Relief of severe retro-orbital pain and vision improvement after optic-nerve decompression in polyostotic fibrous dysplasia: case report and review of the literature

Fibrous dysplasia: A rare cause of optic neuropathy

Fibrous dysplasia (FD) is a progressive and benign osteodystrophic disease where cranial bones are most commonly affected. In this case report, we present a 27-year-old patient with previous diagnosis of FD who was referred to our clinic with sudden loss of visual acuity and color discrimination. Examination of the right eye was normal, whereas visual acuity on the left eye was 6/9 and color vision (CV) with Ishihara test plates was 9/12. The visual field (VF) demonstrated a peripheral concentric defect on the left eye. As visual acuity in the left eye decreased to 6/30 and computed tomography imaging of the brain and orbit showed optic nerve compression by immature bony structures, optic nerve decompression was recommended with the diagnosis of compressive optic neuropathy. Endoscopic transnasal orbital and optic canal decompression was performed. At the postoperative course, visual acuity on the left eye turned to 6/6, CV was 12/12, and VF improved markedly. In subjects with craniofacial FD, a multidisciplinary approach is important. If there is evidence of compressive optic neuropathy, surgery should be performed.

Fibrous dysplasia imitating malignancy

Fibrous dysplasia is a benign bone disease, presenting as monostotic or polyostotic lesions, or as part of a syndrome (McCune-Albright/Mazabraud). Its clinical course shows a variegated picture and the progression of its growth is unpredictable. In the workup of 39 fibrous dysplasia cases in the cranio-facial area, four cases presented fast growth tendencies, of which two patients with McCune-Albright syndrome showed malignant-like rapid growth. This local aggressive form is extremely rare, and the concept of this issue has not been clearly defined. With regard to the speed of growth a volumetric-time analysis in one of our cases demonstrated a 74 days tumor doubling rate with an exponential growth curve. According to the literature the aggressive form presented extra-cranially mainly at an adult age, whereas its appearance in our cranio-facial patient collective was much younger. Distinguishing nonmalignant and malignant aggressive forms is difficult and highly inconsistent in the literature. We therefore implemented a quantitative growth measure analysis to define aggressive forms based on progression and speed of growth and impartial of type of FD, localization or functional incapacity. Due to our study findings and literature review we state a prevalence of an aggressive form might be possibly about 5 %.

McCune-Albright syndrome with craniofacial dysplasia: Clinical review and surgical management

BACKGROUND

Fibrous dysplasia (FD) is a benign fibro-osseous lesion related to an abnormal bone development and replacement by fibrous tissue. FD has three clinical patterns namely monostotic, polyostotic, and the McCune-Albright syndrome (MAS). MAS is a rare genetic disorder (about 3% of all FD's) that comprises a triad of polyostotic FD, café-au-lait skin macules, and precocious puberty. MAS can involve the orbit region and cause stenosis in the optic canal, leading the patient to a progressive visual loss.

METHODS

We reported a case of craniofacial FD in MAS in a 9-year-old male with progressive visual loss, submitted to optic nerve decompression by fronto-orbito-zygomatic approach, with total recovery. A research was made at Bireme, PubMed, Cochrane, LILACS, and MEDLINE with the keywords: FD/craniofacial/McCune-Albright/Optic compression for the clinical review.

RESULTS

A clinical review of the disease was made, the multiple, clinical, and surgical management options were presented, and the case report was reported.

CONCLUSION

MAS is a rare disease with a progressive polyostotic FD. Whenever it affects the orbit region, the optic canal, and it is associated with a progressive visual loss, the urgent optic nerve decompression is mandatory, either manually or with a rapid drill. It is known that aggressive approach is associated with less recurrence; it is also associated with worsening of the visual loss in optic nerve decompression. In MAS cases, multiple and less aggressive surgeries seem to be more suitable.

Craniofacial Fibrous Dysplasia Involving the Orbit: A Case Report and Literature Review

PURPOSE

Craniofacial fibrous dysplasia is a benign slowly progressive disease in which normal craniofacial bones are replaced by immature fibro-osseous tissue. Orbital involvement may present as visual loss in some patients. The etiology of visual loss in orbital fibrous dysplasia is still unclear, with many theories proposed in recent literature. This has led to developments in the controversy regarding the role of prophylactic optic nerve decompression in asymptomatic orbital fibrous dysplasia patients. This case report and literature review evaluates the need for early surgical intervention in such patients, as well as highlights other aspects of the condition and its management.

DESIGN

Case report and literature review.

METHODS

This was a case report of a 12-year-old Chinese girl who developed progressive visual loss in association with craniofacial fibrous dysplasia involving the orbit. Literature regarding the epidemiology, pathophysiology, clinical features, diagnosis, investigations, and management was searched from the PubMed database.

RESULTS

Extradural decompression of the optic nerve resulted in marked visual improvement, with temporal optic atrophy noted postoperatively. Literature review revealed a number of recent studies recommending against prophylactic optic nerve decompression, but early surgical intervention upon onset of visual loss is suggested.

CONCLUSIONS

Immediate surgical referral and early optic nerve decompression is recommended upon onset of visual loss. Periodic follow-up is recommended to monitor for recurrence and malignant transformation.

A case of craniofacial fibrous dysplasia associated with McCune-Albright syndrome lost to follow-up

McCune-Albright syndrome is a rare fibro-osseous syndrome characterised by a classic triad of fibrous dysplasia (FD), café-au-lait macules and various underlying endocrinopathies. This case report describes how a patient was rediagnosed by a general dental practitioner following attendance for a routine dental examination. The patient had been previously diagnosed with the condition 28 years earlier but no follow-up or monitoring of her condition had taken place. As a result, she was found to have several undiagnosed and untreated complications of the disease including FD of the mandible, optic neuropathy and potential thyroid involvement.

Surgical approaches to central skull base and postsurgical imaging

The close proximity to or intricate involvement of critical neurovascular structures in the central skull base region or both present unique surgical challenges. Varied surgical approaches may be used to remove tumors in this region, including open craniotomies and minimally invasive transnasal or transfacial endoscopic approaches. The ideal surgical technique is chosen based on multiple factors including the aggressiveness, histopathology, and location of the tumor with respect to regional neurovascular elements. Postsurgical image analysis of the central skull base requires an intimate understanding of preoperative and expected postoperative appearance in relation to the nature of the excision and surgical materials used.

Sudden onset vision loss in an 8-year-old female with McCune-Albright syndrome

We describe a case of an 8-year-old girl with large irregular café au lait macules on the right cheek and right lower extremity presenting with sudden onset vision loss and found to have polyostotic fibrous dysplasia on imaging. The classic triad of McCune-Albright syndrome is discussed along with the importance of recognition in patients with partial presentation. This case also highlights a rare and potentially devastating neurologic complication of McCune-Albright syndrome, as well as the need for early diagnosis and continual surveillance in these patients.