Acute bilateral optic disk edema with a macular star figure in a 12-year-old girl

Diagnostic dilemma of papilledema and pseudopapilledema

BACKGROUND

Papilledema is the optic disc swelling caused by increased intracranial pressure (ICP) that can damage the optic nerve and cause subsequent vision loss. Pseudopapilledema refers to optic disc elevation without peripapillary fluid that can arise from several optic disc disorders, with optic disc drusen (ODD) being the most frequent cause. Occasionally, pseudopapilledema patients are mistakenly diagnosed as papilledema, leading to the possibility of unneeded procedures. We aim to thoroughly examine the most current evidence on papilledema and pseudopapilledema causes and several methods for distinguishing between both conditions.

METHODS

An extensive literature search was conducted on electronic databases including PubMed and google scholar using keywords that were relevant to the assessed pathologies. Data were collected and then summarized in comprehensive form.

RESULTS

Various techniques are employed to distinguish between papilledema and pseudopapilledema. These techniques include Fundus fluorescein angiography, optical coherence tomography, ultrasonography, and magnetic resonance imaging. Lumbar puncture and other invasive procedures may be needed if results are suspicious.

CONCLUSION

Papilledema is a sight-threatening condition that may lead to visual affection. Many disc conditions may mimic papilledema. Accordingly, differentiation between papilledema and pseudopailledema is crucial and can be conducted through many modalities.

A multi-centre case series of patients with coexistent intracranial hypertension and malignant arterial hypertension

OBJECTIVE

To describe the clinical characteristics, outcomes, and management of a large cohort of patients with concomitant malignant arterial hypertension and intracranial hypertension.

METHODS

Design: Retrospective case series.

SUBJECTS

Patients aged ≥ 18 years with bilateral optic disc oedema (ODE), malignant arterial hypertension and intracranial hypertension at five academic institutions. Patient demographics, clinical characteristics, diagnostic studies, and management were collected.

RESULTS

Nineteen patients (58% female, 63% Black) were included. Median age was 35 years; body mass index (BMI) was 30 kg/m2. Fourteen (74%) patients had pre-existing hypertension. The most common presenting symptom was blurred vision (89%). Median blood pressure (BP) was 220 mmHg systolic (IQR 199-231.5 mmHg) and 130 mmHg diastolic (IQR 116-136 mmHg) mmHg), and median lumbar puncture opening pressure was 36.5 cmH2O. All patients received treatment for arterial hypertension. Seventeen (89%) patients received medical treatment for raised intracranial pressure, while six (30%) patients underwent a surgical intervention. There was significant improvement in ODE, peripapillary retinal nerve fibre layer thickness, and visual field in the worst eye (p < 0.05). Considering the worst eye, 9 (47%) presented with acuity ≥ 20/25, while 5 (26%) presented with ≤ 20/200. Overall, 7 patients maintained ≥ 20/25 acuity or better, 6 demonstrated improvement, and 5 demonstrated worsening.

CONCLUSIONS

Papilloedema and malignant arterial hypertension can occur simultaneously with potentially greater risk for severe visual loss. Clinicians should consider a workup for papilloedema among patients with significantly elevated blood pressure and bilateral optic disc oedema.

Bilateral disc edema: An unusual presentation of renal tuberculosis in a child

Renal tuberculosis (TB) is a rare clinical disorder in the pediatric population. A 15-year-old female presented with intermittent blurring of vision in both eyes associated with fever, abdominal pain, and weight loss. Fundus examination showed bilateral disc edema. Her blood pressure was 220/110 mmHg. Renal parameters were deranged with bilaterally enlarged kidneys. Renal biopsy was suggestive of epithelioid cell granuloma with Langhans type giant cells. The patient was diagnosed with as a case of refractory hypertension due to tubercular interstitial nephritis with bilateral Grade IV hypertensive retinopathy. She was started on antitubercular therapy and antihypertensives. There was a complete resolution of disc edema 2 months following initiation of therapy. Optic disc edema can be a presenting sign in renal TB. Early diagnosis and prompt referral can be associated with good visual and systemic outcomes.

Bilateral swollen optic nerve head etiology and management: A cross-sectional study

Background

The differential diagnosis of optic disc edema varies according to the presence of unilateral or bilateral edema. Papilledema may occur due to benign and life-threatening causes, but even benign causes may leave serious consequences for vision if not treated emergently. This study aimed to find out the prevalence of these causes in two major hospitals in Syria and observing the response of edema to treatment within a month and how visual acuity can be saved if edema is treated urgently.

Methods

This cross-sectional study was conducted in Al-Assad and Al-Mowasat Hospitals in Syria from October 2020 to the beginning of February 2022. It included 50 patients who had bilateral optic disc edema. Then a full study was carried out to reach the diagnosis and management appropriately and to monitor the extent of the efficacy of conservative measure in reducing edema, and how many of them needed surgical intervention.

