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A previously healthy 64-year-old man was referred for a neuro-ophthalmological evaluation of bilateral optic nerve head edema that was noticed 2 months previously during a routine optometric examination. He denied having any symptoms of increased intracranial pressure (ICP), including headaches, pulsatile tinnitus, and transient visual obscurations. Findings on computed tomography of the brain without contrast were unremarkable. He was then seen by an ophthalmologist who confirmed bilateral severe optic nerve edema and requested magnetic resonance imaging of the brain and orbits without contrast. It demonstrated signs of increased ICP, including empty sella, posterior flattening of the globes, and widened optic nerve sheaths, but no other abnormalities (Figure 1A).
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C. Obtain venography (computed tomography or magnetic resonance) of the brain
This patient had bilateral optic nerve edema with signs of increased ICP on brain imaging and normal visual function, indicating papilledema as the most likely culprit. Venous imaging study was not performed, so ruling out venous sinus thrombosis is the most important next step.
Enhanced depth imaging–optical coherence tomography (choice A) of the optic nerve is the criterion standard for detecting buried optic nerve head drusen,1 but the presence of radiologic signs of increased ICP indicates papilledema as the most likely etiology of bilateral optic nerve head edema. Lumbar puncture (choice B) is an important diagnostic procedure to quantify the opening pressure and detect abnormalities in cerebrospinal fluid composition in a patient with increased ICP. It should be performed after venous sinus thrombosis and dural sinus fistulas have been ruled out by computed tomography venography or magnetic resonance venography, as it may obviate the need for lumbar puncture. Acetazolamide (choice D) is a carbonic anhydrase inhibitor used for treatment of idiopathic intracranial hypertension.2 Idiopathic intracranial hypertension is a diagnosis of exclusion, and treatment should not commence until other diagnoses are ruled out.
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Corresponding Author: Edward Margolin, MD, Department of Ophthalmology and Vision Sciences, University of Toronto, 801 Eglinton Ave W, Ste 301, Toronto, ON M5N1E3, Canada (firstname.lastname@example.org).
Published Online: June 11, 2020. doi:10.1001/jamaophthalmol.2020.0875
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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