Open Journal of Ophthalmology, 2013, 3, 87-89 Published Online August 2013 (
Falx Meningeoma Induced Optic Neuropathy—Clinical
Manifestation and Differential Diagnosis: A Case Report*
Skevas Christos#, Görsch Isabel Carolin, Richard Gisbert, Linke Johannes Stephan
Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Augenheilkunde, Hamburg, Germany.
Received March 25th, 2013; revised April 26th, 2013; accepted June 20th, 2013
Copyright © 2013 Skevas Christos et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose: Meningiomas are the most frequently diagnosed neoplasms. Ocular symptoms vary depending on size and
localisation of the tumor, which is capable of compressing critical anatomic structures. Patients and Methods: A
44-year-old immunocompetent male was admitted to our hospital for further investigation of his bilateral optic disc
swelling. A complete ophthalmological examination was performed including visual field assessment (VF), visual
evoked potentials (VEP), fluorescein angiography (FLA) and magnetic resonance imaging (MRI). The patient had ex-
perienced only minor visual disturbances. Serological testing was performed. Results: Serological testing showed posi-
tive IgM and IgGtiters for cytomegalovirus (CMV) and subsequent imaging (MRI) revealed a frontal falxcerebri men-
ingioma. Conclusions: We present a case of falx meningioma with overlapping serologically active CMV in an other-
wise healthy and immunocompetent individual. Detailed differential diagnostic workup in immunocompetent individu-
als presenting with clinically unremarkable bilateral disc swelling is recommended.
Keywords: Falx Meningeoma; Optic Neuropathy; Cytomegalovirus (CMV); Visual Disturbances; Fluorescein
Angiography (FLA); Magnetic Resonance Imaging (MRI); Visual Evoked Potentials (VEP)
1. Introduction
Meningiomas are the most frequently diagnosed neo-
plasms accounting for 33.8% of all brain and central
nervous system tumors reported in the USA between
2002 and 2006 [1]. Cushing defined falx meningioma as
a tumor arising from the falxcerebri and concealed by the
overlying cortex [2].
Ocular symptoms vary depending on size and localisa-
tion of the tumor, which is capable of compressing criti-
cal anatomic structures. Visual field abnormalities, optic
atrophy, optic disc edema, diplopia and proptosis can be
presented. Intracranial hypertension is defined as an in-
crease in the intracranial pressure >20 mmHg. Typical
manifestations are headaches, vomiting and visual symp-
toms (transient visual obscurations, loss of visual acuity)
[3]. We report on a 44-year-old immunocompetent male
with bilateral swelling of the optic discs due to falxmen-
ingeoma. The diagnosis was overlapped by positive IgM
and IgGtiters for CMV.
2. Materials and Methods
A 44-year-old male with unremarkable medical history
presented in our clinic with a bilateral optic disc swelling,
which was diagnosed during a routine ophthalmological
examination. Patient was not taking any medication and
denied having any reduced visual acuity, transient visual
disturbances or headaches. A complete ophthalmological
examination was performed including corrected distance
visual acuity (CDVA), visual field (VF) assessment,
fundoscopy, visual evoked potentials (VEP), fluorescein
angiography (FLA), serological examinations and mag-
netic resonance imaging (MRI).
3. Results
Corrected distance visual acuity (CDVA) was 20/20 for
both eyes (R 4.5 sph 0.75 cyl A 83 and L 4.5 sph
1.25 cyl A 177) but visual field (VF) assessment (Hum-
phrey Visual Field Analyzer, protocol 24-2; Carl Zeiss
Ophthalmic Systems Inc., Dublin, CA) showed bilateral
(R > L) inferior altitudinal field defects. No afferent pu-
pillary defect or colour desaturation was evident. Ante-
rior chamber assessment showed no pathology, and fun-
*Disclosure declaration: There are no proprietary interests and no fi-
nancial support was received. No conflicts of interest regarding this
article exist.
#Corresponding author.
Copyright © 2013 SciRes. OJOph
Falx Meningeoma Induced Optic Neuropathy—Clinical Manifestation and Differential Diagnosis: A Case Report
doscopy confirmed a bilateral (R > L) optic disc edema
without any signs of retinal haemorrhages and no cells in
the hyaloidbody. Visual evoked potentials (VEP) were
within normal limits and fluorescein angiography (FLA)
showed a late phase disc staining. Ultrasonography of the
optic nerve sheath, Doppler ultrasonography and color-
doppler imaging (CDI) elicited no abnormalities. Routine
and differential blood counts, C-reactive protein (CRP),
protein C and S deficiency, APC resistance, Factor V
Leiden, anti-cardiolipin antibodies were all within nor-
mal range. Further infectious serologic blood tests (Her-
pes Simplex virus, Varizella Zoster virus, Cytomega-
lovirus, Ebstein-Barr virus, Lues, Toxoplasmosis, Bor-
reliosis, HIV) were performed and revealed positive IgG
and IgMtiters for Cytomegalovirus (CMV) indicative for
an active CMV infection. The ensuing physical, neuro-
logical as well as chest X-ray examinations were unre-
markable with no signs of splenomegaly. A 2-week
course of intravenous ganciclovir (2 × 5 mg pro Kg i.v)
treatment was commenced and additionally a cerebral
imaging (MR) was performed. A 4.0 cm × 4.5 cm × 4.0
cm solitary, well defined, parasagittal frontal meningio-
ma (Figures 1 and 2) originating from falxcerebri was
diagnosed. A surgical resection of the tumor had been
scheduled after consultation with the department of neu-
4. Discussion
Among the differential diagnosis of bilateral optic disc
edema, intracranial hypertension and infectious papillitis
are most frequently reported. The differentiation can fur-
Figure 1. A 4.0 cm × 4.5 cm × 4.0 cm solitary, well defined,
parasagittal frontal meningioma originating from falxcere-
Figure 2. A 4.0 cm × 4.5 cm × 4.0 cm solitary, well defined,
parasagittal frontal meningioma originating from falxcere-
ther be hampered by the absence of neurological symp-
toms. Classification of meningiomas according to Cush-
ing and Eisenhardt was based on surgical findings of a
dural or bony site of origin and depending on their origin
in the falx, they can be divided into anterior, middle or
posterior types [2]. Optic disc edema which is fortui-
tously discovered in patients without complaints can in-
sidiously lead to visual handicap, due to chronic optic
disc edema and optic atrophy. One feature of optic disc
edema from raised ICH is that normal vision usually
continues without interference for many weeks or even
months. Hayreh speculated that the cause of the laminar
transport block is mechanical and the visual loss in
chronic optic disc edema results from ischaemia secon-
dary to optic disc swelling [4].
