Journal of Clinical Neuroscience 68 (2019) 162–167

Contents lists available at ScienceDirect

Journal of Clinical Neuroscience

journal homepage: www.elsevier.com/locate/jocn

Clinical study

Long-term treatment outcomes of patients with primary optic nerve

sheath meningioma treated with stereotactic radiotherapy
Gishan Ratnayake a,c,⇑, Tracy Oh a, Rhuju Mehta b, Thomas Hardy b, Katrina Woodford a,c,
Rebecca Haward b, Jeremy D. Ruben a,c, Michael J. Dally d
a
Alfred Health Radiation Oncology, The Alfred Hospital, Victoria, Australia
b
Royal Victorian Eye and Ear Hospital, Victoria, Australia
c
Monash University, Melbourne, Victoria, Australia
d
Epworth Radiation Oncology, Melbourne, Victoria, Australia

a r t i c l e i n f o a b s t r a c t

Article history: We analysed the long-term outcomes of patients with primary optic nerve sheath meningioma (ONSM)
Received 31 January 2019 treated with stereotactic radiotherapy (SRT). 26 patients with primary ONSM were treated with SRT
Accepted 5 July 2019 between 2004 and 2013 at a single institution. SRT was delivered with image guidance to a median dose
of 50.4 Gy in 28 fractions. 4 patients had prior surgical debulking. At a median radiological follow-up of
68 months, the MRI based tumour control was 100%. Visual acuity improved in 10 (38.4%), remained
Keywords: stable in 10 (38.4%) and was reduced in 6 (23.1%) patients following treatment. Stable or improved vision
Benign tumour
post-treatment was seen in 92.3% of patients with good pre-treatment vision (best corrected visual acuity
Dose fractionation
Optic nerve sheath meningioma
6/18 or better), compared to only 61.5% of patients with poor pre-treatment vision (best corrected visual
Radiosurgery acuity 6/24 or worse). Overall, the treatment was well tolerated with no Grade 2 or greater acute toxicity.
Stereotactic radiotherapy Minimal other ophthalmic complications were seen with only one patient developing late onset Grade 3
radiation retinopathy.
Ó 2019 Published by Elsevier Ltd.

1. Background
Primary optic nerve sheath meningioma (ONSM) is a rare
benign tumour making up approximately 2% of all orbital tumours
and represents about 1–2% of all meningiomas [1–3]. Primary
ONSM tumors arise from the intraorbital or intracanicular optic
nerve sheath [4–6] whilst secondary tumours originate from sites
outside of the orbit [4]. The majority of patients with primary
ONSM present with a loss of visual acuity or visual field deficits
progressing over several years, but can also present with orbital
pain, headaches, proptosis, and decreased colour vision [7].
Radiotherapy therapy has emerged as the preferred treatment
option for patients in whom treatment is indicated [8–13]. Micro-
surgical intervention is limited by the anatomical location of pri-
mary ONSM and difficulty with preserving the optic nerve [14].
Fractionated stereotactic radiotherapy (SRT) is the standard treat-
ment technique with radiation delivered using a highly conformal
technique with a precise image-guided setup. Treatment delivery
⇑ Corresponding author at: Alfred Health Radiation Oncology, The Alfred Hospital,
55 Commercial Road, Prahran 3181, Victoria, Australia.
E-mail address: gishan.ratnayake@gmail.com (G. Ratnayake).
with multiple fractions over a six week period minimizes the
long-term toxicity to normal structures such as the optic nerve
and retina [15], which can be monitored using visual acuity and
imaging technologies including Ocular Coherence Tomography.
There have been several small series that have demonstrated the
safety and efficacy of this approach [1,16–31].
The aim of this study is to assess visual outcome, tumour con-
trol and treatment-related toxicities in patients with primary
ONSM in an Australian institution.
2. Patients and methods
2.1. Study population
Patients with a diagnosis of primary ONSM were extracted from
a prospective institutional database between January 2004 and
December 2013. Patients with meningiomas of the sphenoid wing
or planum sphenoidale with secondary involvement of the optic
nerve were excluded. All patients were diagnosed based on charac-
teristic radiological appearance on MRI. All patients had an oph-
thalmology assessment performed prior to treatment.

https://doi.org/10.1016/j.jocn.2019.07.005
0967-5868/Ó 2019 Published by Elsevier Ltd.
 G. Ratnayake et al. / Journal of Clinical Neuroscience 68 (2019) 162–167 163

2.2. Treatment protocol Table 1

Patient baseline characteristics and visual function.

