Distinct clinical characteristics of optic compressive neuropathyassociated with anterior clinoid process pneumatization

Distinct clinical characteristics of optic compressive neuropathyassociated with anterior clinoid process pneumatization | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Distinct clinical characteristics of optic compressive neuropathyassociated with anterior clinoid process pneumatization mingxing wu, quangang xu, mingming sun, yuyu li, shihui wei, huanfen zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5083544/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Objective Anterior clinoid process (ACP) pneumatization is an uncommon entity. The goal of the research was to explore the diagnostic characteristics and prognosis of the compressive optic neuropathy (CON) caused by ACP pneumatization. Methods Clinical information were retrospectively gathered via those in hospitals diagnosed alongside CON companied with ACP pneumatization at the Neuro-Ophthalmology Department at the Chinese People’s Liberation Army General Hospital from January 2021 to August 2023. Results A overall of thirteen sufferers ( three females and ten males, sixteen involved eyes) participated alongside an average age of 34.38 ± 16.12 years. All the eyes were assessed with the ACP pneumatization classification system established by Da Costa:pneumatization Type 0 occurred in 3/26 sides (11.5%), Type 1 in 8/26 sides (30.8%), Type 2a in 8/26 sides (30.8%), Type 2b in 5/26 sides (19.2%), Type 3 in 2/26 sides (7.7%). 69.6% (16/23) eyes had optic compressive neuropathy in these patients.Among the ten patients with bilateral pneumatization, only three induced bilateral compressive optic neuropathy. 37.5%(6/16) eyes with visual field defect as the first symptom. Ultimately, two patients had endoscopic sphenoidotomy and optic canal decompression surgery, resulting in improved visual acuity in the operated eyes. Conclusions CON caused by ACP pneumatization can lead to transient visual obscuration, varying degrees of visual field defects and vision loss. HRCT is advised in cases of unexplained vision loss and visual field defects to determine whether or not ACP gasification is occurring. While whether it requires surgery intervention and its effectiveness, still require large-scale research and verification. Compressive optic neuropathy Anterior clinoid process pneumatization Neuro-ophthalmology Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Compressive optic neuropathy(CON) could be developed due to intrinsic or extrinsic compression anywhere along the optic nerve. The most typical symptom is gradual, progressive monocular vision loss, which can occasionally be accompanied by headaches. Treating the underlying illness is the most important aspect of treatment. Corticosteroids are useful for inflammatory lesions, and surgery is for patients with prominent radiological evidence of compression[ 1 ]. The prognosis for sight recovery differs depending on what caused the optic nerve to be compressed. New research finds that pneumatization of anterior clinoid process (ACP) may affect the optic nerve canal, subsequentially compress the optic nerve[ 2 ], leading to unexplained vision loss and visual field defect. This condition is easily to be misdiagnosed as optic neuritis and be given inappropriate treatments with high-dose corticosteroids. The lateral wall of the optic canal and the lesser sphenoid wing project medially to form the ACP. It has a pyramidal form alongside a tip and a base that is fixed with three points[ 3 ]; It is connected to the optic strut inferomedially, the lesser sphenoid wing laterally, and the planum sphenoidale medially. The floor of the optic canal and the ceiling of the superior orbital fissure are formed by the optic strut, which typically continues less than the optic nerve to the body of the sphenoid[ 4 ]. There have only been a few cases of ACP pneumatization accompanied compressive optic neuropathy documented to far, making it an extremely rare syndrome. Though the exact mechanism of pneumatization induced optic compressive neuropathy remains unclear[ 5 ], ophthalmologists speculated about the insidious etiology. It is believed that the optic strut allows the sphenoid sinus air chamber to typically extend into the ACP, and this would impair the bone wall supporting strength for the optic nerve, expose the optic nerve within the sphenoid sinus cavity. Because of its close relationship to the optic canal, the optic nerve would be compressed as a result of the ACP's pressure shift[ 6 , 7 ]. Prior research on the ACP has mostly concentrated on its anatomic changes based on computed tomography (CT) scans, with the goal of enhancing the safety of surgical methods for removing the ACP in the disciplines of neurosurgery. At least four clinoid pneumatization classifications[ 8 – 11 ] have been proposed, of which the classification published by Da Costa et al. in 2016 unifying multiple existing systems and showing great potential and reproducibility[ 12 ]. To our knowledge, there are no studies of CON associated with ACP pneumatization, to determine ocular symptoms and prognosis of the disease, including visual field defects and optical coherence tomography (OCT). This study aims to bridge that gap via the examination of a Chinese patient cohort, assessing the clinical characteristics and outcomes of the disease, to provide fully understanding the disease in the clinic. Methods The Chinese People's Liberation Army General Hospital (PLAGH) database was used to select medical files of hospitalized individuals identified as having compressive optic neuropathy caused by ACP pneumatization between January 2021 and August 2023, alongside follow-up periods ranging from three to thirty-one months. All of those who suffer gave their informed permission. The PLAGH's institutional review board authorized the study protocol, which was carried out in compliance with the Helsinki Declaration's principles. Sufferers participating in the present investigation must have met what follows criteria based to the publication[ 10 , 14 ]: 1) at least one of the following manifestations: patients may complaint of transient amaurosis, or decrease in visual acuity, or visual field defects; 2) a minimum of one of the anomalies listed here: an RAPD, visual field defects, decreased color vision, thinning of GCL in the macular, or thinning of RNFL in the optic disc; 3) definite imaging evidence (orbital MRI and CT) for ACP pneumatization;4) optic neuropathy with vascular, compressive, hereditary, infiltrative, toxic and metabolic causes checked out; causative ocular illnesses that might cause vision loss must also be determined out. -Ophthalmological investigations Ophthalmological investigations encompassed testing for RAPD and ophthalmoscopy for examining the retina. The best corrected visual acuity (BCVA) was assessed employing a Snellen chart, and a BCVA less than 0.01 was recorded alongside count finger, hand motion, perceived light and no perceived light. Optic Disc Cube 200×200 circular scan and Macular Cube 512×128 scan were carried out according to standard procedure utilizing one of two spectral-domain optic coherence tomography (OCT) instruments (Carl Zeiss Meditec, USA, or Heidelberg Engineering, Germany).Color vision was applied with Farnsworth Munsell 100 hue. The CSV-1000E contrast sensitivity chart test face was used for contrast sensitivity test. -Imaging examination All patients underwent optic nerve magnetic resonance imaging(MRI), optional sequences including coronal T1-weighted imaging (T1WI), axial T2WI with fat suppression and oblique sagittal T1WI post-contrast oriented along the optic nerve(Trio; GE Healthcare Europe GmbH, Freiburg, Germany). Pictures of skull base high-resolution computed tomography (internal and mastoid) were acquired as well, employing the Brilliance computed tomography (CT) 64 system (Philips) alongside the subsequent technical specifications: collimation 20 × 0.625, pitch 0.348, matrix 512, field of view 200 mm, 140 kpv, 278–600 mA, and cut thickness 0.67 mm. When buildings with the same air density were present, pneumatization was evident. -ACP Pneumatization Category The type of ACP pneumatization was evaluated via the classification published by da Costa et al. in 2016. Pneumatization of the optic pillar is included in the categorization as a component of the ACP pneumatization complex, giving rise to four forms of pneumatization and five subtypes in overall: Type 0 – not becoming pneumatized; Type 1 – pneumatization in the ACP body absent from the optic strut; Type 2A – pneumatization via the optic strut of ≤ 50% of the ACP body; Type 2B – pneumatization via the optic strut of > 50% of the ACP body; and Type 3 – ACP pneumatization via the sphenoidal plane (utilizing a pneumatized optic strut or not). Results -Demographic data and clinical manifestation An overall of 13 sufferers (ten males and three females) alongside ACP pneumatization were chosen based on the inclusion standards stated above(Table 1 ). The average age at onset was 34.38 ± 