Results

the study included 50 patients, 13 males and 37 females, the most common diagnosis was venous sinus thrombosis (12 cases with 24%), followed by idiopathic intracranial hypertension and tumors (10 cases each by 20%), infectious meningitis (8 cases by 16%), leptomeningeal metastasis (5 cases by 10%), arterial hypertension (3 cases by 6%) and autoimmune meningitis (2 by 4%). Edema improved after management within a month in most patients (37 patients by 74%) and edema was accompanied by low visual acuity in 21 patients (42%). 20 patients (40%) needed surgical intervention. Visual acuity reduced in 10 patients (20%) despite all treatments.

Conclusion

venous sinus thrombosis is the most common cause of bilateral optic disc edema then idiopathic intracranial hypertension and tumors, and despite the provision of all treatments, the visual acuity of 20% of patients has decreased.

Bilateral papilledema and abducens nerve palsy following cerebral venous sinus thrombosis due to Gradenigo's syndrome in a pediatric patient

Purpose

To report a case of bilateral papilledema and abducens nerve palsy following cerebral venous sinus thrombosis in a 9-year-old female with undiagnosed Gradenigo's Syndrome.

Observations

The patient presented to our Emergency Room with a unilateral left 6th nerve palsy, left eye relative afferent pupillary defect, and bilateral papilledema. She underwent cranial magnetic resonance imaging with gadolinium contrast and magnetic resonance venography, which diagnosed a left mastoiditis, left sigmoid sinus and jugular vein thrombosis. The patient underwent urgent mastoidectomy and myringotomy with tube placement and was admitted for adequate treatment with intravenous antibiotics and anticoagulants.

Conclusions and importance

Gradenigo's syndrome is a rare complication of otitis media, and even rarer is cerebral venous thrombosis. This potentially life-threatening situation requires immediate surgical and antibiotic therapy. Ocular symptoms can be the initial signs of this illness.

Final Diagnosis in Patients Referred with a Diagnosis of Neuroretinitis

The purpose of this study was to determine final diagnosis of patients referred with a diagnosis of neuroretinitis. A retrospective study of 40 patients with optic disc oedema with macular star (ODOMS) referred with a diagnosis of neuroretinitis was conducted. The final diagnosis was neuroretinitis in 26 patients (65%), with most of these patients (96.1%) having unilateral involvement. Main underlying aetiologies included cat scratch disease (30.8%), rickettsiosis (19.2%), and idiopathic neuroretinitis (23.1%). The remaining 14 patients (35%) had ODOMS that had been mistaken for neuroretinitis. Of these patients, 42.8% were found to have a previously unknown malignant systemic hypertension in association with bilateral ODOMS. Neuroretinitis, usually unilateral, should be differentiated from other causes of unilateral or most often bilateral ODOMS that may masquerade as neuroretinitis, mainly malignant systemic hypertension. This is essential to avoid inappropriate work-up and management and subsequent potential visual or systemic morbidity.

Bilateral papillopathy as a presenting sign of pheochromocytoma associated with von Hippel-Lindau disease

A 7-year-old girl presented with decreased vision in both eyes for 1 month. Examination showed visual acuity of 20/50 and 20/60, no afferent pupillary defect, cecocentral scotomas, and bilateral optic disc edema with extensive peripapillary and macular exudates. Magnetic resonance imaging showed multiple cortical and subcortical white matter lesions. Both the laboratory workup and the systemic examination were unrevealing. However, on follow-up, the patient showed episodic elevations of blood pressure as high as 240/160. Further workup revealed elevated urine catecholamines and a right supra-adrenal mass proven to be a pheochromocytoma by histopathologic analysis. The paroxysmal hypertension resolved, and the visual acuity, visual fields, fundus exam, and neuroimaging improved. The patient was lost to follow-up until age 18 when she developed shortness of breath and was found to have multiple pulmonary metastases identified as pheochromocytoma by biopsy. Genetic testing identified a 3p25-26 (c.482 G>A) VHL gene chromosomal mutation consistent with von Hippel–Lindau disease genotype. Multiple peripheral retinal vascular dilations and small retinal capillary hemangioblastomas were also found. This case highlights the importance of recognizing the lability of blood pressure often seen with pheochromocytomas, which may mask the underlying cause of hypertensive papillopathy and retinopathy, a diagnosis of low clinical suspicion in the pediatric population. The case also underscores the importance of thorough systemic workup, including genotyping to detect conditions where pheochromocytoma may be the presenting sign of the disease, such as multiple endocrine neoplasia 2A and 2B, von Hippel–Lindau disease, von Recklinghausen disease, tuberous sclerosis, and Sturge–Weber syndrome.

Diagnosis of malignant hypertension with ocular examination: a child case

A 12-year-old female patient was admitted to our clinic complaining about low vision. Bilateral optic disc edema, macular star, and preretinal hemorrhages were found in fundoscopic examination. In fundus fluorescein angiography, massive leakage in the late phase was seen in the optic nerve head and macular area. These findings were compatible with high-grade hypertensive retinopathy. The patient consulted with pediatrics and a diagnosis of vesicourethral reflux and malignant hypertension was made.

