Quiz: Headache and Sudden Loss of Vision

A 20-year-old female presented with headache and sudden loss of vision in both eyes. Her past ocular, medical, social, and family histories are unremarkable and she is on no medications. Best corrected visual acuity at presentation was 20/200 right eye and CF (counting fingers) left eye. Pupillary responses were reported as normal. Intraocular pressures were 18mmHg right and 20mmHg left. Anterior segment examination was normal but the posterior segments are as shown in the photos. What do you think could be going on?

 

Last Updated: September 12, 2022

12 thoughts on “Quiz: Headache and Sudden Loss of Vision”

  1. Migrain can cause sudden and temporary loss of vision since IOP, Pupillary response and anterior segment appears normal but the disc colour is grey, damage to the neural tissue due to Ischaemia is also a likelyhood. Hypertensive retinopathy is also visible.

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  2. What was the outcome of the case? For me it looks typical of a hypertensive retinopathy but the patient is rather young for this – however I have seen it. What was the patient’s systemic blood pressure? Many thanks

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  3. I really disagree with question 3. The bilateral nature is not atypical at all for idiopathic intracranial hypertension (IIH). Although bilateral optic neuritis is atypical, the presentation is classic for a young female, especially one who is overtly overweight (which was not divulged in the history, unless I misread).

    Also, in the USA emergency departments, CT is often chosen over MR initially for speed and cost. In this case, IIH is first on the differential diagnosis list. Lumbar puncture can then be performed expeditiously for both diagnosis and treatment (assuming it’s IIH).

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    • I agree that CT is often preferable when simply wanting to rule-out intracranial mass prior to lumbar puncture. However, if one is able to rapidly get an MRI, it does allow one to eliminate neuroimaging her twice if the CT is normal and LP shows a normal opening pressure. Then the next step might be an MRI with contrast for suspected optic neuritis. Agree that IIH is typically bilateral. Bilateral optic neuritis is less common but still possible and to be considered.

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  4. The only time I have seen this bilateral appearance was in a 50 yo female with Type2 diabetes. Cause: meningitis.
    She saw a lot of physicians in one day after my referral and says she remembers two young residents bouncing up to her to say “it’s not a brain tumour”.

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    • I dont think its related to hypertensive retinopathy because of the patients age. Also I would rule out optic neuritis because it often occurs unilaterally but the case presented is bilateral. Looking from noticeable signs like blurred disc margin, macular oedema, retinal hemorrhages, reduced vision, severe headache and being bilateral, i would suspect papilledema

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