16.12 years (ranged from 16 to 60 years). The pneumatization of ACP had a bilaterality preponderance(10/13, 76.9%) vs. unilaterality (3/13, 23.1%). Among these patients, 69.6% (16/23) eyes with ACP were diagnosed with compressive optic neuropathy. Among the ten patients with bilateral pneumatization, only three induced bilateral compressive optic neuropathy. When waking up every morning, two patients experienced several bouts of transitory amaurosis in both eyes. 37.5%(6/16) eyes with visual field defect as the first symptom. BCVA of the affected eye ranged from 0.08 to 1.2, including 12/16 (75.0%) eyes ≥ 0.5, and only 2/16(12.5%) eyes presented with severe vision loss (≤ 0.1). Table 1 Clinical features data for patients with CON companied with ACP pneumatization Patient/sex/age Symptoms Disease Course (month) ACP laterality Involved eye BCVA at onset Treatment Follow up (for the involved eyes) OD OS Duration (month) BCVA Visual field 1/M/16 Amaurosis after getting up every morning for LE 36 Bilateral Left \ 1.0 Clinical follow-up 31 Unchanged Fluctuant 2/M/47 Visual field defect with decreased vision in LE 24 Bilateral Left \ 0.5 Medication,vit B, etc 4 Unchanged Stable 3/M/26 Progressive decrease in vision for RE 24 Right Right 0.08 \ Recommended operation 4 Unchanged Fluctuant 4/F/16 Visual field defect in LE 2 Bilateral Left \ 1.0 Medication,vit B, etc 4 Unchanged Stable 5/M/27 Progressive decreased vision with visual field defect in RE 24 Bilateral Right 0.3 \ Recommended operation 4 Unchanged Fluctuant 6/F/23 Blurred vision in LE 2 Bilateral Left \ 1.0 Clinical follow-up 3 Unchanged Stable 7/M/28 Visual field defect in both eyes 36 Bilateral Bilateral 1.0 1.2 Clinical follow-up 4 Unchanged Stable 8/M/55 Blurred vision in both eyes 0.5 Bilateral Bilateral 0.6 0.3 Endoscopic sphenoidotomy and optic canal decompression for LE 5 Improved to 0.5 for LE Slightly improved 9/M/22 Decreased vision in LE 6 Bilateral Left \ 0.1 Endoscopic sphenoidotomy and optic canal decompression for LE 7 Improved to 0.12 for LE Stable 10/M/46 Decreased vision in RE 1 Right Right 0.5 \ Medication,vit B, etc 3 Unchanged Stable 11/F/60 Decreased vision in RE 2 Right Right 0.5 \ Medication,vit B, etc 3 Unchanged Stable 12/M/57 Visual field defect in both eyes 12 Bilateral Bilateral 1.0 0.6 Medication,vit B, etc 3 Unchanged Stable 13/M/24 Amaurosis after getting up every morning 10 Bilateral Left \ 1.0 Clinical follow-up 3 Unchanged Fluctuant Note: ACP: anterior clinoid process. BCVA: best corrected visual acuity. LE: left eye. RE: right eye. -Ophthalmological findings Table 2 showed the ophthalmic examinations in ACP Pneumatization patients. 84.6% (11/13) patients had positive RAPD. 38.5% (5/13) patients had abnormal optic discs, including two optic atrophy, one faded temporal optic disc and two swelling disc. Peripapillary circular OCT scan revealed thinning of retinal nerve fiber layer(RNFL) in three eyes, macular OCT scan recording retinal ganglion cells loss in six eyes. It could be referred that the loss of retinal ganglion cells may occur earlier than the thinning of RNFL. The ophthalmological records for patient 8 were shown in Supplementary Fig. 1(A-C). The changes in the visual field were variable. A majority of patients assumed unilateral mild visual field defect, central or peripheral, scotoma or other variations of nerve fiber bundle defects. Three patients exhibited bilateral visual field changes. Bilateral enlarged blind spot were detected for patient 7, while bilateral nasal visual field defect predominant changes were observed for patient 8 and patient 10. Only patient 9 had normal view till now. Eight patients had color vision and contrast sensitivity examination, among which three patients had normal results. As for the color vision, all of the other five patients were detected for a tritan defect for the involved eyes. Accordingly, these involved eyes had low-mid spatial frequency decrease in the contrast sensitivity test as well. Table 2 Ophthalmological findings for patients No. Patient/sex/age Ophthalmological examination for first recorded visit (R/L) RAPD Fundus photography Average GCL + IPL Thickness (R/L) (µm) Average RNFL Thickness (R/L) (µm) VFD Color vision score (R/L) Contrast sensitivity 1 1/M/16 LE(+) Normal 95/82 132/104 Inferior VFD in LE N/A N/A 2 2/M/47 LE(+) Optic atrophy in LE 83/57↓ 92/61↓ Diffuse VFD in LE N/A N/A 3 3/M/26 RE(+) Normal 83’/82 98/96 Superior multiple foci in RE Normal Low-mid spatial frequency decrease in RE 4 4/F/16 LE(+) Normal 74/75 98/112 Temporal rim in LE N/A N/A 5 5/M/27 RE(+) Normal 80/88 96/100 Nasal diffuse VFD in RE Normal Low-mid spatial frequency decrease in RE 6 6/F/23 LE(+) Normal 84/82 88/94 Central scotoma in LE N/A N/A 7 7/M/28 Negative Normal 72↓/72↓ 87/88 Bilateral enlarged blind spot N/A N/A 8 8/M/55 Negative Bilateral optic disc swelling N/A 167↑/172↑ Bilateral nasal VFD in RE, diffuse VFD in LE 208/96 Low-mid spatial frequency decrease in both eyes 9 9/M/22 LE(+) Normal 88/83 107/108 Central scotoma in LE Normal Low-mid spatial frequency decrease in LE 10 10/M/46 RE(+) Optic atrophy in RE 58↓/84 94/100 Peripheral multiple foci in RE 312/84 Low spatial frequency decrease in RE 11 11/F/60 RE(+) Normal 78/75 82/80 Normal 152/77 Low spatial frequency decrease in RE 12 12/M/57 LE(+) Optic atrophy in LE 68↓/48↓ 76↓/52↓ Bilateral nasal nasal VFD 188/312 Low-mild spatial frequency decrease in RE, Low-mild-high spatial frequency decrease in LE 13 13/M/24 LE(+) Normal 92/93 85/85 Nasal and inferior multiple foci in LE 100/104 Normal Note: RAPD: relative afferent pupillary defect. RNFL: retinal nerve fibre layer. OCT: Optical coherence tomography. GCL: ganglion cell layer. IPL: inner plexiform layer. BCVA: best corrected visual acuity. LE: left eye. RE: right eye. N/A: not applicable. F-VEP: flash visual evoked potential. VED: Visual fields defect. -Imaging features and ACP Pneumatization classification There were no optic nerve anomalies in five of the individuals. Five patients(eight eyes) presented with broadening of optic nerve sheath within T2WI(Fig. 1 A-F). Long T2-weighted hypersignal and thinning could be seem in three eyes in three patients (Fig. 1 G-I). CT scans was examined through an overall of two evaluators, of which one was neuro-ophthalmologists and one was radiologist. Each evaluator independently reviewed the images, and any divergence was solved after collective deliberation. Pneumatization degrees were classified on the basis of the volume of pneumatization into five types as introduced in the “method” part. When calculated on the basis of total 26 sides (Fig. 2 ), pneumatization Type 0 occurred in 3/26 sides (11.5%), Type 1 in 8/26 sides (30.8%), Type 2a in 8/26 sides (30.8%), Type 2b in 5/26 sides (19.2%), Type 3 in 2/26 sides (7.7%). The imaging evidences implied optic compressive neuropathy for patient 1 with transient amaurosis after getting up every morning for LE were displayed in Fig. 3 . The MRI and CT imaging evidences for patient 8 were displayed in Fig. 4 . -Treatment and prognosis The treatment of compressive optic neuropathy derived from ACP pneumatization included medication therapy and surgery. Personalized treatment was applied for these patients. Five patients were under medication treatment with vitamins and neurotrophic drugs. Patient 8 and 9 were performed with the operation of endoscopic sphenoidotomy and optic canal decompression. Patient 3 and 5 were recommended to undergo surgical treatment to avoid further deterioration of vision, but they didn't undergo surgery because of considering the side effects of surgery and the uncertainty of visual prognosis. The rest four patients with decent visual function were advised to continue routine follow-up. The follow-up period averaged 6.00 ± 7.29 months. Within the follow-up period, the BCVA in all patients kept unchanged except for the two patients with surgery. After the surgical intervention, both patient 8 and 9 obtained an improved eyesight for the operated eye, from 0.3 to 0.5 and 0.1 to 0.12,respectively. 