Patients were simulated supine and immobilized in a thermo- Patient Characteristics Number of patients (%
plastic mask. Computed tomography (CT) images were acquired of total)
at 1.25 mm slice thickness and fused with MRI T1 weighted images Age (at start of SRT) 47 years (18–78 years)
with Gadolinium contrast. Radiotherapy planning was completed Gender Male 7 (26.9%)
with Brainlab iPlan version 4.1.1. The gross tumour volume Female 19 (73.1%)
Laterality Right 12 (46.2%)
(GTV) was defined as the visible tumour on the diagnostic MRI Left 14 (53.8%)
and planning CT images. The planning target volume (PTV) was Presenting symptom Decreased Visual acuity 19 (73.1%)
generated by a geometric expansion of the GTV ranging from Proptosis 5 (38.4%)
0 mm to 1 mm to account for setup error. Organs at risk such as Incidental finding 2 (7.8%)
Diagnosis Year Before 2005 7 (26.9%)
the orbit, optic nerves and optic chiasm were also outlined. The
2005–2010 13 (50.0%)
treatment doses varied from a mildly hypofractionated approach After 2010 6 (23.1%)
of 37.5 Gy in 15 fractions to conventionally fractionated 50.4– Initial visual acuity ‘Good’ vision (BCVA 6/18 13 (50.0%)
54 Gy in 28–30 fractions, prescribed to the 90–95% covering iso- or better)
dose line treating with 5 fractions per week. Treatment was deliv- ‘Poor vision’ (BCVA 6/24 13 (50.0%)
or worse)
ered with multiple non-coplanar dynamic conformal megavoltage
Previous surgical Gross total resection 0 (0.0%)
(MV) beams using a Novalis TX linear accelerator with ExacTrac intervention Subtotal resection 4 (15.4%)
image guidance (BrainLAB A.G, Heimstetten, Germany).

2.3. Clinical assessment and follow-up

Toxicities were retrospectively obtained from descriptive med-
ical records and graded according to the Common Terminology Cri-
teria for Adverse Events version 4 (CTCAE). Patients were assessed
weekly during their treatment and annually thereafter. Upon com-
pletion of treatment all patients had regular 12–24 monthly follow
up. Tumour response was assessed by MRI performed annually
reviewed by a radiologist. As there is no accepted standard criteria
to assess response, the response was determined by the concluding
statement of the reporting radiologist. Ophthalmological follow up
included assessment of symptoms (e.g. visual function, pain,
diplopia), best corrected visual acuity (BCVA), ocular motility
assessment, visual fields, exophthalmometry readings and optic
disc assessment. Good vision was defined as BCVA 6/18 or better
and poor vision as BCVA 6/24 or worse according to the visual stan-
dards of International Council of Ophthalmology, 2010. Visual acu-
ity (VA) was defined as either ‘improved’ if VA improved by at least
two lines on the Snellen chart or an improvement in the semiquan-
titative scale for low vision (e.g. no light perception to light
perception).
2.4. Statistical analysis
Summary statistics calculated for patient baseline characteris-
tics and treatment. All statistical analysis was performed on Stata
(StataCorp. 2017. Stata Statistical Software: Release 15. College
Station, TX: StataCorp LLC).
had poor vision pre-SRT (BCVA 6/24 or worse). 4 patients (15.4%)
had prior surgical intervention with subtotal resection.
All patients received radiotherapy with the majority (76.9%)
receiving a dose 50.4 Gy in 28 fractions, 15.4% receiving 54 Gy in
30 fractions and remaining 7.7% receiving a dose of 37.5 Gy in 15
fractions. The covering isodose prescription ranged from 90% to
100%. The planning target volume (PTV) and dose to organs at risk
are summarised in Table 2.
3.2. Clinical outcomes
The median duration of radiological follow-up was 68 months
post-SRT (range 20–134 months). There were no cases of radiolog-
ical disease progression. The majority of tumours (96.1%) remained
stable in size and one (3.8%) demonstrated a mild reduction in size.
Visual acuity (Table 3) improved in 10 patients (38.4%),
remained stable in 10 patients (38.4%) and was reduced in 6
(23.1%) patients following treatment. In the patients that had good
vision pre-SRT, 46.2% (6/13) had improved VA, 46.2% (6/13) had
stable VA and only 7.6% (1/13) had a deterioration in VA recorded.
However, in patients that had poor vision pre-SRT, 30.8% (4/13) had
some improvement in VA, 30.8% (4/13) demonstrated stable VA
and 38.5% (5/13) continued to have deterioration in their VA.
Table 2
Summary of radiotherapy planning volumes and maximum dose (Dmax) to organs at
risk.

