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A 37-year old lady was referred from an optometrist with a two-week history of mild frontal headache and transient loss of vision.
A 37-year-old recently married lady was referred by her optometrist with a two-week history of mild frontal headaches and transient visual obscurations. Humphrey visual field tests 24-2 showed bilateral enlargement of the physiological blind spots (Figure 2), and some mild scattered peripheral field defects. The patient was commenced on oral acetazolamide (Diamox) 250mg qid for 2 weeks, tapering down to 250mg daily over 3 months.
The optic nerve head swelling and blind spot enlargement were resolving by 5 weeks, and had completely resolved by 3 months (Figure 3). Idiopathic intracranial hypertension (IIH), presents with symptoms and signs of raised intracranial pressure. Previously the condition had been called “benign intracranial hypertension” or “pseudotumour cerebri”.
Adult patients who present with papilloedema and symptoms of raised intracranial pressure need urgent multidisciplinary assessment including neuroimaging to exclude life-threatening causes. All patients with optic disc swelling should be suspected of having an intracranial mass until proven otherwise.
Idiopathic intracranial hypertension (IIH) is a diagnosis of exclusion: There is raised intracranial pressure in the absence of an intracranial mass lesion or hydrocephalus, with normal cerebrospinal fluid constituents (on lumbar puncture).
Visual loss such as blindspot enlargement in IIH may occur either early or late in the disease process and is usually insidious. Case Of The MonthEvery month Retina and Macula Specialists will publish an interesting case of a retinal condition.
Bilateral optic disc swelling with blurring of the disc margins and retinal nerve fibre layer haemorrhages. Magnetic resonance imaging (MRI) and venography (MRV) of the brain was normal, with no intracerebral abnormality or cerebral venous sinus thrombosis. She was also told about the importance of weight loss in the treatment of this condition, and saw a dietitian and her general practitioner to assist with this. Resolution of the optic disc swelling, 3 months after commencement of acetazolamide (Diamox).

Restoration of normal visual fields, 3 months after commencement of acetazolamide (Diamox). Over a 10-week period OCT of the retinal nerve fibre layer showed a reduction in thickness from 125?m to 101?m (right eye) and 132?m to 97?m (left eye).
Headache, nausea and vomiting are common, and additional complaints may include transient visual obscurations (secondary to papilledema), diplopia (secondary to sixth nerve palsy), visual field loss, pulsatile tinnitus, and dizziness. Our patient was very fortunate in that she responded well to Diamox and having her Implanon® implant removed. A practical approach to, diagnosis, assessment and management of idiopathic intracranial hypertension. The role of weight loss and acetazolamide in the treatment of idiopathic intracranial hypertension. 1: Axial, sagittal and coronal MPR obtained from high definition CT revealed a soft-tissue mass filling the hypotympanum of the left middle ear. 2: Axial, sagittal and coronal MPR obtained from high definition CT revealed a soft-tissue mass filling the hypotympanum of the left middle ear. 3: Axial, sagittal and coronal MPR obtained from high definition CT revealed a soft-tissue mass filling the hypotympanum of the left middle ear.
The results of overabundance weight include absence of vitality, loss of self esteem and confidence in your life. There were no other associated symptoms such as diplopia, vomiting, fevers, speech disturbance or limb weakness. Both eyes were quiet with severely swollen optic discs causing blurring of the disc margins (Figure 1). She had some mild paraesthesiae in her hands from the acetazolamide tablets, but otherwise had no other side effects. Over a 10-week period, OCT of the retinal nerve fibre layer showed a reduction in thickness from 125?m to 101?m (right eye) and 132?m to 97?m (left eye) (Figure 5). Most patients (>90%) with IIH have papilloedema (optic disc swelling secondary to raised intracranial pressure). Neuroimaging, best in the form of a MRI brain and orbits, and MRV (venogram), is done to exclude a space occupying lesion or cerebral venous sinus thrombosis.

Some patients are intolerant of the Diamox, or have progressive visual loss or severe headache despite maximal medical therapy. Follow-up of 57 patients from five to 41 years and a profile of 14 patients with severe visual loss.
Nerve fibre layer haemorrhages were present at both optic discs and spontaneous venous pulsations were absent. Serum electrolytes were monitored, as sodium and potassium levels can be lowered by acetazolamide. Hydrocephalus and cerebral haemorrhage are other important differential diagnosis to exclude. Dural venous sinus stenting and optic nerve sheath fenestration are potential surgical alternatives for such patients.
She had an Implanon® (etonogestrel, a steroidal progestin) contraceptive implant, but was on no other medications. A neurologist was consulted to perform a lumbar puncture, which showed an elevated intracranial pressure at 34cmH2O.
As is typical with acute papilledema, visual acuity is most often normal; visual fields may show an enlarged blind spot but usually no additional defects. A lumbar puncture should also be performed by a neurologist, which usually shows a cerebrospinal fluid pressure greater than 20cm H20 and the fluid to be cytologically and chemically normal.4 When there is no apparent underlying cause found for the elevated intracranial pressure, IIH can be diagnosed. Soft-tissue attenuation fills some of the left mastoid air cells secondary to inflammatory change. Analysis of the cerebrospinal fluid showed normal protein and glucose and no white blood cells, red blood cells or organisms.
In longstanding, untreated, or severe cases, optic nerve function may deteriorate, with the development of visual field defects.
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13.09.2014 admin

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