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Publication Exclusive: 29-year-old woman presents with subacute vision loss and headaches
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A 29-year-old obese white woman with a known history of idiopathic intracranial hypertension, or IIH, presented to the New England Eye Center with 1 month of progressively decreasing vision in her right eye and positional headaches. She was diagnosed with IIH 5 years prior, after presenting with transient visual obscurations in her right eye and headaches. She was noncompliant with oral medications and had a recent 45-pound weight gain.
Examination
On examination, best corrected visual acuity was 20/200 in the right eye and 20/20 in the left eye. The patient had an afferent pupillary defect and color desaturation in the right eye. Humphrey visual field 30-2 testing revealed paracentral loss and an inferotemporal scotoma in the right eye; testing was normal in the left eye. Fundus examination was notable for bilateral optic disc edema and venous tortuosity. There was a superotemporal peripapillary subretinal hemorrhage with subretinal fluid and exudate in the right eye, which was consistent with choroidal neovascularization on fluorescein angiography. Spectral-domain OCT of the macula revealed a distorted foveal contour with intraretinal and subretinal fluid in the right eye.
What is your diagnosis?
Blurred vision, headaches
The differential diagnosis of blurred vision in a young woman with bilateral optic disc edema includes papilledema secondary to increased intracranial pressure, papillitis, hypertensive optic neuropathy, diabetic papillopathy, optic disc infiltration (secondary to sarcoidosis, tuberculosis, inflammatory disease or tumor), and idiopathic intracranial hypertension, among others.
Although the patient already had a diagnosis of IIH, considering the unilaterality of symptoms and choroidal neovascularization were atypical, repeat neuroimaging with MRI and magnetic resonance venography of the brain and orbits with gadolinium was obtained. Imaging was unremarkable for a secondary cause of increased intracranial pressure, and she was diagnosed with papilledema-associated peripapillary choroidal neovascularization (PP-CNV) secondary to IIH.
Click here to read the full publication exclusive, Grand Rounds at the New England Eye Center, published in Ocular Surgery News U.S. Edition, February 10, 2016.