61.5% (8/13) of patients had stable visual fields. Figure 4 showed the images of CT and MRI presentation before therapy in patients 8. Changes in fundus, OCT and VDF pre-operation and post-operation for patients 8 were displayed in Supplementary Fig. 1(D-I). Discussion The compressive optic neuropathy caused by ACP pneumatization has aroused great concern among neuro-ophthalmologists. This article revealed clinical characteristics resulted from ACP pneumatization in detail in 13 patients, with a male predominance, which is the same as reported as before[ 13 ]. Previous studies stated that mucocele around the ACP was a cause of compressive optic neuropathy that led to monocular visual loss[ 14 , 15 ], while the symptoms of simple ACP pneumatization have rarely been reported. Our study firstly demonstrated the clinical features of compression optic neuropathy due to pneumatization within the ACP religion. In our cohort,76.9% (10/13) patients had bilateral involvement of the pneumatization of ACP. Among these patients, 69.6% (16/23) eyes with ACP were diagnosed with CON. Depending on the degree of pneumatization, all patients in our cohort have been graded on the basis of CT scans. But we couldn't figure out the relationship between grading and visual impairment because of small group. When waking up every morning, two patients experienced several bouts of transitory amaurosis in their unilateral eye. 37.5% eyes with visual field defect as the first symptom. Only 2/16 (12.5%) eyes at onset presented with severe vision loss (≤ 0.1), 12/16 (75.0%) eyes had VA ≥ 0.5.Decreased visual function is strongly correlated with COP caused by ACP pneumatization leading to the narrowing of the optic canal. Yet the subtle compressive neuropathy caused by low-level pneumatization should also be valued since it is easily be ignored clinically. Other signs verifying compressive optic neuropathy[ 16 ] including a positive RAPD in the affected eye, varying degrees of visual field defects, decreased color vision and contrast sensitivity. More importantly, we observed the demise of retinal ganglion cells within the macular predated the retinal nerve fiber layer (RNFL) thinning upon OCT. Meanwhile the widening of the subarachnoid space of the optic nerve in the orbital segment presented in five patients in the orbit MRI, was strongly suggestive of a compressive pathogenesis from the intraductal segment of optic nerve. So far, these features have not been reported in previous literature. A uncommon disorder known as pneumosinus dilatans causes dilated paranasal sinuses bordered via normal mucosa to fill alongside air[ 13 , 17 ]. Anatomically, pneumatization of the ACP is a variant that affects 6.6–27.7% of people[ 12 ], the precise mechanism behind which is unclear. Overpneumatization may cause the canal wall to thin and the optic nerve to become compressed[ 18 ]. Since the optic nerve was in close contact with the air within the sphenoid sinus, when hyperaerated anterior clinoid process may develop beyond its normal anatomical boundary, it was easily led to pathogenic compression. Sudden changes in altitude or intra-sinus pressure have been proposed as potential triggers for acute clinical manifestations, including amaurosis fugax. For instance, when the patient with anterior clinoid process sneezed violently, a suction impact on the optic nerve as well as the supply of blood had been evoked, thus would cause damage to the exposed optic nerve [ 17 ]. Visual degradation was observed by Gilles Danassegarane et al. [ 19 ] to have started with a gradual decline in visual acuity linked to temporal pallor of the optic disc and a nasal visual field defect. This appearance, like others[ 17 , 20 ], may be clarified through the optic nerve's intracanalicular segment, containing fibers from the nasal visual field, becoming compressed over time. The result of secondary evolution was optic atrophy. In our study, both case7 and case12 manifested similar nasal visual field defect, while the subsequent development needs further observation and follow-up. There's still no consensus on how to manage these patients. If the patients had severe visual impairment, surgery should be recommended. The literature[ 7 , 19 ] states that in order to preserve the sufferer's ability to see and relieve symptoms before signs of severe visual abnormalities and optic atrophy appear, an early surgical decompression of the optic canal should be taken into consideration. Various surgical techniques have been suggested, including endonasal endoscopy[ 21 – 23 ] or by craniotomy[ 24 , 25 ]. In our study, patient 8 and 9 with severe visual loss in unilateral eye underwent a transnasal endoscopic sphenoidostomy and optic canal decompression. Main procedures included creating an outlet for decompression from sphenoid into anterior clinoid process, excising septum sphenoid sinus to remove the bone wall of the optic canal, exposing the anterior wall of optic canal from orbital apex to chiasma, therefore effectively establishing a pressure balance and preventing the anticipated suction impact. After surgery, both of them had mild visual improvement in the operated eye. For patients with mild visual impairment or visual field loss, they may have concerns about undergoing surgery due to the side effects of surgery and the uncertainty of visual prognosis. Based on experience with other types of CON, surgical decompression before RNFL thinning may better improve visual function. There were several restrictions on this cohort research. First, challenges in evaluating the prognosis were caused by the limited sample size and follow-up duration. Second, the mechanism of CON was unknown, with gasification of the anterior clinoid process in both eyes, but only one eye developing the disease. Third, the relationship between the degree of anterior clinoid gasification and visual impairment was unclear and not elaborated in the text. To date, nevertheless, the research has offered more thorough clinical features of the COP patients brought on by the ACP pneumatization. Further research with a more extensive sample size and extended follow-up period is necessary to validate our results. In summary In conclusion, the COP caused by ACP was uncommon, which can lead to transient visual obscuration, varying degrees of visual field defects and vision loss. In cases of inexplicable vision loss and visual field defects, HRCT is advised to determine whether ACP gasification is present. Decompression surgery can be considered during an early phase. However, its effectiveness still requires more investigation and validation. Declarations Ethics approval and consent to participate The experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of the 3rd Medical Center of Chinese PLA General Hospital. Written informed consent was obtained from individual or guardian participants. Funding This work was supported by the National Natural Science Foundation for Youth of China (No. 82101110)，Kuanren Talents Program of the second affiliated hospital of Chongqing Medical University，China Postdoctoral Science Foundation(2024M753888) and Chongqing Postdoctoral Research Project Special Suppot(2023CQBSHTB3106). Data Availability Statement The data that support the findings of this study are available on request from the corresponding authors upon reasonable request. Disclosure of interest The authors declare that they have no competing interests. Author contributions Mingxing Wu performed writing original draft and funding acquisition. Quangang Xu performed Formal analysis. Mingming Sunperformed investigation. Yuyu Li performed methodology. Huanfen Zhou performed funding acquisition and writing review& editing. Shihui Wei performed conceptualization and supervision. Acknowledgments All authors approved the submitted manuscript and contributed actively to the study. Mingxing Wu and Quangang Xu are co-first authors and contributed equally to this study. Huanfen Zhou and Shihui Wei are co-corresponding authors and contributed equally to this study. References Rodriguez-Beato FY, De Jesus O, Neuropathy CO. StatPearls, Treasure Island (FL) with ineligible companies. Disclosure: Orlando De Jesus declares no relevant financial relationships with ineligible companies., 2023. Aghdam KA, Aghajani A, Sanjari MS. Bilateral Visual Loss Caused by Pneumosinus Dilatans: Idiopathic Cases are not Always Reversible. 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Pneumosinus dilatans of the sphenoid and visual loss: when should the optic nerve be decompressed? Childs Nerv Syst. 2021;37(8):2677–82. Kim KM. Binasal hemianopia caused by pneumosinus dilatans of the sphenoid sinuses. Indian J Ophthalmol. 2019;67:1772–5. Bachor WR, Kahle E, Draf G. Temporary unilateral amaurosis with pneumosinus dilatans of the sphenoid sinus. Skull Base Surg. 1994;4:169–75. Aryan TS, Jagannatha S, Channegowda AT, Rao C, Hegde AS. Pneumosinus dilatans of the spheno-ethmoidal complex associated with hypovitaminosis D causing bilateral optic canal stenosis. Childs Nerv Syst. 2017;33:1005–8. Juhl BC, Bollinger HJ. An extensive maxillary pneumosinus dilatans. Rhinology. 2001;39:236–8. Stretch PM. Pneumosinus dilatans as the aetiology of progressive bilateral blindness. Br J Plast Surg. 1992;45:469–73. Sanjari MM, Tarassoly MS. Pneumosinus dilatans in a 13 year old female. Br J Ophthalmol. 