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.
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.