Mean Minimum Maximum

3. Results
Planning Target Volume (cm3) 4.00 1.28 15.83
3.1. Patient and treatment characteristics Ipsilateral Globe (Gy) 35.67 5.40 56.76
Ipsilateral Lacrimal Gland (Gy) 11.89 0.60 36.94
Ipsilateral Optic Nerve (Gy) 53.35 40.41 60.80
26 patients with ONSM treated with SRT met the criteria for Brainstem (Gy) 5.07 0.41 25.32
inclusion in the study (Table 1). The median age of patients at
the start of treatment was 47 years (range 18–78) and the majority
of patients were female (73.1%). All patients had unilateral diseases Table 3
and were diagnosed based on characteristic radiological appear- Patient visual function post-treatment.
ance of ONSM on MRI. The median time from diagnosis to treat-
Patient Group Visual Function
ment was 8.4 months (range 1.4–122 months).
The most common presentation was decreased visual acuity Improved Stable Reduced
(73.1%) and proptosis (38.4%). In 7.8% the tumour was an incidental All patients (n = 26) 10 (38.4%) 10 (38.4%) 6 (23.1%)
finding following investigation of papilloedema. 13 patients (50%) Pre-treatment good vision (n = 13) 6 (46.2%) 6 (46.2%) 1 (7.6%)
Pre-treatment poor vision (n = 13) 4 (30.8%) 4 (30.8%) 5 (38.5%)
had good vision pre-SRT and (BCVA 6/18 or better) and 13 (50%)
164 G. Ratnayake et al. / Journal of Clinical Neuroscience 68 (2019) 162–167

Table 4
Studies of SRT for ONSM.