Bilateral serous retinal detachments associated with accelerated hypertensive choroidopathy

Purpose. We report a case of hypertensive choroidopathy with bilateral serous retinal detachments. Patient. A 50-year-old man underwent bilateral serous retinal detachments. Retinal arteriolar narrowing, vascular tortuosity, and arteriovenous nicking were identified in both eyes. The blood pressure was 206/125 mmHg. The patient was diagnosed with bilateral hypertensive choroidopathy and treated with oral antihypertensive treatment. Results and discussion. One month after antihypertensive treatment, the serous retinal detachments resolved and the visual acuity improved. A patient with those findings should be considered as having hypertensive choroidopathy and treated as soon as possible.

Hypertensive retinopathy grade iv in an 11-year-old girl with renal arterial hypertension due to recurrent reflux pyelonephritis

PURPOSE

The prevalence of retinal vascular abnormalities in children is shown to be similar to that in adults. Swelling of the optic disk in children may have different etiologies. The differential diagnosis necessitates an interdisciplinary workup.

METHODS

This study presents a case of bilateral edema of the optic disk with unilateral diminution of visual acuity in an 11-year-old girl due to malignant hypertension caused by reflux nephropathy in consequence of vesicoureteric reflux and recurrent urinary tract infections.

CONCLUSION

Early diagnosis of malignant hypertension in children and adequate therapy are essential for avoiding permanent visual dysfunction.

An unusual cause of acute bilateral optic disk swelling with macular star in a 9-year-old girl

We report a rare case of bilateral optic disk swelling with macular exudates and cottonwool spots secondary to a pheochromocytoma in a 9-year-old girl. Malignant hypertensive changes in the eyes are uncommon and may sometimes resemble neuroretinitis. Overaggressive treatment of malignant hypertension can cause optic nerve infarction, leading to blindness.

Update on the ocular manifestations of systemic arterial hypertension

PURPOSE OF REVIEW

In a society with a steadily increasing population of patients with hypertension, a significant mortality risk factor, it is important that clinicians be cognizant of the changes seen in ophthalmic examination. This paper demonstrates both the acute and chronic stages of the disease.

RECENT FINDINGS

This paper first presents the history of classifying different stages of hypertensive retinopathy, a condition associated with systemic arterial hypertension, as defined by Keith-Wagener-Barker. The most recent recommendations published in the Seventh Report of the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure are also described; this report defines the current status and classification of hypertension in the United States, as well as recommendations for its treatment and management. Finally, disease management strategies and currently accepted treatment options are presented.

SUMMARY

Since systemic arterial hypertension is a key modifiable risk factor for various diseases such as myocardial infarction and stroke, it is crucial that we detect early signs of hypertension to promote better health for our patient population.

Optic neuropathy: puls/minus

A 26-year-old Asian woman presented with bilateral disk swelling, retinal exudates and infarcts. Evaluation found the underlying cause of the hypertensive optic neuropathy to be renal artery stenosis due to Takayasu's arteritis.

Neuroretinitis in patients with multiple sclerosis

PURPOSE

To present a case series of three patients with neuroretinitis associated with multiple sclerosis.

DESIGN

Retrospective, noncomparative, consecutive, interventional case series.

PARTICIPANTS

Thirty-five consecutive patients with neuroretinitis.

METHODS

The records of 35 consecutive patients with neuroretinitis were reviewed for prior, concurrent, or subsequent development of multiple sclerosis.

MAIN OUTCOME MEASURES

Presentation, clinical course, and diagnosis of multiple sclerosis.

RESULTS

Three of 35 patients (8.6%) with neuroretinitis were diagnosed with multiple sclerosis by the McDonald criteria. One of the three patients underwent brain biopsy that further confirmed multiple sclerosis. Neuroretinitis in the three patients occurred after the diagnosis of multiple sclerosis. All three patients with multiple sclerosis had been treated with interferon beta before or concurrently with the development of neuroretinitis.

CONCLUSIONS

Neuroretinitis can be an associated manifestation of multiple sclerosis. The possible association between neuroretinitis and interferon beta warrants further investigation.

An uncommon presentation of Bartonella-associated neuroretinitis

BACKGROUND

This article documents a case of neuroretinitis initially presenting with ocular pain, 20/20 visual acuities, optic disc edema, and macular serous detachment without macular star formation in the absence of a history of exposure to pets or cats or symptoms suggestive of Bartonella infection. This initial clinical presentation appeared unilateral, but later became bilateral.

CASE REPORT

Physical and neuroophthalmologic consultation, neuroimaging studies, blood chemistry, and serologic analysis were requested. Positive serologic (IGG) titers to Bartonella henselae and Bartonella quintana were detected. Treatment was instituted initially with oral tetracycline (250 mg) qid and subsequently with doxycycline (100 mg) bid and prednisone (20 mg) qd.

CONCLUSION

Bartonella infection may cause optic disc edema and serous detachment without macular star formation. This presentation may occur without the generally characteristic signs and symptoms of Bartonella-associated neuroretinitis. A bilateral involvement may follow an initial unilateral presentation during the affliction period of this disorder.