated with 1 g tranexamic acid daily to inhibit fibrinolysis. All other medications were continued after a long discussion about the risks and benefits of withdrawing medical therapy.FIG. 2: Precontrast sagittal CT shows a superior orbital subperiosteal hematoma (arrow).Two days later visual acuity was 20/20 in both eyes and pupil reactions remained normal. Ophthalmoscopy revealed superotemporal choroidal folds of the right eye. A follow-up brain and orbit CT showed no change in the size of the hematomas. All ocular motility examinations were comparable to his examination on presentation. The diplopia was alleviated with a 30Δ base up Fresnel prism in the right spectacle. Four weeks after the onset of his symptoms, the ocular alignment (Fig. 3) and movements had returned to normal, the diplopia had resolved, and the subperiosteal hematoma had decreased in size.FIG. 3: Four weeks after thrombolysis and anticoagulation, the eyes are in normal position and aligned.The fact that our patient had no visual symptoms on presentation but developed them 7 hours after thrombolysis leads us to believe that the combination treatment consisting of a fibrinolytic, an anticoagulant, and a high-dose antiplatelet agent was responsible for the development of a subperiosteal hematoma. The orbital hematoma was unlikely to have been an extension of the frontal hematoma, as there was no evidence of an orbital roof fracture or communication between the intracranial and orbital compartments. Although early surgical management of subperiosteal hematomas by needle aspiration or surgical evacuation of the hematoma (2-4) may be important for the prevention of significant ocular morbidity, in this case there was no optic nerve compromise and no progression of the ductional deficits, so intervention was not necessary. Kwesi N. Amissah-Arthur, MBChb Victoria Eye Unit Hereford County Hospital Hereford, UK Birmingham and Midland Eye Centre City Hospital Birmingham, UK Markus Groppe, MBBS, MRCOphth Victoria Eye Unit Hereford County Hospital Hereford, UK Prince Charles Eye Unit King Edward VII Hospital Windsor, UK Stephen Scotcher, MBChb, MRCP, FRCOphth Victoria Eye Unit Hereford County Hospital Hereford, UK [email protected]

Ocular Advancement in Monobloc Distraction

Monobloc distraction has been demonstrated to be an efficacious, safe, and stable method of providing functional and aesthetic improvement in children with syndromic craniosynostosis. Although the movement of bony structures following monobloc distraction has been quantitatively assessed before, objective analysis of the movement of soft tissues, such as the globe, has not been published previously. The authors present a method that assesses globe movement following monobloc distraction, using computed tomographic scan data. The preoperative and postoperative computed tomographic scans of 10 patients with Pfeiffer's and Crouzon's syndromes, undergoing monobloc distraction, were assessed. Scan data were loaded into voxel image-rendering software that produced a three-dimensional reconstruction. Direct measurements between preoperative and postoperative images were taken. An average upper face osseous distraction distance of 12.94 mm, with an average lower face distraction of 14.19 mm, was achieved in all 10 children. The authors measured average globe movements on three planes and calculated an average left eye forward movement of 5.28 mm and average right eye forward movement of 6.33 mm. In all, globe advancement was approximately two fifths of the distance advanced by the surrounding bone. Forward movement of the globe following monobloc distraction has not previously been described. Although there is no current evidence for optic nerve stretch and compromise in monobloc surgery, the functional implications of these findings should be formally assessed.

Rituximab is effective in the treatment of refractory ophthalmic Wegener's granulomatosis

To investigate the efficacy of rituximab in patients with refractory ophthalmic Wegener's granulomatosis (WG). Data from 10 consecutive patients with refractory ophthalmic WG treated with rituximab were retrospectively reviewed. In all patients, the ophthalmic disease was driving treatment decisions, and disease activity had persisted despite standard immunosuppressive treatment. Patients had refractory scleritis (n=3), orbital granulomas causing optic nerve compromise (n=4), or a combination of both conditions (n=3). All patients had been treated with at least 3 different immunosuppressive agents, and 5 patients had previously been treated with tumor necrosis factor alpha blockade. Rituximab was administered intravenously in 2 doses, 2 weeks apart, in combination with standard treatment. Disease activity was monitored clinically by an interdisciplinary approach, including disease activity scoring, immunodiagnostics, and magnetic resonance imaging, as well as by corresponding reductions in the required dose of conventional medication. A beneficial response to treatment with rituximab was seen in all 10 patients, including induction of clinical remission. In all patients, the peripheral blood B cell count fell to zero during treatment with rituximab. Titers of classic antineutrophil cytoplasmic antibodies fell in association with B cell counts, and this reduction was correlated with improved clinical findings. In contrast to previous observations, this study showed that treatment with rituximab was associated with clinical improvement in patients with refractory ophthalmic WG.

Orbital Compression Syndrome in Sickle Cell Disease

To present 3 cases of orbital compression syndrome caused by infarction of the greater wing of the sphenoid in patients with sickle cell disease. Case report and review of the literature. Three patients with sickle cell disease (2 males aged 22 and 16 years, and a 10-year-old girl) who presented with proptosis, limited ocular motility, and chemosis were found to have an infarction of the marrow space of the greater wing of the sphenoid that produced an orbital subperiosteal hemorrhage and exudate demonstrated on MRI. Two patients suffered compressive optic neuropathy; both patients recovered normal optic nerve function. Orbital edema resolved within 48 hours of receiving 1 g methylprednosolone daily. The third patient had normal optic nerve function and his orbital edema improved with methylprednisolone 250 mg/day and intravenous Kefzol over 3 days. In the literature, there are 27 similar cases; 5 were treated surgically and the remainder were managed medically. Patients with sickle cell disease are at risk for orbital compression syndrome secondary to orbital bone infarction, in the setting of vaso-occlusive crises. This diagnosis should be considered when a patient with sickle cell disease presents with headache, proptosis, decreased motility, and/or optic nerve compromise.