Author Pub Primary/ Pts (n) Dose and LC (%) Vision Median FU Late Toxicity
Year Secondary Fractions Stable/ (m)
Imp (%)
Liu et al. [16] 2002 Primary 5 45–54 Gy; 1.8 Gy/f 100% 100% 24 1 transient periorbital oedema
Andrews et al. [24] 2002 Both 30 50–54 Gy; 1.8 Gy/f 100% 92% 22 2 vision loss, 1 optic neuritis, 1
transient orbital pain
Becker et al. [10] 2002 Both 39 54 Gy; 1.8 Gy/f 100% 86% 36 10% endocrinologic deficits
Narayan et al. [25] 2003 Primary 14 50.4–56 Gy; 1.8–2 Gy/f 100% 100% 51 1 radiation retinopathy,
1 transient orbital pain,
1 dry eye, 2 iritis
Baumert et al. [27] 2004 Primary 23 45–54 Gy; 1.8–2 Gy/f 100% 95% 20 1 radiation retinopathy and
vitreous haemorrhage
Richards et al. [28] 2005 Primary 4 43.5 Gy/26f 100% 100% 30 1 radiological cerebral change
Landert et al. [29] 2005 Primary 7 50–54 Gy; 1.8–1.8 Gy/f 100% 86% 57 NR
Sitathanee et al. [30] 2006 Primary 12 55.7 Gy mean; 1.8 Gy/f 100% 92% 34 1 vitreous haemorrhage
Litre et al. [31] 2007 Primary 8 Mean 45 Gy; 1.8 Gy/f 100% 100% 27 NR
Arvold et al. [18] 2009 Primary 25 45–59.4 Gy; 1.8 Gy/f 95% 95% 30 3 radiation retinopathy
Milker-Zabel et al. 2009 Primary 32 Median 54.9 Gy; 1.8 Gy/f 100% 97% 54 Nil
[22]
Smee et al. [19] 2009 Primary 15 50.4 Gy; 1.8 Gy/f 100% 93% 86 Nil
Saeed et al. [40] 2010 Primary 34 45–54 Gy, 1.8 Gy/f NR 91% 58 5 dry eye, 3 retinopathy, 3 cataracts
Metellus et al. [17] 2011 Primary 9 Mean 51.2 Gy; 1.8–2 Gy/ 100% 100% 98 1 radiation retinopathy
f
Adeberg et al. [20] 2011 Primary 40 54 Gy; 1.8 Gy/f 100% 93% 60 None
Paulsen et al. [21] 2011 Both 109 54 Gy; 1.8 Gy/f 98% 91% 30 7% partial alopecia, 24% pain, 10% fatigue,
6% sensory loss, 9% hypopituitism
Solda et al. [1] 2012 Primary 45 50 Gy/30–33f 100% 89% 30 2 radiation retinopathy, 1 right retinal
artery occlusion
Hamilton et al. [23] 2018 Both 74 50–50.4 Gy; 1.8 Gy/f 100% 100% 52 7% retinopathy, 13% pituitary dysfunction,
primary primary 5% ocular pain, 2% cataracts
Current study 2018 Primary 26 50.4–54 Gy/28-30f 100% 77% 68 1 radiation retinopathy, 1 multiple
intracranial meningiomas (radiation
induced)

Therefore a greater proportion of patients with good vision had
stable or improved VA compared to poor vision (92.3% vs 61.5%).
In the 10 patients with proptosis on presentation, 4 had a
reduction in proptosis measured on exophthalmometry, 2
remained stable and 6 had no post-treatment data to assess
response. In the three patients who presented initially with diplop-
ia, all had an improvement in their symptoms.
3.3. Toxicities
14 patients (53.8%) reported acute toxicity during treatment all
of which were Grade 1. The reported acute toxicities in order of fre-
quency were fatigue (23.1%), headaches (19.2%), alopecia (3.8%)
and dizziness (3.8%). Late toxicities include grade 1 dry eye in
11.6% of patients. One patient developed late grade 2 radiation
retinopathy requiring treatment with an intravitreal VEGF inhibi-
tor. One patient developed multiple intracranial meningiomas
