Asymptomatic Papilledema in a 64-Year-Old Man | Neuro-ophthalmology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Asymptomatic Papilledema in a 64-Year-Old Man

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 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).

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Papilledema

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.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Edward Margolin, MD, Department of Ophthalmology and Vision Sciences, University of Toronto, 801 Eglinton Ave W, Ste 301, Toronto, ON M5N1E3, Canada (edward.margolin@uhn.ca).

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.

References
1.
Malmqvist  L , Bursztyn  L , Costello  F ,  et al.  The Optic Disc Drusen Studies Consortium recommendations for diagnosis of optic disc drusen using optical coherence tomography.   J Neuroophthalmol. 2018;38(3):299-307. doi:10.1097/WNO.0000000000000585PubMedGoogle ScholarCrossref
2.
ten Hove  MW , Friedman  DI , Patel  AD , Irrcher  I , Wall  M , McDermott  MP ; NORDIC Idiopathic Intracranial Hypertension Study Group.  Safety and tolerability of acetazolamide in the Idiopathic Intracranial Hypertension Treatment trial.   J Neuroophthalmol. 2016;36(1):13-19. doi:10.1097/WNO.0000000000000322PubMedGoogle ScholarCrossref
3.
Margolin  E .  The swollen optic nerve: an approach to diagnosis and management.   Pract Neurol. 2019;19(4):302-309. doi:10.1136/practneurol-2018-002057PubMedGoogle ScholarCrossref
4.
Agrawal  K , Burger  K , Rothrock  JF .  Cerebral sinus thrombosis.   Headache. 2016;56(8):1380-1389. doi:10.1111/head.12873PubMedGoogle ScholarCrossref
5.
Friedman  DI , Liu  GT , Digre  KB .  Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children.   Neurology. 2013;81(13):1159-1165. doi:10.1212/WNL.0b013e3182a55f17PubMedGoogle ScholarCrossref
6.
Ferro  JM , Canhão  P , Stam  J , Bousser  MG , Barinagarrementeria  F ; ISCVT Investigators.  Prognosis of cerebral vein and dural sinus thrombosis: results of the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT).   Stroke. 2004;35(3):664-670. doi:10.1161/01.STR.0000117571.76197.26PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close