Intended for healthcare professionals

Endgames Spot Diagnosis

Headache and amaurosis fugax in an obese woman

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6365 (Published 01 December 2015) Cite this as: BMJ 2015;351:h6365
  1. Koushik Tripathy, senior resident1,
  2. Priyanka Ramesh, junior resident1,
  3. Yog Raj Sharma, professor and chief1
  1. 1Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029, India
  1. Correspondence to: K Tripathy koushiktripathy{at}gmail.com

A 42 year old obese woman presented with transient visual obscurations (amaurosis fugax) and headache for six months. She was alert and had no focal neurological deficit. Fundoscopy showed a similar picture in both eyes . What is the diagnosis?

Answer

Established stage of papilloedema.

Discussion

Both eyes show raised pink optic discs, a blurred disc margin, a circumferential peripapillary halo, and obscuration of vessels at the disc (established stage of papilloedema). Differential diagnoses include raised cerebrospinal fluid (CSF) pressure secondary to a space occupying lesion in the brain or brainstem, thrombosis of cerebral venous sinuses, hypertension, and idiopathic intracranial hypertension. A similar ophthalmoscopic appearance (pseudopapilloedema) can be seen in hypermetropia (crowded disc) or optic disc drusen. However, the disc margin vasculature is typically not obscured, the elevation is confined to the disc, and a cupless disc is often seen in these conditions. Blood pressure should be measured and neuroimaging performed to determine the cause of increased CSF pressure. Blood pressure and visual acuity were normal in this patient. The visual field showed an enlarged blind spot corresponding to the optic disc swelling. Magnetic resonance imaging showed bilateral stenosis of the transverse sinus with no space occupying lesion. Lumbar puncture in lateral decubitus showed a CSF opening pressure of 270 mm of water (reference value <250). Biochemical and cytological evaluation was unremarkable. Idiopathic intracranial hypertension was diagnosed on the basis of the modified Dandy criteria. Idiopathic intracranial hypertension is clinically characterised by papilloedema, and visual fields can be used to monitor the disease.

Notes

Cite this as: BMJ 2015;351:h6365

Footnotes

  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.

  • Patient consent obtained.

View Abstract

Log in

Log in through your institution

Subscribe

* For online subscription