which were identified on imaging 10.9 years post completion of
radiotherapy. These occurred in section of meninges receiving a
low dose of radiation and may have been radiation induced. There
was continued local control of the treated ONSM in this patient,
and the new meningiomas and were treated with a combination
of surgery and further radiotherapy.
4. Discussion
ONSM is a rare benign tumour that often presents with the
pathognomonic clinical triad of painless, slowly progressive vision
loss, optic atrophy and optociliary shunt vessels [32]. Surgical
resection of these tumours are associated with difficulty in pre-
serving the optic nerve and associated vessels [33]. In a series of
148 patients with ONSM managed with surgery alone there was
a 25% local recurrence rate and a 94% risk of post-operative visual
deterioration [4].
Over the past two decades, radiotherapy has become the pre-
ferred standard of care management over surgery. This has primar-
ily been due to the technological development of fractionated
stereotactic radiotherapy (SRT) allowing for accurate delivery of
smaller radiation fields with better dosimetry to minimise the dose
to the surrounding normal tissue. SRT is most commonly delivered
with a linear accelerator based system with the patient immo-
bilised using image guidance for precision targeting of the tumour.
Table 4 summarises the published series to date employing
FSRT to treat ONSM. Our retrospective series offers further evi-
dence that SRT is an effective, non-invasive treatment for primary
ONSM resulting in excellent MRI based local control rates of 100%
at 5 years. The findings are in keeping with other published series
with rates of radiological control of 90–100%.
Our study showed 20 of 26 (76.9%) patients with primary ONSM
treated with stereotactic radiotherapy reported stable or improved
visual acuity. The visual outcomes were particularly good in those
with initial good vision of which 92.3% had preserved or improved
VA post-treatment. This is consistent with other studies, which
have reported better visual outcomes including visual acuity in
patients receiving early treatment before vision was compromised
[9,15]. MRI, optical coherence tomography (OCT) and retinal nerve
fibre layer (RFNL) thickness imaging demonstrates that SRT can
cause a reduction in the tumour leading to a reduction in optic
nerve swelling (Fig. 1). The variable clinical course of this tumour
makes it difficult to find the optimal timing of intervention. How-
ever, our finding suggests early treatment prior to developing
visual deficits is justified.
Prior studies have shown an approach of surgery followed by
radiotherapy can lead to lower rates of visual improvement in
patients potentially due to combined damage of both modalities
to the optic structures [20,34]. This finding was not reflected in
 G. Ratnayake et al. / Journal of Clinical Neuroscience 68 (2019) 162–167 165