2005;89:1537–8. Additional Declarations No competing interests reported. Supplementary Files 74suplementarymaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Sep, 2024 Editor assigned by journal 13 Sep, 2024 Submission checks completed at journal 13 Sep, 2024 First submitted to journal 13 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5083544","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":354447053,"identity":"3bc0bc96-b06f-4208-ae4e-849263452518","order_by":0,"name":"mingxing wu","email":"","orcid":"","institution":"The 3rd Medical Center of Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"mingxing","middleName":"","lastName":"wu","suffix":""},{"id":354447055,"identity":"3e9eb809-8d02-47a2-a44c-982d7fb6b7d7","order_by":1,"name":"quangang xu","email":"","orcid":"","institution":"The 3rd Medical Center of Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"quangang","middleName":"","lastName":"xu","suffix":""},{"id":354447056,"identity":"d77b5b9d-8490-4c01-8eec-2af366ea96e9","order_by":2,"name":"mingming sun","email":"","orcid":"","institution":"The 3rd Medical Center of Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"mingming","middleName":"","lastName":"sun","suffix":""},{"id":354447058,"identity":"d6d14686-be0f-4078-9955-9af7b5e21da4","order_by":3,"name":"yuyu li","email":"","orcid":"","institution":"The 3rd Medical Center of Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"yuyu","middleName":"","lastName":"li","suffix":""},{"id":354447061,"identity":"70e6ea8f-6271-4083-ba8d-7cc69436cf4d","order_by":4,"name":"shihui wei","email":"","orcid":"","institution":"The 3rd Medical Center of Chinese PLA General Hospital","correspondingAuthor":false,"prefix":"","firstName":"shihui","middleName":"","lastName":"wei","suffix":""},{"id":354447064,"identity":"e9854bb8-dd99-4f52-a14a-fb70e6a280ff","order_by":5,"name":"huanfen zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACCSBmbAAzGR8kVNSQpoXZ4MGZY6RpYZN82MJMWIf87OZjkj932CT2SyQfq0hsYGPgb+9OwKuFcc6xNAnJM2mJM2ekpd1I3CHDIHHm7Aa8WpglcswkDNsOJ264kWN2I/EMG4OBRC5+LWwgLYlALftv5H8rSGxjJqyFB6TlIMgWiRw2BqK0SEikJVs2tqUZzzjzzFgi4cwxHoJ+kZ+RfPDmzzYb2f725Icff1TUyPG39+LXggACCRCXEqkcBPgPkKB4FIyCUTAKRhQAALC2Sb7npmODAAAAAElFTkSuQmCC","orcid":"","institution":"The 3rd Medical Center of Chinese PLA General Hospital","correspondingAuthor":true,"prefix":"","firstName":"huanfen","middleName":"","lastName":"zhou","suffix":""}],"badges":[],"createdAt":"2024-09-13 11:44:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5083544/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5083544/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67999891,"identity":"62e378ba-d3ab-468f-99fc-72112cfed0ed","added_by":"auto","created_at":"2024-11-01 07:50:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":511910,"visible":true,"origin":"","legend":"\u003cp\u003eOrbit MRI in CON patients companied with ACP pneumatization. Five patients(eight eyes) presented with broadening of optic nerve sheath in T2WI(A-F), and white arrow showed widening of the subarachnoid space of the optic nerve in the orbital segment. Long T2-weighted hypersignal and thinning could be seem in three eyes in three patients (G-I), with white arrow head showing T2 hyperintense and thinning in optic nerve.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-5083544/v1/15786b13c7f0950f4e910ee3.png"},{"id":68000972,"identity":"9745c767-fc9f-46a6-8944-69f92a8b8fc0","added_by":"auto","created_at":"2024-11-01 07:58:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":680147,"visible":true,"origin":"","legend":"\u003cp\u003eOrbit HRCT in CON patients companied with ACP pneumatization. 10 patients had bilateral ACP pneumatization, among them 3 patients(patient 7,8,12) had bilateral CON. White arrow showed the laterality with different degrees ACP pneumatization, while without inducing CON yet. Yellow arrow indicated the involved eyes with CON companied with ACP pneumatization. The grading for pneumatization was as follows: patient1 with 1-R and 3-L, patient2 with1-R and 2b-L, patient3 with 2a-R and 0-L, patient4 with 2b-R and 2a-L, patient5 with 2b-R and 2a-L, patient6 with 1-R and 2a-L, patient7 with 2b-R and 2a-L, patient8 with 1-R and 3-L, patient9 with 2a-R and 2b-L, patient9 with 2a-R and 2b-L, patient10 with 1-R and 0-L, patient11 with 2a-R and 0-L, patient12 with 1-R and 1-L, patient 13 with 1-R and 2a-L.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-5083544/v1/e23d94e8a678a4c66082d33c.png"},{"id":67999894,"identity":"7f5fb837-fe45-48fc-be79-c8eeea8f4118","added_by":"auto","created_at":"2024-11-01 07:50:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":716365,"visible":true,"origin":"","legend":"\u003cp\u003eImaging evidence in patients with AC0 pneumatization associated CON in the left eye (patient 1). Orbital MRI with T2WI in axial (A) and coronal (B) showed the broadening of optic nerve sheath on the left eye (white arrow) indicating optic nerve compression .Postcontrast T1WI in axial (C) and coronal (D) revealed the intracranial optic nerve thinning in the left eye in close contact with the air in the sphenoid sinus (white arrow head), with no enhancement of optic nerves bilaterally. Axial(E) and coronal(F) CT bone window shows an abnormal extensive pneumatization of the sphenoid sinus into the left anterior clinoid process(dotted white arrow), characterizing pneumosinus dilatans of the sphenoid. The patient complained with amaurosis after getting up every morning for left eye with fluctuant visual field defect .The central 30‑2 visual field testing shows the visual field changes from January 2021 to January 2022 in the left eye. The test in 2021(G) indicated an inferior visual field deficit. Then one year passed, the first result(H) in 2022 depicted a more extensive loss of visual field than the former year. While in less than ten days, the second result demonstrated a markedly improved visual field(I).\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-5083544/v1/b87fcfab56c26f3f757f29b2.png"},{"id":67999893,"identity":"0fc25e0e-5b80-4222-a3cd-0088d13fbdc5","added_by":"auto","created_at":"2024-11-01 07:50:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":561162,"visible":true,"origin":"","legend":"\u003cp\u003eImages evidence in patient 8. Orbital MRI(A-F) and CT(G-I) images show enlarged sphenoid sinus and extreme narrowing of the optic nerve canal, which is more severe on the left side. T2WI in coronal(D) reveals the broadening of optic nerve sheath on the left side(white arrow), implying the occurrence of compressive optic neuropathy.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-5083544/v1/1d85e5d4a8d8bb8e3e05de1d.png"},{"id":68001729,"identity":"40aa456b-5a52-4d2d-a72e-c8948b13ad8b","added_by":"auto","created_at":"2024-11-01 08:06:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3571887,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5083544/v1/78e11098-014d-473e-be52-2ec8ee82a5e6.pdf"},{"id":67999896,"identity":"9d8073de-0870-46ec-8313-f3a176dee18b","added_by":"auto","created_at":"2024-11-01 07:50:08","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1316319,"visible":true,"origin":"","legend":"","description":"","filename":"74suplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-5083544/v1/3ef31e7cfb07c80360c1708c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Distinct clinical characteristics of optic compressive neuropathyassociated with anterior clinoid process pneumatization","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCompressive optic neuropathy(CON) could be developed due to intrinsic or extrinsic compression anywhere along the optic nerve. The most typical symptom is gradual, progressive monocular vision loss, which can occasionally be accompanied by headaches. Treating the underlying illness is the most important aspect of treatment. Corticosteroids are useful for inflammatory lesions, and surgery is for patients with prominent radiological evidence of compression[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prognosis for sight recovery differs depending on what caused the optic nerve to be compressed. New research finds that pneumatization of anterior clinoid process (ACP) may affect the optic nerve canal, subsequentially compress the optic nerve[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], leading to unexplained vision loss and visual field defect. This condition is easily to be misdiagnosed as optic neuritis and be given inappropriate treatments with high-dose corticosteroids.\u003c/p\u003e \u003cp\u003eThe lateral wall of the optic canal and the lesser sphenoid wing project medially to form the ACP. It has a pyramidal form alongside a tip and a base that is fixed with three points[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]; It is connected to the optic strut inferomedially, the lesser sphenoid wing laterally, and the planum sphenoidale medially. The floor of the optic canal and the ceiling of the superior orbital fissure are formed by the optic strut, which typically continues less than the optic nerve to the body of the sphenoid[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere have only been a few cases of ACP pneumatization accompanied compressive optic neuropathy documented to far, making it an extremely rare syndrome. Though the exact mechanism of pneumatization induced optic compressive neuropathy remains unclear[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], ophthalmologists speculated about the insidious etiology. It is believed that the optic strut allows the sphenoid sinus air chamber to typically extend into the ACP, and this would impair the bone wall supporting strength for the optic nerve, expose the optic nerve within the sphenoid sinus cavity. Because of its close relationship to the optic canal, the optic nerve would be compressed as a result of the ACP's pressure shift[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrior research on the ACP has mostly concentrated on its anatomic changes based on computed tomography (CT) scans, with the goal of enhancing the safety of surgical methods for removing the ACP in the disciplines of neurosurgery. At least four clinoid pneumatization classifications[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] have been proposed, of which the classification published by Da Costa et al. in 2016 unifying multiple existing systems and showing great potential and reproducibility[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo our knowledge, there are no studies of CON associated with ACP pneumatization, to determine ocular symptoms and prognosis of the disease, including visual field defects and optical coherence tomography (OCT). This study aims to bridge that gap via the examination of a Chinese patient cohort, assessing the clinical characteristics and outcomes of the disease, to provide fully understanding the disease in the clinic.