Acute Vision Loss and Headache From Rhinogenic Optic Neuropathy

A 64-year-old man presented with a 5-day frontal headache and 3-day right visual impairment. He had sinusitis and prior sinus surgery in his late teens. On presentation, he exhibited right-hand motion vision, a relative afferent pupillary defect (RAPD), and a central scotoma. Laboratory tests showed no systemic inflammation (WBC 6.4 × 103/μL, CRP 0.06 mg/dL). MRI revealed a cystic lesion in the right ethmoid sinus compressing the optic nerve, appearing hyperintense on T2-weighted (Figure 1A) and short tau inversion recovery (STIR) (Figure 1B) imaging, with contrast enhancement on T1-weighted imaging (Figure 1C). CT revealed a bony defect in the ethmoid sinus adjacent to the optic nerve (Figure 1D). Coronal T2-weighted MRI confirmed optic nerve contact (Figure 1E). Coronal STIR MRI revealed perineuritis (Figure 1F). The patient was diagnosed with rhinogenic optic neuropathy due to a postoperative ethmoid sinus cyst. He underwent urgent endoscopic sinus surgery, resulting in visual recovery. Negative cultures and histopathology ruled out bacterial and fungal infection and a tumor. Rhinogenic optic neuropathy, though rare, is documented [1]. Proposed mechanisms include compression, perineural inflammation, and vascular compromise [2]. Early surgery improves prognosis, as shown in a meta-analysis [3]. Sinonasal cysts typically develop 15–20 years postsurgery [4]. Recognizing this condition enables prompt diagnosis. This study has been performed following the ethical standards laid down in an appropriate version of the Declaration of Helsinki. Consent for publication was obtained from the patient. The author declares no conflicts of interest.