Fig. 1. (a, b): Radiotherapy plan for patient with a right ONSM treated with SRT to 50.4 Gy in 28 fractions prescribed to the 95% isodose line. Representative dosimetry on
axial (a) and sagittal (b) MRI sections. (c, d): Pre-treatment (c) and 2-year post-treatment (d) T1 weighted gadolinium contrast enhanced MRI on same patient showing
reduction in axial dimension of tumour. Sclera remains flattened but eversion of optic head resolved. (e, f): Pre-treatment OCT/RNFL (e) shows gross thickening of all
quadrants, consistent with clinical optic nerve swelling and enlargement (f) 5-year post-treatment OCT/RNFL shows normalisation of retinal nerve fibre layer thickness post
treatment with only slight residual thickening in superior quadrant.

our series, where four patients underwent subtotal resection of
ONSM before proceeding on to SRT for residual disease or tumour
progression. Of the visual function recorded for these patients all
either remained stable or improved. Symptoms such as proptosis
and diplopia also improved following radiotherapy which has been
similarly reported in studies [1,20,21,23].
In our study, the SRT was well tolerated with no patients devel-
oping Grade 2 or greater adverse events during treatment. These
findings are consistent with previous series [1,20,21,23]. With
doses of up to 54 Gy, the risk of optic nerve injury is expected to
be <3% and if it occur usually develops some years after treatment
[35]. In patients with ONSM, radiation optic neuropathy may be
166 G. Ratnayake et al. / Journal of Clinical Neuroscience 68 (2019) 162–167
difficult to distinguish from tumour related damage. Radiation
retinopathy can occur with doses in excess of 50 Gy usually with
a latency period of 6 months to 3 years. Due the locations of some
tumours, the posterior part of the retina may be difficult to spare
from receiving the full radiation dose [36,37]. Radiation induced
hypopituitism has been reported at a rate of 19% at 5 years [21]
in tumours extending to the sella resulting in exposure to the pitu-
itary gland to doses greater than 45 Gy. The patients in our study
did not have regular endocrine testing so subclinical hypopituitism
cannot be excluded. A shortcoming of the study was that the first
follow-up was scheduled 12 months post completion of radiother-
apy which means acute or subacute post-treatment events (e.g. eye
irritation) that subsequently resolved may not have been recorded.
Meningiomas as a consequence of exposure to radiation has
been described in multiple settings although the exact incidence
in unknown [38]. A cohort study following children (in whom
radio-oncogenicity is highest) receiving low dose radiotherapy
for tinea capitis found that in comparison to sporadic menin-
giomas, radiation induced meningiomas tend to be multiple, occur
at younger ages, be of calvarial location and have higher rates of
recurrence [39]. The mean latency period from date of radiation
exposure to development of a meningioma was approximately
36 years.
5. Conclusion
Patients with primary ONSM treated with SRT had excellent and
durable local tumour control on MRI follow-up. Our series found
that a greater proportion of patients with good vision pre-SRT
had stable or improved vision indicating that early treatment
should be considered in patients prior to visual deterioration.
These findings are comparable to the published literature and
superior to surgical series.
The treatment was well tolerated with no grade 2 or greater
acute toxicity. Serious grade 3 late toxicity occurred in on patient
who developed radiation retinopathy requiring intervention. Con-
tinued long-term follow-up is required to determine the risk of late
toxicity in this rare but highly curable disease.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jocn.2019.07.005.
References
[1] Solda F, Wharram B. Fractionated stereotactic conformal radiotherapy for optic
nerve sheath meningiomas. Clin Oncol 2012;24:106–12.
[2] Shields JA, Shields CL, Scartozzi R. Survey of 1264 patients with orbital tumors
