Editors Selection (IGR: 18-4) | International Glaucoma Review #117

Editors Selection IGR 18-4

Clinical glaucoma: Disc hemorrhages

Comment by Jost Jonas on:

13565 The optic nerve: A new window into cerebrospinal fluid composition?, Killer HE; Jaggi GP; Flammer J et al., Brain, 2006; 129: 1027-1030

Killer et al. (286) performed a very interesting clinical interventional small case-series study on the 'optic nerve sheath compartment syndrome'. The authors examined the composition of perioptic cerebrospinal fluid obtained during optic nerve sheath fenestration in six patients, and compared it with the composition of the cerebrospinal fluid obtained by lumbar puncture from the same patients. The patients suffered from anterior ischemic optic neuropathy (n = 1), optic nerve sheath meningeoma (n = 1), idiopathic optic disc swelling (n = 1), pachymeningitis (n = 1), idiopathic intracranial hypertension (n = 1), and cerebral hemorrhage (n = 1). Finding marked differences between both groups of samples (perioptic versus lumbar), the authors conclude that the optic nerve can develop into a separate cerebrospinal fluid compartment under certain pathologic conditions.

This result may have profound importance for the physiology and pathophysiology of the optic nerve, since the perioptic cerebrospinal fluid pressure is the real counter-pressure against the intraocular pressure across the lamina cribrosa. If the space around the optic nerve may develop a compartment syndrome, it may theoretically be associated with an abnormally low pressure in some situations. It is only one step forward then to postulate than in that condition, so-called 'normal-pressure glaucoma' may be caused by an abnormally low perioptic cerebrospinal fluid pressure and a normal intraocular pressure, leading to an increased trans lamina cribrosa pressure difference, similar as if the intraocular pressure is elevated and the perioptic cerebrospinal fluid pressure is normal.

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