Acute Vision Change in a 16-year-old Female.

DIAGNOSIS

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, defined as elevated intracranial pressure with no evident cause found on extensive evaluation. Figures 1 and 2 show bilateral papilledema. Headache is absent in some patients with IIH, especially in the pediatric population.1,2 Abducens nerve palsy is a common finding. Oculomotor palsy (as in our case) and other cranial nerve deficits are rare symptoms.1,3,4 Loss of vision is the major morbidity in IIH. While most cases follow a slow and insidious course, some patients experience rapid development of vision loss within a few weeks of symptom onset. Aggressive surgical treatment is indicated in such fulminant cases, often with temporizing measures in place (e.g. serial lumbar puncture, lumbar drain) until surgery can be performed.5 The patient underwent a lumbar puncture in the ED, with an opening pressure recorded to be over 400 mmH2O. Magnetic resonance image of the brain was unremarkable. She was admitted to the hospital and started on intravenous methylprednisolone and acetazolamide. A lumboperitoneal shunt was eventually placed and she was discharged home. On follow up 1 year later, her vision was noted to be 20/50 in the left eye and 20/20 in the right eye with correction.

Figure 1:

Fundoscopic examination of the right eye.

Figure 2:

Fundoscopic examination of the left eye.