and simulating lesions: the 2002 Montgomery Lecture, part 1. Ophthalmology
2004;111:997–1008. https://doi.org/10.1016/j.ophtha.2003.01.002.
[3] Wright JE, McNab AA, McDonald WI. Optic nerve glioma and the management
of optic nerve tumours in the young. Br J Ophthalmol 1989;73:967–74.
[4] Dutton JJ. Optic nerve sheath meningiomas. Surv Ophthalmol
1992;37:167–83.
[5] Carrasco JR, Penne RB. Optic nerve sheath meningiomas and advanced
treatment options. Curr Opin Ophthalmol 2004;15:406–10.
[6] Eddleman CS, Liu JK. Optic nerve sheath meningioma: current diagnosis and
treatment. Neurosurg Focus 2007;23:E4. https://doi.org/10.3171/FOC-07/11/
E4.
[7] Bloch O, Sun M, Kaur G, Barani IJ, Parsa AT. Fractionated radiotherapy for optic
nerve sheath meningiomas. J Clin Neurosci 2012;19:1210–5. https://doi.org/
10.1016/j.jocn.2012.02.010.
[8] Shapey J, Sabin HI, Danesh-Meyer HV, Kaye AH. Diagnosis and management of
optic nerve sheath meningiomas. J Clin Neurosci 2013;20:1045–56. https://
doi.org/10.1016/j.jocn.2013.03.008.
[9] Abouaf L, Girard N, Lefort T, D’hombres A, Tilikete C, Vighetto A, et al. Standard-
fractionated radiotherapy for optic nerve sheath meningioma: visual outcome
is predicted by mean eye dose. Int J Radiat Oncol Biol Phys 2012;82:1268–77.
https://doi.org/10.1016/j.ijrobp.2011.04.010.
[10] Becker G, Jeremic B, Pitz S, Buchgeister M, Wilhelm H, Schiefer U, et al.
Stereotactic fractionated radiotherapy in patients with optic nerve sheath
meningioma. Int J Radiat Oncol Biol Phys 2002;54:1422–9.
[11] Brower JV, Amdur RJ, Kirwan J, Mendenhall WM, Friedman W. Radiation
therapy for optic nerve sheath meningioma. Pract Radiat Oncol 2013;3:223–8.
https://doi.org/10.1016/j.prro.2012.06.010.
[12] Lesser RL, Knisely JPS, Wang SL, Yu JB, Kupersmith MJ. Long-term response to
fractionated radiotherapy of presumed optic nerve sheath meningioma. Br J
Ophthalmol 2010;94:559–63. https://doi.org/10.1136/bjo.2009.167346.
[13] Moyer PD, Golnik KC, Breneman J. Treatment of optic nerve sheath
meningioma with three-dimensional conformal radiation. Am J Ophthalmol
2000;129:694–6.
[14] Roser F, Nakamura M, Martini-Thomas R, Samii M, Tatagiba M. The role of
surgery in meningiomas involving the optic nerve sheath. Clin Neurol
Neurosurg 2006;108:470–6. https://doi.org/10.1016/J.CLINEURO.2005.08.001.
[15] Liu D, Xu D, Zhang Z, Zhang Y, Li Y, Liu X, et al. Long-term results of Gamma
Knife surgery for optic nerve sheath meningioma. J Neurosurg 2010;113
(Suppl):28–33. https://doi.org/10.3171/2010.7.GKS10869.
[16] Liu JK, Forman S, Hershewe GL, Moorthy CR, Benzil DL. Optic nerve sheath
meningiomas: visual improvement after stereotactic radiotherapy.
Neurosurgery 2002;50:950–5.
[17] Metellus P, Kapoor S, Kharkar S, Batra S, Jackson JF, Kleinberg L, et al.
Fractionated conformal radiotherapy for management of optic nerve sheath
meningiomas: long-term outcomes of tumor control and visual function at a
single institution. Int J Radiat Oncol Biol Phys 2011;80:185–92. https://doi.org/
10.1016/j.ijrobp.2010.01.034.
[18] Arvold ND, Lessell S, Bussiere M, Beaudette K, Rizzo JF, Loeffler JS, et al. Visual
outcome and tumor control after conformal radiotherapy for patients with
optic nerve sheath meningioma. Int J Radiat Oncol Biol Phys 2009;75:1166–72.
https://doi.org/10.1016/j.ijrobp.2008.12.056.
[19] Smee RI, Schneider M, Williams JR. Optic nerve sheath meningiomas–non-
surgical treatment. Clin Oncol (R Coll Radiol) 2009;21:8–13. https://doi.org/
10.1016/j.clon.2008.10.010.
[20] Adeberg S, Welzel T, Rieken S, Debus J, Combs SE. Prior surgical intervention
and tumor size impact clinical outcome after precision radiotherapy for the
treatment of optic nerve sheath meningiomas (ONSM). Radiat Oncol
2011;6:117. https://doi.org/10.1186/1748-717X-6-117.
[21] Paulsen F, Doerr S, Wilhelm H, Becker G, Bamberg M, Claßen J. Fractionated
stereotactic radiotherapy in patients with optic nerve sheath meningioma. Int
J Radiat Oncol 2012;82:773–8. https://doi.org/10.1016/j.ijrobp.2010.11.018.
[22] Milker-Zabel S, Huber P, Schlegel W, Debus J, Zabel-du Bois A. Fractionated