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe Chinese People's Liberation Army General Hospital (PLAGH) database was used to select medical files of hospitalized individuals identified as having compressive optic neuropathy caused by ACP pneumatization between January 2021 and August 2023, alongside follow-up periods ranging from three to thirty-one months. All of those who suffer gave their informed permission. The PLAGH's institutional review board authorized the study protocol, which was carried out in compliance with the Helsinki Declaration's principles.\u003c/p\u003e \u003cp\u003eSufferers participating in the present investigation must have met what follows criteria based to the publication[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]: 1) at least one of the following manifestations: patients may complaint of transient amaurosis, or decrease in visual acuity, or visual field defects; 2) a minimum of one of the anomalies listed here: an RAPD, visual field defects, decreased color vision, thinning of GCL in the macular, or thinning of RNFL in the optic disc; 3) definite imaging evidence (orbital MRI and CT) for ACP pneumatization;4) optic neuropathy with vascular, compressive, hereditary, infiltrative, toxic and metabolic causes checked out; causative ocular illnesses that might cause vision loss must also be determined out.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e-Ophthalmological investigations\u003c/h2\u003e \u003cp\u003eOphthalmological investigations encompassed testing for RAPD and ophthalmoscopy for examining the retina. The best corrected visual acuity (BCVA) was assessed employing a Snellen chart, and a BCVA less than 0.01 was recorded alongside count finger, hand motion, perceived light and no perceived light. Optic Disc Cube 200\u0026times;200 circular scan and Macular Cube 512\u0026times;128 scan were carried out according to standard procedure utilizing one of two spectral-domain optic coherence tomography (OCT) instruments (Carl Zeiss Meditec, USA, or Heidelberg Engineering, Germany).Color vision was applied with Farnsworth Munsell 100 hue. The CSV-1000E contrast sensitivity chart test face was used for contrast sensitivity test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e-Imaging examination\u003c/h2\u003e \u003cp\u003eAll patients underwent optic nerve magnetic resonance imaging(MRI), optional sequences including coronal T1-weighted imaging (T1WI), axial T2WI with fat suppression and oblique sagittal T1WI post-contrast oriented along the optic nerve(Trio; GE Healthcare Europe GmbH, Freiburg, Germany). Pictures of skull base high-resolution computed tomography (internal and mastoid) were acquired as well, employing the Brilliance computed tomography (CT) 64 system (Philips) alongside the subsequent technical specifications: collimation 20 \u0026times; 0.625, pitch 0.348, matrix 512, field of view 200 mm, 140 kpv, 278\u0026ndash;600 mA, and cut thickness 0.67 mm. When buildings with the same air density were present, pneumatization was evident.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e-ACP Pneumatization Category\u003c/h2\u003e \u003cp\u003eThe type of ACP pneumatization was evaluated via the classification published by da Costa et al. in 2016. Pneumatization of the optic pillar is included in the categorization as a component of the ACP pneumatization complex, giving rise to four forms of pneumatization and five subtypes in overall: Type 0 \u0026ndash; not becoming pneumatized; Type 1 \u0026ndash; pneumatization in the ACP body absent from the optic strut; Type 2A \u0026ndash; pneumatization via the optic strut of \u0026le;\u0026thinsp;50% of the ACP body; Type 2B \u0026ndash; pneumatization via the optic strut of \u0026gt;\u0026thinsp;50% of the ACP body; and Type 3 \u0026ndash; ACP pneumatization via the sphenoidal plane (utilizing a pneumatized optic strut or not).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e-Demographic data and clinical manifestation\u003c/h2\u003e \u003cp\u003eAn overall of 13 sufferers (ten males and three females) alongside ACP pneumatization were chosen based on the inclusion standards stated above(Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The average age at onset was 34.38\u0026thinsp;\u0026plusmn;\u0026thinsp;16.12 years (ranged from 16 to 60 years). The pneumatization of ACP had a bilaterality preponderance(10/13, 76.9%) vs. unilaterality (3/13, 23.1%). Among these patients, 69.6% (16/23) eyes with ACP were diagnosed with compressive optic neuropathy. Among the ten patients with bilateral pneumatization, only three induced bilateral compressive optic neuropathy. When waking up every morning, two patients experienced several bouts of transitory amaurosis in both eyes. 37.5%(6/16) eyes with visual field defect as the first symptom. BCVA of the affected eye ranged from 0.08 to 1.2, including 12/16 (75.0%) eyes\u0026thinsp;\u0026ge;\u0026thinsp;0.5, and only 2/16(12.5%) eyes presented with severe vision loss (\u0026le;\u0026thinsp;0.1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical features data for patients with CON companied with ACP pneumatization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePatient/sex/age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDisease Course\u003c/p\u003e \u003cp\u003e(month)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eACP laterality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInvolved eye\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eBCVA at onset\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eFollow up (for the involved eyes)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDuration\u003c/p\u003e \u003cp\u003e(month)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBCVA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eVisual field\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1/M/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmaurosis after getting up every morning for LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eClinical follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFluctuant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2/M/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisual field defect with decreased vision in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedication,vit B, etc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3/M/26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProgressive decrease in vision for RE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRecommended operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFluctuant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4/F/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisual field defect in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedication,vit B, etc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5/M/27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProgressive decreased vision with visual field defect in RE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRecommended operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFluctuant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6/F/23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlurred vision in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eClinical follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7/M/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisual field defect in both eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eClinical follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8/M/55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlurred vision in both eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopic\u003c/p\u003e \u003cp\u003esphenoidotomy and optic canal decompression for LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved to 0.5 for LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSlightly improved\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9/M/22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecreased vision in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEndoscopic\u003c/p\u003e \u003cp\u003esphenoidotomy and optic canal decompression for LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved to 0.12 for LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10/M/46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecreased vision in RE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedication,vit B, etc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11/F/60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecreased vision in RE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedication,vit B, etc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12/M/57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisual field defect in both eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedication,vit B, etc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13/M/24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmaurosis after getting up every morning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\\\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eClinical follow-up\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUnchanged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFluctuant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eNote: ACP: anterior clinoid process. BCVA: best corrected visual acuity. LE: left eye. RE: right eye.