A 39-year-old woman with rheumatoid arthritis, sleep apnea and a body mass index of 55 presented with nausea, vomiting and floaters in the right eye for two days. Two weeks prior, she developed positional headaches, blurry vision and transient visual obscurations. On presentation, her best corrected visual acuity was 20/25 in each eye, there was no relative afferent pupillary defect and the examination of external structures and anterior segment was unremarkable.\nFunduscopic examination revealed Frisen grade 4 papilledema in the right eye with vitreous, subretinal and intraretinal hemorrhages, and grade 3 in the left eye with flame-shaped hemorrhages (A, ).\nHead CT with contrast appeared normal, an MRI was not possible due to body habitus and weight restrictions. Lumbar puncture under fluoroscopic guidance revealed opening pressure of 310 mm CSF with normal composition. Humphrey visual field 24-2 SITA Fast was reliable with an enlarged blind spot and a few central changes in the right eye (mean deviation −4.00 dB) and was essentially full with mild central depression in the left eye (mean deviation −3.55 dB).\nShe was started on acetazolamide 500 mg twice daily, which was titrated up to 1500 mg twice daily with gradual resolution of symptoms over a month. At two month follow up, the vitreous hemorrhage had resolved and there was marked improvement in the papilledema bilaterally ( C, D).
A 44-year-old obese woman with a medical history of iron-deficiency anemia (pretreatment hemoglobin of 8.8 g/dL) presented with blurred vision in her right eye and new headaches over 1 month. She described the headaches as holocephalic, rated them 4–5 out of 10 (where 1 is minimal intensity and 10 is maximal intensity) without any diurnal or positional variation. She had associated intermittent nausea, but no vomiting. She denied any characteristics consistent with a thunderclap headache. She initially saw her optometrist and was referred to neuro-ophthalmology for bilateral optic disc edema. Examination revealed a visual acuity of 20/30 OD and 20/20 OS, and Humphrey visual field testing showed an enlarged blind spot OD (MD −4.60 dB) and was normal OS (MD −2.10 dB). Slit-lamp examination revealed a posterior subcapsular cataract in the OD and dilated fundus examination showed moderate optic disc edema in both eyes with hemorrhages in all 3 retinal layers in the OD (shown in Fig. ). Her blood pressure was 128/78, and her hemoglobin was found to be 9.0 g/dL with mean corpuscular volume of 70.4 fL. Magnetic resonance imaging/magnetic resonance venography of the head was normal apart from signs of raised ICP, and lumbar puncture showed an opening pressure of 34 cm of water with normal CSF contents. She was started on acetazolamide 500 mg BID and continued her recent supplementation with ferrous fumarate. With significant weight loss, her optic disc edema resolved after 4 months, and she continued to maintain normal visual function. The final Humphrey mean deviation was −2.80 dB OD and −0.72 dB OS.