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Subacute Vision Loss in a Young, Obese Female
Subacute Vision Loss in a Young, Obese Female
A
17-year-old Caucasian female with a medical history of obesity, diet-controlled type II diabetes, and hypertension presented to the emergency department with bilateral vision loss. One month prior, she presented to her primary care provider with complaints of decreased vision, which was attributed to severe hypertension. Her visual disturbances progressively worsened despite improved blood pressure control. She denied being pregnant or using oral contraceptives. She also denied headaches, transient vision loss, intracranial noise, and diplopia. On examination in the emergency room, blood pressure was 124/78 mm Hg.
Visual acuity was test with hand-motions in front of either eye. Her pupils were sluggishly reactive to light, and eye movements were full. Funduscopic examination showed bilateral optic nerve head swelling, with 360 degrees elevation and blurring of the disc margins, complete disc border, and complete obscuration of the disc border and vessels (Figure 1).1 There also were bilateral flame hemorrhages, exudates, and macular stars (Figure 1). The differential diagnosis of bilateral papilledema includes an intracranial mass, venous sinus thrombosis, meningitis, certain medications (tetracyclines, growth hormone, oral
Figure 1. Optic nerve photos of the right and left eyes, respectively, demonstrating grade 5 optic nerve head edema with characteristics including: A, total obscuration of the optic cup; B, total obscuration of a segment of a major blood vessel; C, total obscuration of disc margin; and D, macular star.
Figure 2. Bilateral optic atrophy is evident upon resolution of the papilledema, 1 month after bilateral optic nerve sheath fenestrations.
J Pediatr 2013;163:1518-9. 0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.06.022
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Vol. 163, No. 5 November 2013 contraceptives, and vitamin A), malignant hypertension, and idiopathic intracranial hypertension. Optic nerve head edema associated with increased intracranial pressure is termed papilledema. The patient underwent a workup including cranial contrast-enhanced magnetic resonance imaging and computed tomography venogram, which showed no intracranial pathology or venous sinus thrombosis. Lumbar puncture revealed an opening pressure of 55 cm of water and normal cerebrospinal fluid composition. The final diagnosis was fulminant idiopathic intracranial hypertension.2 She underwent right then left optic nerve sheath fenestrations on days 2 and 3 of admission, respectively. At 2 weeks follow-up, the patient’s visual acuity was 20/200 in either eye. Her papilledema was resolving and was being
replaced by significant optic nerve pallor indicating severe optic atrophy (Figure 2). n Laura Ann Vickers, MD, MA Mays A. El-Dairi, MD Duke University Eye Center Durham, North Carolina
References 1. Frisen L. Swelling of the optic nerve head: a staging scheme. J Neurol Neurosurg Psychiatry 1982;45:13-8. 2. Thambisetty M, Lavin PJ, Newman NJ, Biousse V. Fulminant idiopathic intracranial hypertension. Neurology 2007;68:229-32.
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A
17-year-old Caucasian female with a medical history of obesity, diet-controlled type II diabetes, and hypertension presented to the emergency department with bilateral vision loss. One month prior, she presented to her primary care provider with complaints of decreased vision, which was attributed to severe hypertension. Her visual disturbances progressively worsened despite improved blood pressure control. She denied being pregnant or using oral contraceptives. She also denied headaches, transient vision loss, intracranial noise, and diplopia. On examination in the emergency room, blood pressure was 124/78 mm Hg.
Visual acuity was test with hand-motions in front of either eye. Her pupils were sluggishly reactive to light, and eye movements were full. Funduscopic examination showed bilateral optic nerve head swelling, with 360 degrees elevation and blurring of the disc margins, complete disc border, and complete obscuration of the disc border and vessels (Figure 1).1 There also were bilateral flame hemorrhages, exudates, and macular stars (Figure 1). The differential diagnosis of bilateral papilledema includes an intracranial mass, venous sinus thrombosis, meningitis, certain medications (tetracyclines, growth hormone, oral
Figure 1. Optic nerve photos of the right and left eyes, respectively, demonstrating grade 5 optic nerve head edema with characteristics including: A, total obscuration of the optic cup; B, total obscuration of a segment of a major blood vessel; C, total obscuration of disc margin; and D, macular star.
Figure 2. Bilateral optic atrophy is evident upon resolution of the papilledema, 1 month after bilateral optic nerve sheath fenestrations.
J Pediatr 2013;163:1518-9. 0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.06.022
1518
Vol. 163, No. 5 November 2013 contraceptives, and vitamin A), malignant hypertension, and idiopathic intracranial hypertension. Optic nerve head edema associated with increased intracranial pressure is termed papilledema. The patient underwent a workup including cranial contrast-enhanced magnetic resonance imaging and computed tomography venogram, which showed no intracranial pathology or venous sinus thrombosis. Lumbar puncture revealed an opening pressure of 55 cm of water and normal cerebrospinal fluid composition. The final diagnosis was fulminant idiopathic intracranial hypertension.2 She underwent right then left optic nerve sheath fenestrations on days 2 and 3 of admission, respectively. At 2 weeks follow-up, the patient’s visual acuity was 20/200 in either eye. Her papilledema was resolving and was being
replaced by significant optic nerve pallor indicating severe optic atrophy (Figure 2). n Laura Ann Vickers, MD, MA Mays A. El-Dairi, MD Duke University Eye Center Durham, North Carolina
References 1. Frisen L. Swelling of the optic nerve head: a staging scheme. J Neurol Neurosurg Psychiatry 1982;45:13-8. 2. Thambisetty M, Lavin PJ, Newman NJ, Biousse V. Fulminant idiopathic intracranial hypertension. Neurology 2007;68:229-32.
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