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A Look Into The Brain Through The Eyes

An optometrist shares a case where his knowledge of IIH and its relation to papilledema translated to his patient receiving the diagnosis of IIH

Everything in your body is interrelated, including a connection between the eyes and the brain. Certain brain conditions, like IIH, can manifest in changes to your vision. By looking into your eyes with tools like an ophthalmoscope by an optometrist, she can look at interior structures of the eye like the retina and the optic nerve. Visual field changes is usually one of the first symptoms experienced with IIH, and papilledema is usually the first clinical finding seen by a provider. Papilledema occurs when there is increased pressure in the brain causing swelling to the optic disc and nerve. Swelling of this area causes decreased blood flow to the important structures of the eye, causing vision changes like visual field defects. Unfortunately, if this swelling is left untreated, it can lead to blindness.

Dr. H, a diligent optometrist, shares a case where his knowledge of IIH and its relation to papilledema translated to his patient receiving the diagnosis of IIH and expeditious treatment. Thanks to his expertise, his patient is now near symptom-free and without papilledema.

 

Here is a recount of his patient’s IIH journey:

In August of 2021, a 40-year-old female was sent to the optometrist by an urgent care center for complaints of headaches and visual disturbances. On the initial exam, the patient states she has had chronic headaches for years but are worsening along with visual changes. The patient did not have any other complaints and has no significant medical history.

On the physical exam: best corrected visual acuity (BCVA) was 20/20 in both eyes, normal. Fundoscopic exam showed bilateral optic disc edema, papilledema.

Left and right fundoscopic exam showing severe papilledema (swelling of optic disc).

 

Spectral Domain Optical coherence tomography
Spectral Domain Optical coherence tomography of the RNFL (SD-OCT RNFL) results. Another diagnostic tool used by optometrists and ophthalmologists to diagnose structural changes of the eye. In this image, both papilledema and macular thickness measurement (TSNIT) elevations were identified.

Immediately after diagnosing papilledema along with the patient’s complaints, Dr. H arranged for the patient to urgently see a neurologist. The patient underwent an MRI and MRV of the brain  and orbits. The radiologist’s initial reports were described as normal findings.

It is important for a provider to not only order an MRI of the brain, but also an MRV of the brain if one is suspecting IIH.

The patient underwent a lumbar puncture with an opening pressure of 34 cm H₂0. This is higher than normal, so the neurologist had the patient start acetazolamide to help decrease the high pressures in her brain.

 

Humphrey visual field (HVF) results
Humphrey visual field (HVF) results. A Humphery visual field test is another tool an optometrist can use to assess a person’s ability to see objects on the periphery (the sides) rather than the center of your eyesight. It uses various intensities of lights aimed at the visual fields instead of central visual areas. An HVF 30-2 is specifically used for patients with neurological conditions.

In November 2021, Dr. H saw the patient again to reassess her papilledema. On the fundoscopic exam, papilledema was still seen with little to no improvement. Her visual acuity remained normal at 20/20 in both eyes and the Humphrey visual field (HVF) 30-2 in both eyes, had normal findings.

On follow-up with the neurologist, the patient was unable to tolerate acetazolamide so the decision was made to stop it and start topiramate. Unfortunately, the patient could not tolerate this medication either so she was started on furosemide, which she was just barely able to tolerate.

He took matters into his own hands and started a group chat between the patient’s neurologist, a neurosurgeon, and an oculoplastic specialist as optic nerve sheath fenestration was being considered.

In March 2022, Dr. H saw the patient again to reassess her papilledema which had little to no improvement. Her visual acuity and Humphrey visual field tests in both eyes remained normal.

At this point, Dr. H was deeply concerned that her papilledema was going on for way too long.

He took matters into his own hands and started a group chat between the patient’s neurologist, a neurosurgeon, and an oculoplastic specialist as optic nerve sheath fenestration (ONSF ) was being considered.

A neurosurgeon reviewed her MRV of the brain and identified that both of her transverse sinuses were stenosed. This neurosurgeon found an anatomical lesion that could be treated so the patient underwent stenting of the affected areas to relieve her elevated intracranial pressure.

Diagram of venous sinuses of the brain. Image courtesy of REVMed.

In July 2022, Dr. H saw the patient to reassess her papilledema. On examination her papilledema was almost completely resolved and her symptoms were much improved. Her visual acuity in both eyes were 20/20 (normal) and her Humphrey visual field 30-2 was normal.

Fundoscopic exam of left and right eye after transverse venous sinus stenting. Findings show near complete resolution of papilledema.

A special thank you to Dr. H for sharing your images and findings. You can follow him on his Instagram @Optometryreviews where he anonymously posts educational material on eye disorders.

To learn more about papilledema with associated images, The American Academy of Ophthalmology has a webpage called EyeWiki that you can take a deep dive into.

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