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e-Ophthalmological findings\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e showed the ophthalmic examinations in ACP Pneumatization patients. 84.6% (11/13) patients had positive RAPD. 38.5% (5/13) patients had abnormal optic discs, including two optic atrophy, one faded temporal optic disc and two swelling disc. Peripapillary circular OCT scan revealed thinning of retinal nerve fiber layer(RNFL) in three eyes, macular OCT scan recording retinal ganglion cells loss in six eyes. It could be referred that the loss of retinal ganglion cells may occur earlier than the thinning of RNFL. The ophthalmological records for patient 8 were shown in Supplementary Fig.\u0026nbsp;1(A-C).\u003c/p\u003e \u003cp\u003eThe changes in the visual field were variable. A majority of patients assumed unilateral mild visual field defect, central or peripheral, scotoma or other variations of nerve fiber bundle defects. Three patients exhibited bilateral visual field changes. Bilateral enlarged blind spot were detected for patient 7, while bilateral nasal visual field defect predominant changes were observed for patient 8 and patient 10. Only patient 9 had normal view till now.\u003c/p\u003e \u003cp\u003eEight patients had color vision and contrast sensitivity examination, among which three patients had normal results. As for the color vision, all of the other five patients were detected for a tritan defect for the involved eyes. Accordingly, these involved eyes had low-mid spatial frequency decrease in the contrast sensitivity test as well.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOphthalmological findings for patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePatient/sex/age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"8\" nameend=\"c10\" namest=\"c3\"\u003e \u003cp\u003eOphthalmological examination for first recorded visit (R/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c11\" namest=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRAPD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFundus photography\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAverage GCL\u0026thinsp;+\u0026thinsp;IPL Thickness (R/L) (\u0026micro;m)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAverage RNFL Thickness (R/L) (\u0026micro;m)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVFD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eColor vision score (R/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eContrast sensitivity\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/M/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95/82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e132/104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInferior VFD in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/M/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptic atrophy in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83/57\u0026darr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92/61\u0026darr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDiffuse VFD in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/M/26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83\u0026rsquo;/82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98/96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSuperior multiple foci in RE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eLow-mid spatial frequency decrease in RE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/F/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74/75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e98/112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTemporal rim in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/M/27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80/88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96/100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNasal diffuse VFD in RE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eLow-mid spatial frequency decrease in RE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/F/23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e84/82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88/94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCentral scotoma in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/M/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u0026darr;/72\u0026darr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87/88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBilateral enlarged blind spot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8/M/55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBilateral optic disc swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e167\u0026uarr;/172\u0026uarr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBilateral nasal VFD in RE, diffuse VFD in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e208/96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eLow-mid spatial frequency decrease in both eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/M/22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88/83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e107/108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCentral scotoma in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eLow-mid spatial frequency decrease in LE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/M/46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptic atrophy in RE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58\u0026darr;/84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e94/100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePeripheral multiple foci in RE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e312/84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eLow spatial frequency decrease in RE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/F/60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78/75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82/80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e152/77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eLow spatial frequency decrease in RE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/M/57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptic atrophy in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68\u0026darr;/48\u0026darr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e76\u0026darr;/52\u0026darr;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBilateral nasal nasal VFD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e188/312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c11\" namest=\"c9\"\u003e \u003cp\u003eLow-mild spatial frequency decrease in RE, Low-mild-high spatial frequency decrease in LE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/M/24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLE(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92/93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e85/85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNasal and inferior multiple foci in LE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e100/104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eNote: RAPD: relative afferent pupillary defect. RNFL: retinal nerve fibre layer. OCT: Optical coherence tomography. GCL: ganglion cell layer. IPL: inner plexiform layer. BCVA: best corrected visual acuity. LE: left eye. RE: right eye. N/A: not applicable. F-VEP: flash visual evoked potential. VED: Visual fields defect.