Orbital emphysema after endoscopic third ventriculostomy and posterior fossa surgery in the sitting position

Orbital emphysema can be associated with optic nerve and vascular compromise, with subsequent potentially irreversible visual loss. We report a 4-year-old girl who presented right orbital emphysema after posterior fossa surgery for pilocytic astrocytoma resection in the sitting position. Endoscopic third ventriculostomy (ETV) had been previously carried out for the treatment of symptomatic obstructive hydrocephalus. Our hypothesis is that periorbital emphysema developed due to air passing from the intracranial to the extracranial compartment through the ETV burr hole. The emphysema resolved spontaneously without any sequelae. To our knowledge, this is the first description of orbital emphysema after posterior fossa surgery in the sitting position.

Wegener’s Granulomatosis: Ophthalmic Manifestations and Management

To provide an up-to-date and comprehensive review of Wegener's granulomatosis (WG) as a disease entity, focusing on the ophthalmic manifestations and management options. A search of Medline was undertaken between 1966 and 2005 regarding WG, systemic vasculitis, and the ocular manifestations of WG. Major ophthalmic and medical textbooks also were reviewed for content, as well as original references. Involvement of ocular and orbital structures in patients with WG is common and may be a presenting feature. The ocular manifestations range from mild conjunctivitis and episcleritis to more severe inflammation with keratitis, scleritis, uveitis, and retinal vasculitis. Involvement of the nasolacrimal system and orbital tissues also can occur. Except for some cases of anterior segment inflammation, the ocular involvement will not respond to topical agents, but rather to systemic antiinflammatory and immunosuppressive regimens. Surgical intervention may be of value for obtaining tissue diagnosis, in achieving orbital decompression in cases of significant orbital disease with optic nerve compromise, or in cases of nasolacrimal duct obstruction. WG is an important clinical entity that needs to be recognized early and treated appropriately. Ophthalmic manifestations are frequently encountered and can result in significant morbidity and even blindness. The management is challenging and often requires a multidisciplinary approach.

Orbital, Middle Cranial Fossa, and Pterygopalatine Fossa Yolk Sac Tumor in an Infant

A yolk sac tumor, also known as an endodermal sinus tumor, was diagnosed in a 15-month-old infant who presented with rapidly progressive right eye proptosis. Imaging of the orbits and brain revealed a mass in the right orbit, middle cranial fossa, and pterygopalatine fossa. A lateral orbitotomy was performed to take a biopsy specimen and to partially debulk the tumor secondary to signs of optic nerve compromise. The biopsy specimen revealed a yolk sac tumor, and the patient underwent systemic chemotherapeutic treatment. Because orbital endodermal sinus tumors have been infrequently reported, there are no firm prognostic or treatment guidelines. Our case demonstrates that early recognition, limited orbital debulking, and chemotherapy can have an excellent short-term outcome.

Ophthalmic Issues in Hemangiomas of Infancy

Hemangiomas are the most common benign tumor of infancy. Although most hemangiomas remain asymptomatic, certain hemangiomas can cause significant morbidity and require treatment. Periocular hemangiomas require close observation and early therapy for those lesions with potential for visual impairment. Hemangiomas typically cause visual morbidity by induction of amblyopia, strabismus, significant refractive error or optic nerve compromise. Diagnosis is typically straightforward but occasionally other entities may cause diagnostic confusion and radiologic evaluation can be helpful. This is particularly important if the hemangioma is one component of the PHACES syndrome. Therapeutic options which may be useful include steroids (oral, intralesional or topical), interferon alpha (usually reserved for life- or sight-threatening lesions due to serious potential side effects), laser, embolization and surgery. Ophthalmic treatment using patching, atropine, glasses and stabismus surgery may be necessary.

Benefits and complications of photodynamic therapy of papillary capillary hemangiomas

Objective To evaluate the potential benefit and risks of photodynamic therapy (PDT) in the treatment of papillary capillary hemangioma. Design Prospective, noncomparative, interventional case series. Participants Five patients with solitary capillary hemangioma on the temporal portion of the optic nerve presenting with exudative decompensation and decrease in visual acuity (VA). Methods All eyes received a standardized PDT treatment with 6 mg/kg body surface area verteporfin and application of 100 J/cm 2 light at 692 nm. One to three PDT courses were performed until resolution of exudation was achieved. A continuous follow-up was provided with documentation 1 week before and at 4 to 6 weeks, 3 months, and 12 months after the last treatment application. Main outcome measures Functional parameters included best-refracted VA (Early Treatment Diabetic Retinopathy Study), and central scanning laser ophthalmoscope (SLO) scotometry and peripheral (automated perimetry) visual fields; anatomic parameters were presence of retinal edema or serous detachment (ophthalmoscopy) and tumor size (ultrasonography). Results Pretreatment VA levels ranged from 20/40 to 20/800; posttreatment levels ranged from 20/64 to 20/2000. Tumor regression with resolution of macular exudate and serous retinal detachment was obtained in all eyes. A decline in VA of 1, 3, and 10 lines, respectively, was documented in three patients. Complications included transient decompensation of vascular permeability, occlusion of retinal vessels, and ischemia of the optic nerve. Conclusions PDT is successful in reducing tumor size and exudative activity. Vaso-occlusive effects at the level of the retina and optic nerve compromise the functional benefit. Parameters proven safe in choroidal neovascularization may be inappropriate in retinal capillary lesions of the optic nerve.