Comparison of outcome in patients with idiopathic intracranial hypertension (IIH) following optic nerve sheath fenestration (ONSF) using a medial transconjunctival approach with dural window or superomedial lid-crease incision approach

PURPOSE: This study compares outcomes and complications of two common optic nerve sheath fenestration (ONSF) approaches for treating vision loss in idiopathic intracranial hypertension (IIH). METHODS: This retrospective comparative study included 71 eyes of 48 patients with IIH who underwent ONSF by two oculoplastic surgeons at the University of Texas Southwestern Medical Center from January 2010 to December 2023. Patients were grouped by surgical approach: Group 1 underwent a superomedial lid-crease incision with fenestration, and Group 2 underwent a medial transconjunctival approach with dural window. Outcomes measured included operative time and changes in visual acuity, visual fields, and color vision within a 180-day postoperative period. Complications were also recorded. Fisher's exact test was used to compare favorable outcome rates between groups. Mean operation time was compared using a simple paired t-test. RESULTS: Both surgical approaches were successful in preventing progression of vision loss in patients with IIH. Postoperatively, visual acuity was stable or improved in 97% of Group 1 and 85% of Group 2 patients. Both groups showed stability of visual fields and color vision testing. At 6 months, there was no statistically significant difference in outcome between the groups. Furthermore, mean operation time was approximately 30 min shorter in Group 1 compared to Group 2. Both groups had low complication rates. CONCLUSIONS: This study demonstrates that the superomedial lid-crease approach with fenestration and the medial transconjunctival approach with dural window for ONSF are both effective in preventing vision loss in patients with IIH, with similarly low side‑effect profiles.