A 50-year-old African American female presented with a three-week history of intractable headache, confusion, vertical binocular diplopia, photophobia, and difficulty with balance. Examination revealed best corrected visual acuities of 20/25 in the right eye (OD) and 20/20 in the left eye (OS) with intraocular pressures (IOP) of 14 mmHg in both eyes (OU). No afferent pupillary defect was noted, extraocular motility (EOM) was full OU, and confrontational visual fields were full OU. Anterior segment examination in both eyes was unremarkable. Funduscopic examination of both eyes revealed grade-four optic disc edema, blurring of optic disc margin, and obscuration of vasculature of the optic nerve. Preretinal and intraretinal hemorrhages were present in both eyes, largely concentrated in the peripapillary retina, but extending to the mid-peripheral retina (Figures and ). Optic nerve swelling was confirmed on optical coherence tomography (OCT) of the retinal nerve fiber layer (Figures and ). Fluorescein angiography revealed hyperfluorescence of the optic disc OU (Figures and ).\nComputed tomography of the head, magnetic resonance imaging of the brain, and magnetic resonance venography of the brain were unremarkable and had no evidence of intracranial mass, hemorrhage, or ischemia. Cerebrospinal fluid (CSF) analysis revealed an opening pressure of 30 cm H2O, 77 white blood cells/mm3 with 94% lymphocytes, 93 mg/dL protein, and 73 mg/dL glucose. Bacterial and fungal cultures of the CSF were negative. CSF studies for Lyme, syphilis, herpes simplex virus, and West Nile virus were unremarkable. A limited panel consisting of laboratory studies for enterovirus, syphilis, ANA, and p-ANCA was negative. A respiratory viral panel for adenovirus, cytomegalovirus, influenza, parainfluenza, rhinovirus, and respiratory syncytial virus was negative on Polymerase Chain Reaction testing. Based on the patient's presentation and cerebrospinal fluid findings, she was diagnosed with viral meningoencephalitis. She was monitored as an inpatient with conservative management. During the hospital course, the patient noted improvement in her double vision and headaches. A repeated lumbar puncture 5 days later revealed opening pressure of 4 cm H2O, 38 white blood cells/mm3, 75 mg/dL protein, and 57 mg/dL glucose. The patient was subsequently discharged from the hospital.\nFollow-up examinations with serial OCT of the optic nerve showed continued progressive improvement in disc edema (Figures –) along with complete resolution of papilledema and peripapillary hemorrhages (Figures –). Mild residual pallor of both optic nerves was observed at the end of one year. OCT revealed borderline temporal thinning of the right optic nerve. The left optic nerve had borderline temporal thinning, borderline superotemporal thinning, and inferotemporal thinning. The findings of persistent disc pallor and inferotemporal nerve fiber layer thinning on OCT were consistent with the persistent visual field deficit documented on Humphrey visual fields (Figures –).
A 42-year-old obese woman presented to her optometrist after she noticed “after images” following bright light exposure in her left eye (OS). She also noticed transient blurred vision with position changes but denied any regular headaches or pulsatile tinnitus. She denied ever having a severe onset headache. She was referred to neuro-ophthalmology and was found to have a visual acuity of 20/20 in both eyes. Humphrey 24-2 SITA-Fast visual fields showed nonspecific depressed points right eye (OD; MD −6.18 dB) and showed an enlarged blind spot OS (MD −4.84 dB). Dilated fundus examination showed moderate optic disc edema in both eyes with preretinal, intraretinal, and subretinal hemorrhages around the left optic disc (shown in Fig. ). Her blood pressure measured 140/100 and her hemoglobin was normal. Magnetic resonance imaging/magnetic resonance venography was performed and showed signs of raised ICP without a secondary cause. Lumbar puncture showed an opening pressure of 32 cm of water and normal cerebrospinal fluid (CSF) contents. She was started on acetazolamide 500 mg twice-daily (BID) and telmisartan 40 mg daily and the optic disc edema improved and resolved after 4 months with significant weight loss. She maintained normal visual function and the ODH resolved at 3 months. The final Humphrey mean deviation was −3.42 dB OD and −2.98 dB OS.