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e-Imaging features and ACP Pneumatization classification\u003c/h2\u003e \u003cp\u003eThere were no optic nerve anomalies in five of the individuals. Five patients(eight eyes) presented with broadening of optic nerve sheath within T2WI(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-F). Long T2-weighted hypersignal and thinning could be seem in three eyes in three patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eG-I).\u003c/p\u003e \u003cp\u003eCT scans was examined through an overall of two evaluators, of which one was neuro-ophthalmologists and one was radiologist. Each evaluator independently reviewed the images, and any divergence was solved after collective deliberation. Pneumatization degrees were classified on the basis of the volume of pneumatization into five types as introduced in the \u0026ldquo;method\u0026rdquo; part. When calculated on the basis of total 26 sides (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), pneumatization Type 0 occurred in 3/26 sides (11.5%), Type 1 in 8/26 sides (30.8%), Type 2a in 8/26 sides (30.8%), Type 2b in 5/26 sides (19.2%), Type 3 in 2/26 sides (7.7%). The imaging evidences implied optic compressive neuropathy for patient 1 with transient amaurosis after getting up every morning for LE were displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The MRI and CT imaging evidences for patient 8 were displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e-Treatment and prognosis\u003c/h2\u003e \u003cp\u003eThe treatment of compressive optic neuropathy derived from ACP pneumatization included medication therapy and surgery. Personalized treatment was applied for these patients. Five patients were under medication treatment with vitamins and neurotrophic drugs. Patient 8 and 9 were performed with the operation of endoscopic sphenoidotomy and optic canal decompression. Patient 3 and 5 were recommended to undergo surgical treatment to avoid further deterioration of vision, but they didn't undergo surgery because of considering the side effects of surgery and the uncertainty of visual prognosis. The rest four patients with decent visual function were advised to continue routine follow-up.\u003c/p\u003e \u003cp\u003eThe follow-up period averaged 6.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29 months. Within the follow-up period, the BCVA in all patients kept unchanged except for the two patients with surgery. After the surgical intervention, both patient 8 and 9 obtained an improved eyesight for the operated eye, from 0.3 to 0.5 and 0.1 to 0.12,respectively. 61.5% (8/13) of patients had stable visual fields. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e showed the images of CT and MRI presentation before therapy in patients 8. Changes in fundus, OCT and VDF pre-operation and post-operation for patients 8 were displayed in Supplementary Fig.\u0026nbsp;1(D-I).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe compressive optic neuropathy caused by ACP pneumatization has aroused great concern among neuro-ophthalmologists. This article revealed clinical characteristics resulted from ACP pneumatization in detail in 13 patients, with a male predominance, which is the same as reported as before[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Previous studies stated that mucocele around the ACP was a cause of compressive optic neuropathy that led to monocular visual loss[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], while the symptoms of simple ACP pneumatization have rarely been reported. Our study firstly demonstrated the clinical features of compression optic neuropathy due to pneumatization within the ACP religion.\u003c/p\u003e \u003cp\u003eIn our cohort,76.9% (10/13) patients had bilateral involvement of the pneumatization of ACP. Among these patients, 69.6% (16/23) eyes with ACP were diagnosed with CON. Depending on the degree of pneumatization, all patients in our cohort have been graded on the basis of CT scans. But we couldn't figure out the relationship between grading and visual impairment because of small group. When waking up every morning, two patients experienced several bouts of transitory amaurosis in their unilateral eye. 37.5% eyes with visual field defect as the first symptom. Only 2/16 (12.5%) eyes at onset presented with severe vision loss (\u0026le;\u0026thinsp;0.1), 12/16 (75.0%) eyes had VA\u0026thinsp;\u0026ge;\u0026thinsp;0.5.Decreased visual function is strongly correlated with COP caused by ACP pneumatization leading to the narrowing of the optic canal. Yet the subtle compressive neuropathy caused by low-level pneumatization should also be valued since it is easily be ignored clinically.\u003c/p\u003e \u003cp\u003eOther signs verifying compressive optic neuropathy[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] including a positive RAPD in the affected eye, varying degrees of visual field defects, decreased color vision and contrast sensitivity. More importantly, we observed the demise of retinal ganglion cells within the macular predated the retinal nerve fiber layer (RNFL) thinning upon OCT. Meanwhile the widening of the subarachnoid space of the optic nerve in the orbital segment presented in five patients in the orbit MRI, was strongly suggestive of a compressive pathogenesis from the intraductal segment of optic nerve. So far, these features have not been reported in previous literature.\u003c/p\u003e \u003cp\u003eA uncommon disorder known as pneumosinus dilatans causes dilated paranasal sinuses bordered via normal mucosa to fill alongside air[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Anatomically, pneumatization of the ACP is a variant that affects 6.6\u0026ndash;27.7% of people[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], the precise mechanism behind which is unclear. Overpneumatization may cause the canal wall to thin and the optic nerve to become compressed[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Since the optic nerve was in close contact with the air within the sphenoid sinus, when hyperaerated anterior clinoid process may develop beyond its normal anatomical boundary, it was easily led to pathogenic compression. Sudden changes in altitude or intra-sinus pressure have been proposed as potential triggers for acute clinical manifestations, including amaurosis fugax. For instance, when the patient with anterior clinoid process sneezed violently, a suction impact on the optic nerve as well as the supply of blood had been evoked, thus would cause damage to the exposed optic nerve [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Visual degradation was observed by Gilles Danassegarane et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] to have started with a gradual decline in visual acuity linked to temporal pallor of the optic disc and a nasal visual field defect. This appearance, like others[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], may be clarified through the optic nerve's intracanalicular segment, containing fibers from the nasal visual field, becoming compressed over time. The result of secondary evolution was optic atrophy. In our study, both case7 and case12 manifested similar nasal visual field defect, while the subsequent development needs further observation and follow-up.\u003c/p\u003e \u003cp\u003eThere's still no consensus on how to manage these patients. If the patients had severe visual impairment, surgery should be recommended. The literature[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] states that in order to preserve the sufferer's ability to see and relieve symptoms before signs of severe visual abnormalities and optic atrophy appear, an early surgical decompression of the optic canal should be taken into consideration. Various surgical techniques have been suggested, including endonasal endoscopy[\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] or by craniotomy[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In our study, patient 8 and 9 with severe visual loss in unilateral eye underwent a transnasal endoscopic sphenoidostomy and optic canal decompression. Main procedures included creating an outlet for decompression from sphenoid into anterior clinoid process, excising septum sphenoid sinus to remove the bone wall of the optic canal, exposing the anterior wall of optic canal from orbital apex to chiasma, therefore effectively establishing a pressure balance and preventing the anticipated suction impact. After surgery, both of them had mild visual improvement in the operated eye. For patients with mild visual impairment or visual field loss, they may have concerns about undergoing surgery due to the side effects of surgery and the uncertainty of visual prognosis. Based on experience with other types of CON, surgical decompression before RNFL thinning may better improve visual function.\u003c/p\u003e \u003cp\u003eThere were several restrictions on this cohort research. First, challenges in evaluating the prognosis were caused by the limited sample size and follow-up duration. Second, the mechanism of CON was unknown, with gasification of the anterior clinoid process in both eyes, but only one eye developing the disease. Third, the relationship between the degree of anterior clinoid gasification and visual impairment was unclear and not elaborated in the text. To date, nevertheless, the research has offered more thorough clinical features of the COP patients brought on by the ACP pneumatization. Further research with a more extensive sample size and extended follow-up period is necessary to validate our results.