A 23-year-old woman presented with occasional blurred vision at distance, new onset of headaches that had been increasing in frequency, and recent nausea and vomiting. Her ocular and systemic histories were unremarkable, and her body mass index (BMI) was 24.
The patient’s VA was 20/20 OU. Her pupils were equally round and reactive to light with no relative afferent pupillary defect. Ocular motility testing, confrontation field testing, and anterior segment examination were unremarkable. IOP was 19 mm Hg OD and 20 mm Hg OS; blood pressure was 128/85. Dilated fundus examination revealed bilateral optic nerve swelling (Figures).
Because of her chief complaints of headache, nausea, and vomiting, along with her ocular findings, the patient was sent for same-day neuro-ophthalmology evaluation, including MRI, magnetic resonance venography, blood work, and lumbar puncture. The differential diagnosis included idiopathic intracranial hypertension (IIH), intracranial tumor, arteriovenous malformation, brain abscess, dural venous sinus thrombosis, aqueduct stenosis, encephalitis, and meningitis.1
The opening pressure of her lumbar puncture was elevated, and, with other systemic tests negative, IIH was diagnosed. She has been followed by her neuro-ophthalmologist and was treated with acetazolamide 500 mg (Diamox Sequels, McKesson).
Chronic papilledema may cause progressive visual loss and fundus changes, and therefore visual function should be carefully monitored. Studies have shown that patients with a normal BMI (<25, according to WHO guidelines) tend to have better visual outcomes than more typical patients with IIH.2 Because IIH occurs rarely in these patients, careful evaluation for alternative etiologies should be undertaken.2
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