Cytomegalovirus (CMV) is a neurotropic virus with a
predilection to the retina and the central nervous system.
The natural course of CMV papillitis leads to blindness.
Grossniklaus et al. detected CMV inflammation cell in-
filtrated in the retrolaminar portion of the optic nerve.
The pathological examination shows signs of necrosis [5].
CMV retinitis usually affects individuals that have been
already diagnosed with acquired immunodeficiency syn-
drome (AIDS) (stages of advanced immunsupression-CD
4 + counts of < 50 cells/mm3) [6]. The therapy of CMV
Copyright © 2013 SciRes. OJOph
Falx Meningeoma Induced Optic Neuropathy—Clinical Manifestation and Differential Diagnosis: A Case Report
Copyright © 2013 SciRes. OJOph
retinitis/optic neuritis consists of intravenous ganciclovir
or intravenous foscarnet, but their use in combination is
also presented. The combination is more effective in
controlling progression of CMV retinitis in relapsed pa-
tients than monotherapy alone [7,8]. Besides patients
with immune deficiency (AIDS), there are reports of
CMV induced optic neuropathy in healthy immunocom-
petent individuals [9,10].
We present to the best of our knowledge the first case
of falx meningioma with overlapping serologically active
CMV in an otherwise healthy and immunocompetent
individual. A step by step approach for detailed differen-
tial diagnostic workup in immunocompetent individuals
presenting with clinically unremarkable bilateral disc
swelling is recommended. Treatment should involve a
harmonious cooperative effort between the ophthalmolo-
gist and physicians of other specialities such as microbi-
ology, neurology and neurosurgery.
[1] CBTRUS, “Statistical Report: Primary Brain and Central
Nervous System Tumors Diagnosed in Eighteen States in
2002-2006,” Central Brain Tumor Registry of the United
States, Hinsdale, 2009-2010.
[2] H. Cushing and L. Eisenhardt, “Meningiomas. Their Clas-
sification, Regional Behavior, Life History and Surgical
End Results,” Bulletin of the Medical Library Association,
Vol. 27, No. 2, 1938, pp. 224-249.
[3] D. I. Friedman and D. M. Jacobson, “Diagnostic Criteria
for Idiopathic Intracranial Hypertension,” Neurology, Vol.
59, No. 10, 2002, pp. 1492-1495.
[4] S. S. Hayreh, “Optic Disc Edema in Raised Intracranial
Pressure. VI. Associated Visual Disturbances and Their
Pathogenesis,” Archives of Ophthalmology, Vol. 95, No.
9, 1977, pp. 1566-1579.
[5] H. E. Grossniklaus, K. E. Frank and R. L. Tomsak, “Cy-
tomegalovirus Retinitis and Optic Neuritis in Acquired
Immune Deficiency Syndrome: Report of a Case,” Oph-
thalmology, Vol. 94, No. 12, 1987, pp. 1601-1604.
[6] J. D. Roarty, E. J. Fisher and J. J. Nussbaum, “Long-Term
Visual Morbidity of Cytomegalovirus Retinitis in Patients
with Acquired Immune Deficiency Syndrome,” Ophthal-
mology, Vol. 100, No. 11, 1993, pp. 1685-1688.
[7] D. N. Friedberg, “Cytomegalovirus Retinitis: Diagnosis
and Status of Systemic Therapy,” Journal of Acquired
Immune Deficiency Syndromes & Human Retrovirology,
Vol. 14, No. 1, 1997, pp. S1-S6.
[8] A. M. Mansor and H. K. Li, “Cytomegalovirus Optic
Neuritis: Characteristics, Therapy and Survival,” Oph-
thalmologica, Vol. 209, No. 5, 1995, pp. 260-266.
[9] E. Baglivo, P. M. Leuenberger and K. H. Krause, “Pre-
sumed Bilateral Cytomegalovirus-Induced Optic Neu-
ropathy in an Immunocompetent Person: A Case Report,”
Journal of Neuro-Ophthalmology, Vol. 16, No. 1, 1996,
pp. 14-17. doi:10.1097/00041327-199603000-00004
[10] S. R. De Silva, G. Chohan, D. Jones and M. Hu, “Cy-
tomegalovirus Papillitis in an Immunocompetent Patient,”
Journal of Neuro-Ophthalmology, Vol. 28, No. 2, 2008,
pp. 126-127. doi:10.1097/WNO.0b013e3181782fed