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Patient Presentation: A 23-year-old obese female was diagnosed with idiopathic intracranial hypertension (IIH) and referred to neurosurgery for ventriculoperitoneal shunt. A baseline ocular examination was performed prior to the procedure.

On examination, vision was 20/200 in the right eye, and 20/40 in the left eye. There was a right relative afferent pupillary defect. Slit lamp examination was normal.

A dilated fundus examination was performed demonstrating the following:

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Neuro-Ophthalmology

Case 34

Contributor: Dr. Arun Sundaram, MD

Patient Presentation: A 29-year-old woman was referred from her optometrist to a tertiary neuro-ophthalmology clinic for bilateral optic disc edema noticed on routine examination. She had been experiencing headaches, which had increased in intensity over the past few months prior to presentation. Otherwise, she was asymptomatic and had no visual complaints. She was not taking any medications and had no past ocular history. Her BMI was 40, but otherwise had no medical history.

Visual acuity was 20/20 OU, and there was no RAPD. The optic nerves are shown below:

Question 1: Describe the fundus photos of this patient.

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Her Humphrey visual field and OCT RNFL images are shown below:

Question 2: Based on the information provided, what is the most likely diagnosis?

A. Atypical optic neuritis

B. Inflammatory optic neuropathy

C. Multiple Sclerosis

D. Idiopathic intracranial hypertension (IIH)

Question 3: Which of the following investigations is crucial for this patient presenting with bilateral disc edema?

A. NMO/MOG antibody testing

B. MRI/MRV of the brain

C. Fluorescein angiography

D. Lumbar puncture

References:

Riggeal BD, Bruce BB, Saindane AM, et al. Clinical course of idiopathic intracranial hypertension with transverse sinus stenosis. Neurology. 2013;80(3):289-295. doi:10.1212/WNL.0b013e31827debd6
Wang MTM, Prime ZJ, Xu W, et al. Diagnostic performance of neuroimaging in suspected idiopathic intracranial hypertension. Journal of Clinical Neuroscience. 2022;96:56-60. doi:10.1016/j.jocn.2021.12.024
Vosoughi AR, Margolin EA, Micieli JA. Can Lumbar Puncture Be Safely Deferred in Patients With Mild Presumed Idiopathic Intracranial Hypertension? J Neuroophthalmol. 2022;42(4):505-508. doi:10.1097/WNO.0000000000001411

Learning Objectives:

To identify funduscopic and OCT signs of IIH.
To highlight the importance and reasoning behind obtaining neuroimaging in IIH.
To discuss the nuance in obtaining a lumbar puncture for patients with IIH.

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