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Optic Nerve Head Edema in a Healthy Man in His 20s

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A previously healthy African American man in his 20s presented to the emergency department after referral by an optometrist for “bleeding in the back of the eye.” The patient noted that 2 months prior he began experiencing throbbing headaches in the back of his head that were more painful and associated with lightheadedness when laying down. Two weeks prior to presentation, he started noticing black spots in his peripheral vision and progressive blurring of vision in both eyes. The patient denied recent travel, cough, gastrointestinal or genitourinary tract symptoms, ulcers, aching joints, tinnitus, or transient visual obscurations. He reported owning cats.

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Papilledema secondary to intracranial venous sinus stenosis, exacerbated by hypertensive emergency

D. All of the above

Optic nerve edema can result from several causes. In this patient, hypertensive papillitis, neuroretinitis, and papilledema from intracranial hypertension were all in the differential diagnosis. Therefore, all of the above testing (choice D) was warranted to ensure a timely and accurate diagnosis. In the setting of hypertensive emergency, the patient was admitted for control of blood pressure and treatment of systemic sequelae. Hypertensive papillitis can present with macular exudation and optic nerve head edema.1 However, concluding that systemic hypertension was the sole underlying cause of the optic nerve head swelling would be inadequate management (choice A). No further update is available for suspected renal artery stenosis as an underlying cause for his malignant hypertension, as the patient is lost to follow-up.

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Article Information

Corresponding Author: Peter W. MacIntosh, MD, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W Taylor St, Chicago, IL 60612 (pmacint1@uic.edu).

Published Online: January 31, 2019. doi:10.1001/jamaophthalmol.2018.5902

Conflict of Interest Disclosures: Dr Zahid reported serving as a consultant for Allergan outside the submitted work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Stacey  AW, Sozener  CB, Besirli  CG.  Hypertensive emergency presenting as blurry vision in a patient with hypertensive chorioretinopathy.  Int J Emerg Med. 2015;8:13. doi:10.1186/s12245-015-0063-6PubMedGoogle ScholarCrossref
2.
Ray  S, Gragoudas  E.  Neuroretinitis.  Int Ophthalmol Clin. 2001;41(1):83-102. doi:10.1097/00004397-200101000-00009PubMedGoogle ScholarCrossref
3.
Abbasi  HN, Brady  AJ, Cooper  SA.  Fulminant idiopathic intracranial hypertension with malignant systemic hypertension—a case report.  Neuroophthalmology. 2013;37(3):120-123. doi:10.3109/01658107.2013.785573PubMedGoogle ScholarCrossref
4.
Hayreh  SS.  Duke-elder lecture: systemic arterial blood pressure and the eye.  Eye (Lond). 1996;10(pt 1):5-28. doi:10.1038/eye.1996.3PubMedGoogle ScholarCrossref
5.
Corbett  JJ, Savino  PJ, Thompson  HS,  et al.  Visual loss in pseudotumor cerebri: follow-up of 57 patients from five to 41 years and a profile of 14 patients with permanent severe visual loss.  Arch Neurol. 1982;39(8):461-474. doi:10.1001/archneur.1982.00510200003001PubMedGoogle ScholarCrossref
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