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIn summary\u003c/h2\u003e \u003cp\u003eIn conclusion, the COP caused by ACP was uncommon, which can lead to transient visual obscuration, varying degrees of visual field defects and vision loss. In cases of inexplicable vision loss and visual field defects, HRCT is advised to determine whether ACP gasification is present. Decompression surgery can be considered during an early phase. However, its effectiveness still requires more investigation and validation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe experimental protocol was established, according to the ethical guidelines of the Helsinki Declaration and was approved by the Human Ethics Committee of the 3rd Medical Center of Chinese PLA General Hospital. Written informed consent was obtained from individual or guardian participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Foundation for Youth of China (No. 82101110)，Kuanren Talents Program of the second affiliated hospital of Chongqing Medical University，China Postdoctoral Science Foundation(2024M753888) and Chongqing Postdoctoral Research Project Special Suppot(2023CQBSHTB3106).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMingxing Wu performed writing original draft and funding acquisition. Quangang Xu performed Formal analysis. Mingming Sunperformed investigation. Yuyu Li performed methodology. Huanfen Zhou performed funding acquisition and writing review\u0026amp; editing. Shihui Wei performed conceptualization and supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors approved the submitted manuscript and contributed actively to the study. Mingxing Wu and Quangang Xu are co-first authors and contributed equally to this study. Huanfen Zhou and Shihui Wei are co-corresponding authors and contributed equally to this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRodriguez-Beato FY, De Jesus O, Neuropathy CO. StatPearls, Treasure Island (FL) with ineligible companies. 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J Clin Neurosci. 2011;18(1):13\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulwin C, Tubbs RS, Cohen-Gadol AA. Anterior clinoidectomy: Description of an alternative hybrid method and a review of the current techniques with an emphasis on complication avoidance. Surg Neurol Int. 2011;2:140.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eda Costa MDS, de Oliveira Santos BF, de Araujo Paz D, Rodrigues TP, Abdala N, Centeno RS, Cavalheiro S, Lawton MT. Chaddad-Neto, Anatomical Variations of the Anterior Clinoid Process: A Study of 597 Skull Base Computerized Tomography Scans. Oper Neurosurg (Hagerstown). 2016;12(3):289\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaddad-Neto F, da Costa MDS, Santos B, Caramanti RL, Costa BL, Doria-Netto HL, Figueiredo EG. Reproducibility of a new classification of the anterior clinoid process of the sphenoid bone. Surg Neurol Int. 2020;11:281.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndrew JMJ. Bilateral pneumosinus dilatans of the sphenoid sinuses causing visual loss. Int J Pediatr Otorhinolaryngol Extra. 2015;10:79\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerath H, Alahakoon AMBD, Mohideen MS, Goonarathne IK. Anterior clinoid mucocoele presenting as progressive fluctuating visual loss mimicking inflammatory optic neuropathy. Saudi J Ophthalmol. 2021;35(1):78\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedina-Valencia FJ, Garcia-Pretelt EC, Alzate-Carvajal V, Moreno-Huertas CE, Moreno-Arango I. Optic compressive neuropathy secondary to anterior clinoid mucocele: diagnostic approach, a case report. J Surg Case Rep. 2022;2022(9):rjac362.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu VN, Galetta G, Liu S. Volpe, and Galetta\u0026rsquo;s, Neuro\u0026ndash;ophthalmology. 3rd ed. Amsterdam, Netherlands: Elsevier; 2019. pp. 101\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkolnick CA, Mafee MF, Goodwin JA. Pneumosinus dilatans of the sphenoid sinus presenting with visual loss. J Neuroophthalmol. 2000;20(4):259\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiller SP, Patel NR VR, editors. Walsh and Hoyt\u0026rsquo;s Clinical Neuro\u0026ndash;Ophthalmology, The essentials. 3rd ed. USA: Wolters Kluwer Philadelphia; 2016. pp. 33\u0026ndash;178.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDanassegarane G, Bretonnier M, Tinois J, Proisy M, Riffaud L. Pneumosinus dilatans of the sphenoid and visual loss: when should the optic nerve be decompressed? Childs Nerv Syst. 2021;37(8):2677\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim KM. Binasal hemianopia caused by pneumosinus dilatans of the sphenoid sinuses. Indian J Ophthalmol. 2019;67:1772\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBachor WR, Kahle E, Draf G. Temporary unilateral amaurosis with pneumosinus dilatans of the sphenoid sinus. Skull Base Surg. 1994;4:169\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAryan TS, Jagannatha S, Channegowda AT, Rao C, Hegde AS. Pneumosinus dilatans of the spheno-ethmoidal complex associated with hypovitaminosis D causing bilateral optic canal stenosis. Childs Nerv Syst. 2017;33:1005\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJuhl BC, Bollinger HJ. An extensive maxillary pneumosinus dilatans. Rhinology. 2001;39:236\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStretch PM. Pneumosinus dilatans as the aetiology of progressive bilateral blindness. Br J Plast Surg. 1992;45:469\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanjari MM, Tarassoly MS. Pneumosinus dilatans in a 13 year old female. Br J Ophthalmol. 2005;89:1537\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Compressive optic neuropathy, Anterior clinoid process pneumatization, Neuro-ophthalmology","lastPublishedDoi":"10.21203/rs.3.rs-5083544/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5083544/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eAnterior clinoid process (ACP) pneumatization is an uncommon entity. The goal of the research was to explore the diagnostic characteristics and prognosis of the compressive optic neuropathy (CON) caused by ACP pneumatization.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eClinical information were retrospectively gathered via those in hospitals diagnosed alongside CON companied with ACP pneumatization at the Neuro-Ophthalmology Department at the Chinese People\u0026rsquo;s Liberation Army General Hospital from January 2021 to August 2023.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA overall of thirteen sufferers ( three females and ten males, sixteen involved eyes) participated alongside an average age of 34.38\u0026thinsp;\u0026plusmn;\u0026thinsp;16.12 years. All the eyes were assessed with the ACP pneumatization classification system established by Da Costa:pneumatization Type 0 occurred in 3/26 sides (11.5%), Type 1 in 8/26 sides (30.8%), Type 2a in 8/26 sides (30.8%), Type 2b in 5/26 sides (19.2%), Type 3 in 2/26 sides (7.7%). 69.6% (16/23) eyes had optic compressive neuropathy in these patients.Among the ten patients with bilateral pneumatization, only three induced bilateral compressive optic neuropathy. 37.5%(6/16) eyes with visual field defect as the first symptom. Ultimately, two patients had endoscopic sphenoidotomy and optic canal decompression surgery, resulting in improved visual acuity in the operated eyes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCON caused by ACP pneumatization can lead to transient visual obscuration, varying degrees of visual field defects and vision loss. HRCT is advised in cases of unexplained vision loss and visual field defects to determine whether or not ACP gasification is occurring. While whether it requires surgery intervention and its effectiveness, still require large-scale research and verification.\u003c/p\u003e","manuscriptTitle":"Distinct clinical characteristics of optic compressive neuropathyassociated with anterior clinoid process pneumatization","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-01 07:50:03","doi":"10.21203/rs.3.rs-5083544/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-16T05:24:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-13T12:48:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-13T12:44:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2024-09-13T11:42:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a9c579a7-e6c7-4ecf-9a02-45bcc6a34c7c","owner":[],"postedDate":"November 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T11:23:54+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-01 07:50:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5083544","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5083544","identity":"rs-5083544","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}