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Case 14-3, Pseudotumor Cerebri
A 16-year-old obese woman reported trouble focusing at near distances and blurred vision in her left eye. Visual acuity in this eye was 20/70 and there was a 3+ relative afferent pupillary defect. Dilated fundus examination revealed papilledema in both eyes with a few peripapillary flame shaped hemorrhages in the left eye inferior to the optic disc. Significant pallor was also noted in the superior portion of the left disc. A clinical diagnosis of pseudotumor cerebri was established after a spinal tap revealed a cerebrospinal fluid pressure of 440 mm Hg. Optic nerve sheath fenestration was performed to relieve the acute optic neuropathy in the left eye, and the patient began taking acetazolamide 500 mg once a day.
Examination of the right eye one month after the procedure showed reduced papilledema with mild blurring of the disc margin (A), No peripapillary hemorrhage was identified, A Humphrey visual field (C) revealed an inferior nasal step. Visual acuity in this eye was 20/20.
A linear OCT tomogram (B) acquired through the center of the right optic disc and peripapillary region following fenestration showed protrusion of the disc contour consistent with papilledema, A circular OCT scan (D) obtained around the disc at a diameter of 3,4 mm revealed that the superotemporal nerve fiber layer (NFL) was thinned compared to the inferotemporal nerve fiber layer, which was relatively preserved- This attenuated NFL thickness superiorly corresponded with the clinical region of visual field loss.
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