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A Woman With Bilateral Visual Field Defects

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

A 52-year-old woman with no relevant medical history presented for evaluation of visual field defects. Her ocular history was notable for open-angle glaucoma in both eyes, diagnosed 3 months previously. Selective laser trabeculoplasty and application of 4 topical agents in both eyes reduced intraocular pressure to the high single digits, yet visual field deterioration had continued. The patient reported headaches and loss of vision in the right eye, which started several months earlier. She had no history of trauma, neurosurgical procedures, or lumbar puncture.

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Optic neuropathy secondary to spontaneous intracranial hypotension

A. Order magnetic resonance imaging

The constellation of symptoms of new headaches with subacute vision loss accompanied by examination findings of an afferent pupillary defect and dyschromatopsia suggest a neuro-ophthalmologic diagnosis. The presence of neuro-ophthalmologic symptoms and signs warrants further investigation before an incisional glaucoma procedure is performed (choice B). Ongoing symptoms in the setting of progressive visual field loss warrant active management rather than observation to make a diagnosis (choice C), and the presence of symptoms argues against a congenital condition, such as segmental optic nerve hypoplasia or anomalous optic nerves, as the sole reason for the findings (choice D).

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Article Information

Corresponding Author: Andrew M. Williams, MD, Duke Eye Center, 2351 Erwin Rd, Durham, NC 27705 (andrew.m.williams@duke.edu).

Published Online: October 8, 2020. doi:10.1001/jamaophthalmol.2020.2056

Conflict of Interest Disclosures: None reported.

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

References
1.
Schievink  WI .  Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension.   JAMA. 2006;295(19):2286-2296. doi:10.1001/jama.295.19.2286 PubMedGoogle ScholarCrossref
2.
Schievink  WI , Maya  MM , Louy  C , Moser  FG , Tourje  J .  Diagnostic criteria for spontaneous spinal CSF leaks and intracranial hypotension.   AJNR Am J Neuroradiol. 2008;29(5):853-856. doi:10.3174/ajnr.A0956 PubMedGoogle ScholarCrossref
3.
Horton  JC , Fishman  RA .  Neurovisual findings in the syndrome of spontaneous intracranial hypotension from dural cerebrospinal fluid leak.   Ophthalmology. 1994;101(2):244-251. doi:10.1016/S0161-6420(94)31340-6 PubMedGoogle ScholarCrossref
4.
Pilo-de-la-Fuente  B , Gonzalez Martin-Moro  J , Navacerrada  F , Plaza-Nieto  FJ , Jimenez-Jimenez  FJ .  Concentric visual field defect related to spontaneous intracranial hypotension.   Int Ophthalmol. 2013;33(5):583-587. doi:10.1007/s10792-012-9699-x PubMedGoogle ScholarCrossref
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