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Patient History
HPI:
31 year-old female social worker who presents with 2 month history of fluctuating vision in both eyes. The blurriness has become more permanent in the R>L for the last 3 weeks. Vision is worse when lying down; at times her vision goes completely dark in both eyes. Patient denies flashes or floaters. She has noticed some diplopia side to side when watching TV, occasionally, in the last 3 months.

She also reports headaches - intense and persistent- over her whole head for the last month. She though maybe due to the blurry vision. Headaches are also worse when lying down. She can also hear a whooshing sound in her ears once-in-a-while "as if I was listen to the waves".

Past Ocular History:
None

Ocular Medications:
None

Past Medical History:
Obesity

Surgical History:
None

Past Family Ocular History:
Negative for macular degeneration, glaucoma or other blinding diseases.

Social History:
No history of alcohol/tobacco/drug use. No STD risk.

Medications:
Multivitamin. No other medications in the past.

Allergies:
None

ROS:
No recent URI, no sick contacts. No other positive CNS, heart, lungs, GI, skin or joint sxs.

Ocular Exam

Visual Acuity (cc):
OD: 20/40}
OS: 20/200

IOP (tonoapplantation):
OD: 13 mmHg
OS: 12 mmHg

Pupils:
Round and reactive bilaterally; positive APD L eye

Extraocular Movements:
Full OU. No nystagmus.

Confrontational Visual Fields:
Visual field defects superionasally and superiotemporally R eye. Visual field defects in all quadrants L eye.

External:
Normal, both eyes

Slit Lamp:

Other:
Humphrey Visual Field 24-2 OU - significant decrease of visual fields in both eyes with preserved central island of vision

MRI of the brain and orbits - large suprasellar mass abutting the R optic nerve and displacing the L optic nerve

Diagnosis
Bilateral optic nerve head swelling, due to intracranial mass

Discussion

Differential Diagnosis:
This patient presents with decreased vision bilaterally (visual acuity and visual field), an APD in the L eye and bilateral optic nerve head swelling. The MRI demonstrates an intracranial mass. Differential diagnosis of optic nerve head swelling also includes venous sinus thrombosis, idiopathic intracranial hypertension (or any other causes of increased intracranial pressure), and also causes of localized optic nerve swelling (ex. severe hypertension, papillitis, optic nerve glioma).

Definition:
Optic nerve head swelling is seen in cases where fluid in the optic nerve sheath fails to communicate with the subarachnoid space in the brain causing the outer retinal nerve fiber layer to swell and protrude towards the vitreous. Persistent swelling results in death of the ganglion cells and retina nerve fibers which gives the optic nerve head a pale and atrophic appearance.

Examination:
Key parts of the ocular exam include visual acuity and visual field evaluation. An APD will be noticeable if one nerve is more affected than the other. An examination of the optic nerve to determine if there is any swelling, obscuration of the optic nerve vessels, optic nerve hemorrhages, cotton-wool spots or atrophy is critical. This can be done with the direct ophthalmoscope, the slit-lamp biomicroscope or the indirect ophthalmoscope.

Treatment:
In this case prompt evaluation by neurosurgery is needed to decompress the optic nerve sheath. There is a high likelihood of permanent vision loss. In cases where the optic nerve head swelling is due to idiopathic intracranial hypertension oral acetazolamide is used to decrease the intracranial pressure and aid in decreasing optic nerve head swelling. Optic nerve sheath fenestration is another option. The patient needs lifelong eye examinations to ensure no further injury to the visual system.

1. In a 40yr old obese female with a recent history of headaches, vision loss and evidence of bilateral optic nerve head swelling, which detail of her medical history would be most contributory to this presentation?
   • Recent weight loss
   • Use of accutane
   • Family history of brain tumor
   • Tinnitus when laying down
2. Which of the following describes an APD?
   • The light is flashed in one eye and the opposite pupil does not respond
   • The R pupil is larger than the L pupil when both eyes are looking ahead in an dim illuminated room
   • The light is moved from the R to the L eye and the L pupil dilates
   • The patient complains of worse photophobia in one eye vs. the other

1. In a 40yr old obese female with a recent history of headaches, vision loss and evidence of bilateral optic nerve head swelling, which detail of her medical history would be most contributory to this presentation?

b. Use of Accutane
This might confirm an etiology for the presentation.

2. Which of the following describes an APD?

c. The light is moved from the R to the L eye and the L pupil dilates

This would be the typical response in an eye with an APD.