stereotactic radiation therapy in the management of primary optic nerve
sheath meningiomas. J Neurooncol 2009;94:419–24. https://doi.org/10.1007/
s11060-009-9874-8.
[23] Hamilton SN, Nichol A, Truong P, McKenzie M, Hsu F, Cheung A, et al. Visual
outcomes and local control after fractionated stereotactic radiotherapy for
optic nerve sheath meningioma. Ophthal Plast Reconstr Surg 2017;34:217–21.
https://doi.org/10.1097/IOP.0000000000000914.
[24] Andrews DW, Faroozan R, Yang BP. Fractionated stereotactic radiotherapy for
the treatment of optic nerve sheath meningiomas: preliminary observations of
33 optic nerves in 30 patients with historical comparison to observation with
or without prior surgery. Neurosurgery 2002;51:890–903.
[25] Narayan S, Cornblath WT, Sandler HM. Preliminary visual outcomes after
three-dimensional conformal radiation therapy for optic nerve sheath
meningioma. Int Oncol Biol Phys 2003;56:537–43.
[26] Saeed P, Rootman J, Nugent RA, White VA, Mackenzie IR, Koornneef L. Optic
nerve sheath meningiomas. Ophthalmology 2003;110:2019–30. https://doi.
org/10.1016/S0161-6420(03)00787-5.
[27] Baumert BG, Villà S, Studer G, Mirimanoff R-O, Davis JB, Landau K, et al. Early
improvements in vision after fractionated stereotactic radiotherapy for
primary optic nerve sheath meningioma. Radiother Oncol 2004;72:169–74.
https://doi.org/10.1016/j.radonc.2004.04.008.
[28] Richards JC, Roden D, Harper CS. Management of sight-threatening optic nerve
sheath meningioma with fractionated stereotactic radiotherapy. Clin Exper
Ophthalmol 2005;33:137–41.
[29] Landert M, Baumert BG, Bosch MM, Lütolf UM, Landau K. The visual impact of
fractionated stereotactic conformal radiotherapy on seven eyes with optic
nerve sheath meningiomas. J Neuroophthalmol 2005;25:86–91.
[30] Sitathanee C, Dhanachai M, Poonyathalang A, Tuntiyatorn L, Theerapancharoen
V. Stereotactic radiation therapy for optic nerve sheath meningioma; an
experience at Ramathibodi Hospital. J Med Assoc Thai 2006;89:1665–9.
[31] Litre CF, Noudel R, Colin P. Fractionated stereotactic radiotherapy for optic
nerve sheath meningioma: eight cases. Neurochirurgie 2007;53:333–8.
[32] Parker RT, Ovens CA, Fraser CL, Samarawickrama C. Optic nerve sheath
meningiomas: prevalence, impact, and management strategies. Eye Brain
2018;10:85–99. https://doi.org/10.2147/EB.S144345.
[33] Schick U, Dott U, Hassler W. Surgical management of meningiomas involving
the optic nerve sheath. J Neurosurg 2004;101:951–9. https://doi.org/10.3171/
jns.2004.101.6.0951.
[34] Turbin RE, Thompson CR, Kennerdell JS, Cockerham KP, Kupersmith MJ. A long-
term visual outcome comparison in patients with optic nerve sheath
meningioma managed with observation, surgery, radiotherapy, or surgery
and radiotherapy. Ophthalmology 2002;109:890–900.
[35] Liu Y, Balter P, Komaki R, Xu Q, Swisher S, Chang J. Stereotactic ablative
radiation therapy for multiple primary lung cancer. Int J Radiat Oncol Biol Phys
2012;84:S172–3.
 G. Ratnayake et al. / Journal of Clinical Neuroscience 68 (2019) 162–167
[36] Subramanian PS, Bressler NM, Miller NR. Radiation retinopathy after
fractionated stereotactic radiotherapy for optic nerve sheath meningioma.
Ophthalmology 2004;111:565–7.
[37] Parsons JT, Bova FJ, Fitzgerald CR, Mendenhall WM, Million RR. Radiation
retinopathy after external-beam irradiation: analysis of time-dose factors. Int J
Radiat Oncol Biol Phys 1994;30:765–73.
[38] Yamanaka R, Hayano A, Kanayama T. Radiation-induced meningiomas: an
exhaustive review of the literature. World Neurosurg 2017;97. https://doi.org/
10.1016/j.wneu.2016.09.094. 635–644.e8.
167
[39] Sadetzki S, Flint-Richter P, Ben-Tal T, Nass D. Radiation-induced meningioma:
a descriptive study of 253 cases. J Neurosurg 2002;97:1078–82. https://doi.
org/10.3171/jns.2002.97.5.1078.
[40] Saeed P, Blank L, Selva D, Wolbers JG, Nowak PJCM, Geskus RB, et al. Primary
radiotherapy in progressive optic nerve sheath meningiomas: a long-term
follow-up study. Br J Ophthalmol 2010;94:564–8. https://doi.org/10.1136/
bjo.2009.166793.